This form provides you with patient information in addition to the notice of privacy and practices. Please initial each paragraph in the space provided indicating you have read and understood the context of that paragraph. If there are questions please ask before signing.

Confidentiality: All information disclosed within the sessions and the written records pertaining to the sessions are confidential and may not be revealed to anyone without the patient/parent written consent except where required by law. Some exemptions include subpoena or legal proceedings, threats of danger to self or others, and child/elderly abuse reporting.

Health Insurance and Confidentiality disclosure: Disclosure of confidential information may be required by your health insurance provider or another third party payer in order to process the claims. Only the minimum necessary information will be communicated to the carrier. Unless authorized specifically the therapy notes will not be disclosed. Your therapist has no control or knowledge over what insurance companies do with the information once submitted or who has access to it. Submitting mental health invoices for reimbursement carries a certain risk to confidentiality, privacy, and may affect obtaining future life or health insurance benefits. This risk stems from insurance reporting to the National Medical Data Bank database which is a computer system and holds certain risk factors.

Consultation: Your therapist may consult with other professionals regarding their patients, however the names and identifying information is never mentioned. The patients identity remains anonymous and confidentiality is fully maintained. This is done to provide the best possible care your you and/or your family member.

Process of Therapy: participation in therapy can result in a number of benefits including improved interpersonal relationships and resolution of specific concerns. Psychotherapy requires your active involvement, honesty and openness. Your therapist will expect your open responses and involvement in the session. During therapy, remembering and talking about painful memories or unpleasant events, feelings or thoughts can result in experiencing discomfort and strong emotions. The intent of therapy is to help your resolve these issues. Change can be swift and easy and at other times more slow and frustrating. Your therapist will utilize the modalities which seems to be the best fit for your needs. Approaches include but are not limited to EMDR (AIP), Cognitive-Behavioral, Play therapy, Talk therapy, Motivational Interviewing, and biblio-theapy.

Emergency Phone and Procedures: If you need to contact your therapist between sessions, please leave a message and your therapist will return your call. Billing for all phone sessions will be billed at the normal hourly rate for calls that are longer than 5 minutes. In the case of medical emergency, or when there is immediate danger or potential harm to yourself or others, call 911 or for emotional emergencies you can contact the Banner Help Line at 602-254-4357.
Cancelation Policy: Scheduling appointments involves the reservation of time specifically for you, therefore a minimum of 24hrs is required for all cancelations. No show & late cancelations will result in billing for the full hour and the normal billing rate $140/HR.