Professional Disclosure Statement


Psychotherapy can be a very special opportunity to understand more deeply the struggles you are experiencing, and to make the changes which are important to you. Therapy can be a fascinating and stimulating process. It can also be difficult and at times painful. While there are no guarantees, your active participation will contribute greatly to this process.


Professional Qualifications

I hold a Master of Science in Social Work from the University of Wisconsin Madison. My BS is also in Social Work, also from the University of Wisconsin Madison. My clinical experience prior to private practice includes working with children and families as a behavioral health provider at a community clinic for the uninsured. Prior to that, I provided individual and group therapy to adult men and women in the San Francisco county jails. I am a licensed clinical social worker in the state of California since 2007.


My approach to therapy

I combine Western psychotherapy with mindfulness-based practices. Mindfulness is a skill that involves slowing down in order to notice--moment by moment, with curiosity and kindness--what you are doing, thinking, and feeling, so that if you like, you can make desired changes. Since our bodies are connected to our beliefs and feelings, by slowing down and bringing awareness to our bodies, the path towards healing can be revealed. Traditional psychotherapy primarily pays attention to thoughts, emotions and behaviors. In body-oriented psychotherapy, attention is also given to sensations and felt experiences in the body. It may be as simple as bringing attention and awareness to a felt sensation, or it might entail “taking over” a particular tension or holding, in order to explore what lies beneath. The goal of therapy is to encourage communication among parts and to bring attention to those parts that are lost, hidden or isolated. Body-oriented psychotherapy can provide an added dimension to the therapeutic process by presenting information that is often overlooked. With the partnership of the conscious mind, it can provide a deeper and more efficient path to work directly with the unconscious mind, facilitating self-discovery and transformation. I am trained and certified in EMDR and the Hakomi method and find both to be powerful ways to bring transformation and healing. I am in the process of training and certification for Emotion Focused Therapy with couples. I participate in regular professional training practice groups and consultation throughout the year. 


During our initial one to two sessions, we will both be getting to know each other and can both decide if I am the best person to provide the services you seek.  If I feel that I can be of assistance, I will offer you some first impressions of what our work might include.  In deciding whether you would like to continue, you should evaluate this information along with your own sense of whether you feel comfortable with me.  If in my opinion I cannot be of help to you, I will let you know this and will do my best to give you referrals that you can contact.  


Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part.  Psychotherapy requires your very active involvement, honesty and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond honestly.  Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc, or experiencing anxiety, depression, insomnia, etc.  I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about or handling situations. This can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes, another family member views a decision that is positive for one family member quite negatively. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to behavioral, cognitive-behavioral, psychodynamic, system/family, psycho-educational or body oriented.  I provide neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within my scope of practice.


If at any time during the course of therapy you have questions about my procedures, their risks, my expertise, or about the treatment plan, please don’t hesitate to ask when they arise so that we can discuss them. I will also be happy to provide you with names of other qualified professionals whose services you might prefer.  If at any point I assess that I am not effective in helping you, I will discuss it with you, and if appropriate, I will terminate treatment and give you referrals which may be of help to you.


Confidentiality

In therapy, everything we speak about will be held strictly confidential with the following exceptions: 


    1. you authorize the release of information in writing
    2. I’m concerned that you may pose a serious danger to yourself or others
    3. I need to release information to your insurance company for billing and/or authorization purposes 
    4. abuse of a child, elder, or dependent adult is suspected
    5. I am court ordered to release information
    6. I seek individual or group consultation.  In this case, your full name will never be disclosed.


Touch in Therapy

I am trained in some therapeutic modalities that can incorporate touch as part of psychotherapy. This sort of touch is always non-sexual in nature. It is always optional and never required for treatment services. If I consider that using a therapeutic intervention that incorporates touch could potentially be beneficial for your treatment, I will explain the prospective intervention to you and ask your permission before touching you. You always have the right to decline or refuse to be touched without any fear or concern about reprisal.


Availability between Sessions

I am often not immediately available by telephone.  When I am unavailable, my telephone is answered by electronic voice mail.  I will make every effort to return your call as soon as possible, although I may not return calls on weekends or holidays, and I may not receive your call until the next day if you call after 5 p.m.  If you can’t wait for me to return your call, contact your family physician or the nearest hospital emergency room. If you need to speak to someone after hours or on the weekend you may call the Alameda County 24-hr crisis line at 1-800-309-2131, or you may leave a message and I will return your call upon returning to the office. I request that you only email me to send necessary documents or forms, as my email is not encrypted and I do not always check it regularly.


Cancellations

If you are late for an appointment, you will have the remainder of the scheduled session available to you; we will not run over the scheduled time. It is important for the continuity of therapy that you come to all sessions. Since your appointment time is reserved exclusively for you, I have a 24-hour cancellation policy. In other words, if you cancel in less than 24 hours of the appointment time, you will be charged the full fee of the session.


Vacation Policy

I will take some vacation time during the year, usually no more than two weeks in length.  I will provide you with advance notice of any upcoming vacations as well as back-up coverage available.


Fees

The fee for a 50-minute session is discounted if paid by cash or check; $175 for an individual session, and $200 for a 50 minute couples session. If you pay with credit or through an internet service the fee is an additional $5. Fees are due at the beginning of each session. Fees are reviewed yearly and may be raised $5 to $15 per year.  I do not charge for telephone conversations of ten minutes or less, so long as they are not more frequent than twice a month.  Phone consultations that exceed such frequency and/or length are billed at the prorated hourly rate.  Site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. I reserve the right to assess a finance charge on past due bills, or in extremely delinquent cases to turn them over for collections. Should you elect to use your insurance mental health benefits, you should know that a diagnosis is required. Diagnosis and history will become part of your permanent medical records. These records are often accessible to other insurance companies and on occasion can be used by employers and private investigators for credit reports. Fees will be reviewed every six months.  Please notify me if any problem arises during the course of your therapy regarding your ability to make timely payments. 


Health Insurance & Confidentiality of Records 

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims.  If you instruct me only the minimum necessary information will be communicated to the carrier.  I have no control or knowledge over what insurance companies do with the information submitted or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job.  The risk stems from the fact that mental health information is likely to be entered into big insurance companies’ computers and is likely to be reported to the National Medical Data Bank.  Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to break ins and unauthorized access.   Medical data has also been reported to be legally accessed by enforcement and other agencies, which also puts you in a vulnerable position.  


Litigation Limitation 

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.


Consultation  

I consult regularly with other professionals regarding my clients; however, client’s identity remains completely anonymous, and confidentiality is fully maintained.


Consent

I have read the above information and clarified any questions I have. I agree to the stated terms. If I use insurance coverage, my signature authorizes release of information required to process claims and authorizes payment to my therapist.



Name:______________________________________________________


Signature: ___________________________________________________         


Date: _______________________________________________________ 

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