Informed Consent and Disclosure Statements

Information About Me

Prior to beginning treatment, I will discuss my professional background and provide you with information regarding my experience, education, special interests, and professional orientation. I am a Licensed Marriage and Family therapist and a Clinical Hypnotist.

About the Therapy Process

It is my intention to provide services that will assist you in reaching your goals. We are partners in the therapeutic process. As partners, we will work together to develop a plan for your treatment. Based on the information you provide to me and the specifics of your situation, I will offer feedback and recommendations regarding your treatment and progress.

Over the course of therapy, I will attempt to evaluate whether the therapy provided is beneficial to you. While I hope our work together will be effective, the amount and length of treatment varies from client to client. I am unable to predict how long you will be in therapy or guarantee a specific outcome or result of our work together.

Individual therapy sessions are approximately one hour each and Couples therapy is 90 minutes. Typically, sessions are scheduled once per week, at the same day and time each week. Consistent attendance contributes greatly to a successful outcome.

Fees and Insurance

The fee for service is $ 150.00 per individual therapy session.

The fee for service is $ 170.00 per conjoint (marital/pre-marital).

Fees are payable at the time services are rendered. I accept payment in the form of cash, personal checks or bank checks. My goal is to maximize your session time. You are ultimately responsible for payment for services received, even if you are relying on, or expecting, your insurance company or another third-party payor to cover the costs of treatment. I will notify you in the event of any changes to fees or when other charges are to be applied. If you are experiencing financial difficulty, please let me know so we can discuss your payment options.

Please inform me if you wish to use health insurance to pay for your services. I do not accept insurance. I am a private pay/cash pay business only. However, I am happy to provide you with a superbill (a.k.a. a receipt for services) which you can submit to your insurance for potential reimbursement. Depending on the terms of your health coverage, your plan may or may not reimburse for out-of-network services.

Appointment Scheduling and Cancellation Policies

Sessions are typically scheduled to occur once per week on the same day at the same time, if possible. I may suggest a different amount or frequency of therapy depending on the nature and severity of your concerns. Your consistent attendance can greatly contribute to a successful therapy outcome. To cancel or reschedule an appointment, please notify me at least 24 hours in advance of your appointment. If you do not provide me with at least 24 hours’ notice of cancellation, you will be charged the full fee for the missed session. If you are using insurance, please be aware that your insurance company will not pay for missed or cancelled sessions. Accordingly, you will be responsible for covering the cost of missed sessions and sessions cancelled.

Your Right to Confidentiality- As a psychotherapy client, you have a right to confidentiality with respect to information related to our work together. Accordingly, information shared between us will generally remain confidential.

Exceptions to Confidentiality

In certain, limited instances, the law requires me to disclose information pertaining to my work with you. For example, as a therapist, I am required to report suspected child, elder, and dependent adult abuse. Please note that the legal definition of “child abuse” generally includes instances of “sexting” in which a person of any age captures, records, sends, receives, or possesses an image or video depicting a minor engaged in sexual or otherwise obscene conduct.

Similarly, if I believe you present a serious and imminent danger to yourself, another person, or the public, I may be required to disclose information to emergency medical services, law enforcement, and/or another third party that can help to reduce or prevent that danger.

Confidentiality and Treatment of Minors

If a minor’s parent(s) or guardian(s) give consent for me to treat the minor, I typically provide the parent(s) or guardian(s) with general updates about the minor’s treatment. These updates may include the minor’s diagnosis, treatment plan, progress in therapy, session attendance, or similar information. However, I generally do not share specific details about the minor’s treatment or what the minor has shared with me during sessions unless: 1) the minor gives me permission to disclose such information and I believe the disclosure would be clinically appropriate; or 2) the minor is experiencing a crisis or other emergency circumstance that would authorize me to break confidentiality.

If the minor consents to their own treatment, the law generally prohibits me from communicating with their parent(s) or guardian(s) without written authorization from the minor unless the minor is experiencing a crisis or other emergency circumstance that would authorize me to break confidentiality.

Please feel free to reach out to me if you have questions about these policies or if you would like to discuss them further.

Confidentiality and Couples / Family Therapy

If you are participating in couples therapy, please be aware that, in most circumstances, the law prohibits me from disclosing confidential information and records regarding the unit of treatment’s services unless all identified clients provide written authorization to release the information.

No Secrets Policy

I would also like for my couples to be aware that I utilize a “no-secrets” policy. This means, when I determine it is clinically appropriate or necessary to do so, I can disclose information I obtain from one member of the couple, or a participating member of the couple’s therapy unit, (i.e. the “treatment unit”) with the other member(s) of the treatment unit. This policy also applies to information a member of the treatment unit shares with me outside of couples (e.g., via email, text, etc.) and information I obtain during individual session(s) with a member of the treatment unit (should we agree to hold individual sessions in furtherance of your couples / treatment goals). I find that this policy facilitates effective communication with and between my couples therapy clients. It also helps me to avoid potential problems which may arise when a therapist is perceived to be “keeping secrets” from other members of the treatment unit.

My Communication with You

From time to time, I may need to communicate with you outside of our sessions to discuss scheduling, payment, or other issues related to your treatment. To respect your privacy, it is important for me to understand your communication preferences. Please indicate your openness to receive communication from me via the following methods:

Phone

I authorize my therapist to call me at this number. I authorize my therapist to leave messages for me at this number.

Phone

I authorize my therapist to call me at this number. I authorize my therapist to leave messages for me at this number.

Additional Information About Unencrypted Text Messaging:

I value your privacy and take appropriate steps to preserve the confidentiality of information shared between us. However, it is important to be aware that certain risks may still be present when communicating via unencrypted text, such as technological failures or unintended access by third parties.

I understand the information above and authorize my therapist to communicate with me via unencrypted text using the cell phone number I provided.

My Email Address is.

Additional Information About Unencrypted Email: I value your privacy and take appropriate steps to preserve the confidentiality of information shared between us. However, it is important to be aware that certain risks may still be present when communicating via unencrypted email, such as technological failures or unintended access by third parties.

I understand the information above and authorize my therapist to communicate with me via unencrypted email at the email address I provided.

My Home Address is

I authorize my therapist to send necessary treatment-related information to me at this address.

Additional Communication Information and Preferences

I will do my best to honor your communication preferences, but please be aware that in certain instances, such as emergency circumstances, I may need to reach you through other methods.

Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Relationship to Patient

Home Phone Number

Cell Phone Number

Emergency Contact 3

Cell Phone Number

Relationship to Patient

Home Phone Number

Cell Phone Number

Kaufman counseling service