Bring the following completed forms to your initial session:
- Client Information form
- Therapy Information and Agreement form
- CMS 1500 Insurance claim form (if you are planning to use insurance)
- Photocopy of insurance card (front and back) if using insurance
INFORMATION AND AGREEMENT FORM
Nature of Psychotherapy
Therapy can be a rewarding and insightful process. It also involves certain risks:
• During the course of therapy, you may experience changes in the way you think or the way you feel, including having unpleasant feelings as you explore personal issues.
• Therapy may affect your relationships and change your view of those relationships.
• It will require work from you both during and after sessions.
• It is also possible that changes you had hoped for will not occur; there are no guarantees regarding the outcome of treatment.
• Some clients achieve their therapeutic objectives within a few sessions while others may require forty or more sessions.
• Depending on the issue for which you are seeking therapy, there may be alternative treatments possible including other therapeutic approaches, medication prescribed by a psychiatrist or other medical professional, seeking the advice of clergy, or waiting to see if the problem goes away.
• You are free to terminate treatment at any time.
Confidentiality
• All information you reveal during therapy sessions is strictly confidential and cannot be released to anyone without your prior written consent, except in possible cases of harm to self or others, suspected child abuse or dependent adult abuse, or a subpoena by a court of law.
• On occasion, in order to provide you with better services I may consult with a colleague to discuss material arising from our sessions, although your identity will not be revealed. If at any time you wish for me to speak with someone regarding your status as a client or to discuss some part of treatment with a third party, I will require you to sign a Consent for Release of Information Form.
• Legal and professional ethics require that I keep clinical records. These files consist of notes regarding sessions, results of any testing, and a summary of treatment that occurred. The files are kept in a locked filing cabinet behind a locked door in the office. Ten years after termination of treatment these files will be destroyed and only a one-page summary will be retained. In the event of my death or disabling illness, a clinical colleague will take action to maintain the confidentiality of your records. Were I to become incapacitated during a period you are receiving services from me, my colleague will contact you in order to make an appropriate referral to another therapist.
Office Policies
• A standard session is 50 minutes, unless other arrangements are made.
• Twenty-four hours’ notice of cancellation is required to avoid full payment of fee.
• Fees are collected weekly or monthly according to your preference. Payment may be made in cash or by check made out to “Tessa Richardson.” I am on several insurance panels. Use of medical insurance requires a diagnosis that meets criteria for medical necessity. If your insurance does not cover your treatment, you will be responsible for payment. Delinquent accounts may be referred to a collections agency.
• Telephone calls for issues other than scheduling will be billed at the regular rate. Requests for reports, letters, or testing will be evaluated on a case-by-case basis and charged at the regular rate.
• I attempt to return calls promptly, but I am generally not available Saturdays and Sundays. If you are in crisis and unable to reach me, call 911 or the crisis hotline at 415-781-0500.
Please feel free to discuss any of the above with me.
Please indicate by your signature that you understand and accept all of the above.
Signature: _________________________________ Date: __________ Print name: __________________________
Signature: _________________________________ Date: __________ Print name: __________________________
