INFORMED CONSENT AND CONFIDENTIALITY STATEMENT
I
understand and agree to the following:
- that treatment offered is voluntary in nature, unless I am under the age of 18.
- that, within certain limits, information that may be revealed during therapy will be kept strictly confidential, requiring a written authorization from all parties in treatment if any information is to be released to any outside parties, with the exception of my insurance company.
- that if I reveal information indicating that I may be a threat either to myself or others, my therapist may be permitted and/or mandated by law to reveal this information to other persons or agencies for the safety of myself or others. This would include instances of suspected child abuse when treating a child under 18 years of age.
Telemental Health Information -
- We may be using certain technological services and tools, such as Facetime and Zoom.
- Telemental health has both benefits and risks, whilch you and your provider will be monitoring as you proceed with your work.
- You can stop work by telemental health at any time without prejudice.
- You will need to create a private and appropriate space for your sessions.
- You will need to make a plan for managing technology failures, mental health and medical emergencies.
- Your
provider follows security best practices and legal stsandards to protect your
health care information, but you will also need to maintain your own security
and privacy.
Financial Policy –
PAYMENT
IS DUE IN FULL AT THE TIME OF EACH
SESSION. FEES ARE SUBJECT TO
CHANGE EVERY SIX MONTHS.
NO-SHOW AND CANCELLATION POLICY - Your visit has been reserved for you. 24 hours notice is required for cancellation or you will be charged a late cancellation fee of $75.00.
By clicking the Submit button, I acknowledge that I have read and understand this information sheet and informed consent.
MCP_______
EVAL_______
Gene Kayser uses the Gottman Method Couples Therapy system with it's proven techniques & strategies for couples who want to save their relationship. This is a "nuts and bolts" approach based on 40 years of research & treatment.
For a free 20 minute consultation, Call or Text:
You always maintained your impartiality with us. You encouraged Rita to be more assertive in stating what she wanted to get from your counseling sessions, as well as what she wanted to get from the relationship. You taught both of us better communication between ourselves, which lead to an emotional comfort level between us that didn't exist before. You took control of the direction of the session if things were not moving along. Thanks so much for helping us." Rita and Mark |
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