Disclosure Form

Welcome. This psychotherapy disclosure form will answer most of your questions about my telehealth services. Please feel free to ask for clarification or additional information at your initial visit.

What is therapy and how does it work?

Therapy is the process of solving emotional problems by talking with a person professionally trained to help people achieve a more fulfilling individual life, marital relationship, or family relationships. The process of change will, in many ways, be unique to your particular situation. Who you are as a person will help to determine the ways in which you go about changing your life. The process of change begins by first clearly defining the problem, and then discussing your thoughts and feelings, understanding the origin of the difficulty and developing news skills and healthy attitudes about yourself and others. As the patient, you have the right to ask your therapist questions about his/her qualifications, background and orientation. The most important factor in the success of therapy is good communication between therapist and patient. In some instances, talking about your difficulties may exacerbate your symptoms,however over time you should see an improvement. In addition, not all individuals benefit from therapy or working with a particular therapist. If at any time during the therapy you have questions about whether or not the treatment is effective, feelings about something I have said or suggested or need clarification of our goals, do not hesitate to bring this up in our session.

Confidentiality

By law and professional ethics, your sessions are strictly confidential. Generally, no information will be shared with anyone without your written permission. If you are seeing another therapist or health professional it may be necessary for me to contact that person so that we can coordinate our efforts. If this is necessary I will ask for your permission. In addition, some insurance companies require periodic updates. I will only provide this information with your permission. There are however, a number of exceptions to this confidentiality policy.

• If I am ordered by the court to testify or release records.
• If you are a victim or perpetrator of child abuse I am required by law to report this to the authorities responsible for investigating child abuse.
• If you are a victim or perpetrator of elder or dependent adult abuse I am required by law to report this to Adult Protective Services or other appropriate authorities.
• If you threaten harm to yourself, someone else or the property of others, I may be required to call the police and warn the potential victim, or take other reasonable steps to prevent the threaten harm.

Treatment of a minor without parental consent is allowed by law (Civil Code 25.9) if:

• The minor is 12 years of age or older, and the minor is mature enough to participate intelligently in outpatient mental heath treatment or counseling, and the minor has been the alleged victim of incest or child abuse, or without such mental health treatment or counseling the minor would present a danger of serious physical or mental harm to himself/herself or others.

Clinical Fees

My fee for psychotherapy is $225.00 for a fifty minute session. You are expected to pay for your session prior to the beginning of each session. I now accept credit and debit card payments through PayPal. To pay with a credit/debit card prior to your session, go to my payment page on my web site (http://www.danielsonkin.com/psychotherapy/payment.html) and click on the payment button. Most patients give me their credit card information to keep on file. I run the payment the morning of the appointment. Fees may be increased by no more than twenty dollars once a year with reasonable notice.

Forensic consultation

Should you require my testimony or report in a civil, criminal or any other legal matter, my fee shall be $350.00 per sixty-minute hour. This charge will be for all services including, but not limited to: attorney consultation, document review, court testimony, wait-time in court, case correspondence, travel time and all other services relating to forensic activities. Should my testimony or a report be required, payment of the equivalent of a one-day retainer ($2800.00) will be required. Should a scheduled trial appearance be cancelled with less than seventy-two hours notice, this retainer will be non-refundable. Meetings with attorneys or other professionals involved in the forensic matter will be similarly charged at the rate of $350.00 per sixty-minute hour including travel time and preparation (reviewing clinical records, court documents, etc.). These meeting will be scheduled at my convenience, however appointments cancelled with less than 24 hours notice will be charged at the forensic rate of $350.00/hr.

Unpaid balances

Payments received more than thirty days after the date due are subject to 19.8 annual percentage service charge calculated on a monthly rate of 1.65% of the remaining balance. Delinquent bills will be turned over to a collection agency. The patient is responsible for the original bill, service charges, collection fees as well as any legal costs that are incurred as a result of the collection process.

Insurance

I do not accept insurance for services rendered. If you would like to submit a bill to your insurance company to see if they will reimburse you, I will be happy to provide you with a bill at the end of each month.

Cancellations

You will be charged for all missed or cancelled appointments without at least 72 hours notice. If you are unable to attend an appointment we can try to reschedule the same week. You may call leave a message on my voicemail (415-332-6703) or text me at that number or send me an email as soon as you know you have to cancel your appointment.

Effective psychotherapy does take a commitment on both sides. I have found over the years that the more consistent and frequent the client is in attending their sessions, the greater and quicker the progress. Likewise, when I agree to work with a client, those times are reserved for that person and I don't give those hours to someone else. So even when you miss a session, you still know that you have that time with me the following week (unless you reschedule your time before then).

I take approximately 8 weeks off a year. I will tell you when that is, so if you would like to maximize your time in session, you can arrange your vacation schedule to overlap. However, I realize that is not always possible, and so as long as I am given at least a month's notice, you won't be charged for your vacation. Once again, too frequent cancelled appointments for any reason or too lengthy a leave of absence may not only diminish the impact of therapy, but may become a logistical issue in my keeping your appointment available.

After Hours Emergencies

I am not available after my usual business hours for emergencies I do check my messages during weekdays between 9:00 AM and 6:00 PM and I am usually available to speak with you on the telephone (or schedule a time we can talk). There will be a $4.50 per minute charge for all telephones calls other than brief calls concerning rescheduling appointments, confirming appointments, etc.. Leave a message on my voicemail or text me (415-332-6703), or email me (contact@danielsonkin.com) and I will respond as soon as I retrieve the message. For after-hours emergencies or if you need immediate assistance call 911, Marin County Crisis Unit at 499-6666, your medical group or your primary care physician.

Vacations

I will give you reasonable notice (usually several months) before I go on vacation. I usually take eight weeks of vacation a year. You will not be charged for sessions during this time. I will give you those dates with sufficient notice so that you can plan your time away in order to insure continuity of treatment. If I am going to be out of town or unavailable, a colleague will be on call to schedule appointments during regular business hours should you feel the need to see someone in my absence. The name and phone number of this individual will be on my voice mail. However, if you feel that you will need continuing treatment during this time, I will help you make arrangements ahead of time with another therapist.

Terminating Treatment

You have the right to terminate or take a break from your treatment at any time without my permission or agreement. However, if you do decide to exercise this option, I encourage you to talk with me about the reason for your decision in a counseling session so that we can bring sufficient closure to our work together. In our final session we can discuss your progress thus far and explore ways in which you can continue to utilize the skills and knowledge that you have gained through your therapy. We can also discuss any referrals that you may require at that time.

Marriage and Family Therapists are ethically required to continue therapeutic relationships only so long as it is reasonably clear that patients are benefiting from the relationship. Therefore, if I believe that you need additional treatment, or if I believe that I can no longer help you with your problems I will discuss this with you and make an appropriate referral.

Please electronically sign this form and keep a copy for yourself for future reference. Should you have any questions at any time, please ask.

I/we have read, understand and agree to the information and policies described in this patient information form.

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