Office Policies

Agreement for Service / Informed Consent

Welcome to my practice. This document contains important information about my professional services and office policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

RISKS AND BENEFITS OF THERAPY

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and the patient, and the particular problems that you bring forward. There are many different methods that I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. There may be times in which I will challenge your perceptions and assumptions, and offer different perspectives. The issues that you present may result in unintended outcomes, including changes in personal relationships. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

During the therapeutic process, many patients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. You should address with me any concerns that you have regarding your progress in therapy.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be careful about the therapist that you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

MEETINGS

If psychotherapy is begun, I will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I will try to find another time to reschedule the appointment. Cancellation notice should be left on my voice mail at (650) 302-2843, not via email

PROFESSIONAL CONSULTATION

Professional consultation is an important component of a healthy psychotherapy practice. As such, I regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, I will not reveal any personally identifying information regarding my patients.

RECORDS AND RECORD KEEPING

I may take notes during session, and will also produce other notes and records regarding your treatment. These notes constitute my clinical and business records, which by law, I am required to maintain. Such records are my sole property. I will not alter my normal record keeping process at the request of any patient. Should you request a copy of my records, such a request must be made in writing. I reserve the right, under California law, to provide you with a treatment summary in lieu of actual records. I also reserve the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. I will maintain your records for ten years following termination of therapy. However, after ten years, your records will be destroyed in a manner that preserves your confidentiality.

MINORS

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.

PROFESSIONAL FEES

My hourly fee is $___. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. I reserve the right to periodically adjust this fee. You will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with me.

The agreed upon fee between myself and ________________________ is $__.This fee is for________________ (Group/ Individual) work.

PATIENT LITIGATION

I will not voluntarily participate in any litigation or custody dispute in which a patient or another individual, or entity, are parties. I have a policy of not communicating with a patient's attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in a patient's legal matter. I will not provide records or testimony unless compelled to do so. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving a patient, that patient agrees to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my usual and customary hourly rate. You should be aware that you might be waiving the psychotherapist-patient privilege if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the psychotherapist-patient privilege with your attorney.

BILLINGS AND PAYMENTS

You will be expected to pay for each session at the time it is held, in the beginning of each session. Payment schedules for other professional services will be agreed to when they are requested. n circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment.

INSURANCE

I am not a contracted provider with any insurance company or managed care organization. Should you choose to use your insurance, I will provide you with a statement which you can submit to the third-party of your choice to seek reimbursement of fees already paid. Be aware that most insurance companies will want me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer.Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. It is the patient's responsibility to determine the information-sharing policy of their insurance company.

TERMINATION OF THERAPY

I reserve the right to terminate therapy at my discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, patient's needs are outside my scope of competence or practice, or patient is not making adequate progress in therapy. The patient has the right to terminate therapy at his/her discretion. Upon either party's decision to terminate therapy, I will generally recommend that patient participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. I will also attempt to ensure a smooth transition to another therapist by offering referrals.

THERAPIST AVAILABILITY

My office phone is equipped with a voice mail system that allows you to leave a message at any time. I will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee that calls will be returned immediately. I am unable to provide 24-hour crisis service. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911, or go to the nearest emergency room.

ACKNOWLEDGEMENT

By signing below, you acknowledge that you have reviewed and fully understand the terms and conditions of this Agreement. You have discussed such terms and conditions with me, and have had any questions with regard to its terms and conditions answered to your satisfaction. You agree to abide by the terms and conditions of this Agreement and consent to participate in psychotherapy with Corinna Dranow, LMFT. Moreover, you agree to hold this therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

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I (the client), understand that all information disclosed within the sessions are kept confidential and are not revealed to anyone outside the office without my written permission. The only exception to this is where disclosure is required by law (e.g., where there is a reasonable suspicion of abuse of children or elderly persons, where the client presents a serious danger of violence to others, or where the client is likely to harm him/herself unless protective measures are taken).

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Patient Name (please print)

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Signature of Patient (or authorized representative, guardian) Date

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Additional Patient (please print)

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Signature of Additional Patient Date