Kristian Bowden Menotti, LCSW
125 Willow Road
Menlo Park, CA 94025
919-696-4712
Consent to Services Agreement
This agreement is intended to provide important information to you regarding your treatment. Please read the entire consent carefully and be sure to ask any questions you may have regarding its contents.
About the Therapy Process
I believe therapists and patients are partners in the therapeutic process. It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide me and the specifics of your situation, I will provide recommendations to you regarding your treatment. Your full participation in the therapeutic process is a crucial part in your symptom reduction and achievement of your therapeutic goals.
Information about your therapist
I am a Licensed Clinical Social Worker in California (License number 61728). I received my Bachelors Degree in Psychology from North Carolina State University and my Master’s in Social Work from the University North Carolina Greensboro. I have practiced psychotherapy since 2002 and was licensed in 2003. I am also a Registered Yoga Teacher (Registration number 146273) with Yoga Alliance.
Fees, Payments and Cancelations
Fees are established prior to commencement of treatment. Sessions are 50 minutes in length. Payment is expected at time of service. Checks can be made out to Kristian Menotti, LCSW. If you are paying by check, please make out the check prior to your session so that you do not have to use your therapy time to do this. If for some reason you find you are unable to continue paying for your therapy, you should inform me. I will help you consider any options that may be available to you at that time.
Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify me at least 24 hours in advance of your appointment. If you do not provide me with at least 24 hours notice you are responsible for payment for the missed session. Please understand you insurance company will not pay for missed or cancelled sessions.
Confidentiality
All communications between you and I will be held in strict confidence unless you provide written consent to release information about your treatment. There are a few exceptions to this confidentiality. 1) Reasonable concern that you may harm yourself or another; 2) Reasonable concern that child, elder or dependent adult abuse may have occurred; 3) If mandated to by law. Be mindful if you wish to be reimbursed by insurance,your insurance company or program has a right to information about you and the content of our sessions together. In addition, if you introduce your mental health as an issue of litigation, other litigants may be entitled to subpoena your records.
Public Encounters – In the event we encounter each other in a public situation I will not acknowledge you as a counseling client. If you would like to talk to me or say hello I will follow your lead. I do not discuss psychotherapy matters with clients in public. If this subject is broached during a public encounter I will encourage you to contact me.
Facebook– I do maintain a Facebook (FB) page. I post information on meditation, yoga and other information you may find of interest. By choosing to like my page through Facebook you agree to the following: a) you will never be identified as a client on my FB page; b) no form of communication regarding your treatment will take place through FB (including any posts/messages regarding appointments, feedback regarding my services – even if positive). If you choose to communicate in a way that I feel is in violation of these guidelines, I will contact you to clear up any misunderstandings.
Texting/Email- Texting or emailing me short comments and/or questions is appropriate. Please inform me if you would like a text as a reminder of your next appointment. Please note cell phones and email are both insecure forms of communication. If you have any concerns about the confidentiality of your text and or email, I encourage you not to engage me in this form of communication.
Therapist Availability/Emergencies-
You may leave a message for me at any time on my confidential voicemail. If you wish for me to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. You will be billed for any calls over 15 minutes. If you have an urgent need to speak with me, please indicate that fact in your message, and provide sufficient information so that I have an understanding of the nature of your call.
In the event you are experiencing a crisis that cannot wait until our next appointment and you cannot wait for a call back from me I encourage you to do one of the following: 1) Dial 911 2) Go to your closest emergency room or 3) contact the Crisis Intervention and Suicide Hotline- 1-800-273-8255.
Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral to another therapist, changing your treatment plan, or terminating your therapy.
Your signature indicates that you have read this agreement for services carefully and understand its contents. Please ask me to address any questions or concerns that you have about this information before you sign.
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