Agreement for Services/ Informed Consent
Kathy Gelein LMFT
This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask any questions that you may have regarding its contents.
Appointment Scheduling and Cancellation Policies:
Sessions are typically scheduled weekly or bi-weekly (depending on need) at the same time and day if possible. Your consistent attendance greatly contributes to a successful outcome. Client is responsible for payment of agreed upon fees for any missed appointments unless client calls to cancel the session 24 hours in advance. If you do not provide 24 hours notice of cancellation, your credit card will be charged in full for the time reserved for you.
The fee for service is: $120.00 per session for individual therapy and $130.00 per session for couple’s or family therapy session and $65.00 per group therapy session. Kathy Gelein offers a discount of $5.00 for cash or check payments. The fee for service is $275.00 per hour for any time involved with court/ testimony. Kathy Gelein will not voluntarily participate in any litigation, or custody dispute in which the client and another individual are parties. Any letter writing, reports or documentation requests will be billed at the appropriate session rate. (I.e. an individual requesting a ½ hour letter will be billed $60.00) A session is 50 minutes. If we go overtime, that is my responsibility and you will not be charged extra. Fees are payable at the time that services are rendered. Please have your check written and made payable to Kathy Gelein in advance of your session. Please note there is a $30.00 charge for returned checks.
All communications made in session will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release.
There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder abuse. Therapists may be required or permitted to break confidentiality when they have determined that a client presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with requested items and prohibits the therapist from disclosing to the client that the FBI sought or obtained the items.
Minors and Confidentiality:
Communications between therapists and clients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are encouraged to be involved in their treatment. Consequently, I may discuss the treatment progress of a minor client with the parent or caretaker, but not details that would decrease trust between the minor and me. Clients, who are minors, and their parents, are urged to discuss any questions or concerns that they have on this topic with me.
Therapist Availability/ Emergencies:
Telephone consultations between office visits are welcome. However, I will attempt to keep those contacts brief (no more than 5 minutes) due to my belief that important issues are better addressed within regularly scheduled sessions. If the phone call moves into a therapeutic nature you may be billed for the phone call at $2.00 per minute.
You may leave a message for me at any time in my confidential voicemail. If you would like for me to return your call, please be sure to leave your name and phone number (s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal workdays (Monday through Friday) within 24 hours. If you have a medical or psychiatric emergency, please call 911 or A.C.C.E.S.S. at 916-787-8860.
About the Therapy Process:
It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to me and the specifics of your situation, I will provide recommendations to you regarding your treatment. I believe that therapists and clients are partners in the therapeutic process. You have the right to agree or disagree with my recommendations. I will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion. Participation in therapy may involve some discomfort and may evoke strong feelings. There are times when I may challenge the client perception and assumptions and offer differing perspectives. Issues presented by the client in therapy may unintended outcomes, including changes in personal relationships. At times clients may feel worse before they feel better.
Due to the varying nature and severity of problems and the individuality of each client, I am unable to predict the length of your therapy or guarantee a specific outcome or result.
Termination of Therapy:
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination in collaboration with myself. I will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you cease participation in therapy by canceling a session and not making another appointment or returning to therapy the following week, I will generally call or email you. If there is no response I will consider that you are no longer my client and you have ceased treatment. If you or I determine that you are not benefiting from treatment, either you or I may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.
The records are the sole property of the therapist. The notes that are kept cover the here and now process of the client during the session. Therapist reserves the right, under California law, to provide a treatment summary if requested in lieu of actual records.
I will not be your friend on Facebook, Twitter, My Space etc so please do not ask. You may however “like” my Kathy Gelein, LMFT The Marriage Mender Professional Facebook page.
How were you referred to Kathy (friend, therapist etc.)? If you found Kathy through a web site or search engine, which one was it? _____________________________________
I have read and agree to the above policies. I give my permission to use the following credit card in the event of a late cancellation as defined above.
Credit Card #____________________________________ Exp:_________Security code_________(3 digit)
Kathy Gelein, LMFT, 901 Sunrise Ave. Ste. A3, Roseville, CA 95661 916-804-6471