Download consent for psychotherapy

JOANNA INTARA ZIM, M.A., M.F.T., R.Y.T.
PSYCHOTHERAPY FOR TEENS, INDIVIDUALS, COUPLES, & GROUPS
2282 UNION STREET, SAN FRANCISCO, CA 94123
155A KENTUCKY STREET, SUITE NO. 4, PETALUMA, CA 94952
Tel. (415) 923-0481 ~ (707) 781-9231
CONSENT FOR PSYCHOTHERAPY
Name ______________________________
Birth Date ______________________________
Address _____________________________________________________________________________
City ______________________ State ____________________
Home Phone ______________________________
Email Address ______________________________
Zip ____________________________
Work Phone ____________________________
Okay to notify of workshops?_____________
Emergency Contact ________________________ Phone _________________________________
Social Security No. __________________________ (for insurance forms)
PERSON RESPONSIBLE FOR PAYMENT (If different from patient)
Name _____________________________________________________ Age __________ Sex _______
Address ______________________________________________________________________________
City __________________________________ State _____ Zip _______________ DOB _____________
Home Phone ( ) ________________________________ SSN ______________________________
Employer Work Phone ( ) ____________________________________________________________
Relationship to Patient ________________________________________________________________
Please read the following office policies and agreements that are offered to support our work together. The
goal is to have minimal interruptions in your therapy as well as respecting the commitment we both make
to your process. Should you have any questions about any policy, please feel free to discuss them with me.
By working together, we can establish a rewarding therapeutic relationship.
BENEFITS, RISKS AND ALTERNATIVES TO TREATMENT
Most people benefit from psychotherapy. Success can vary depending on particular problems and the
uniqueness of each person. Self-exploration, gaining understanding, finding ways of working with your
inner life, understanding your dreams, dealing with challenges and complexes, as well as learning new
skills, are helpful and contribute to change.
CONFIDENTIALITY
I understand that all information disclosed in therapy is confidential and will not be released to a third party
without my written consent, except when disclosure is required by law. Disclosure is required in the
following circumstances.
When there is reasonable suspicion of child, dependent adult, or elder abuse or neglect.
When a client presents a danger of violence to others.
When a client is likely to harm him or herself unless protective measures are taken.
Disclosure may also be required pursuant to a legal proceeding.
Please initial acknowledgement and acceptance here __________________
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 such information. However, it is important that you know that I utilize a “no-secrets” policy
when conducting family or marital/couples therapy. This means that if you participate in family, and/or
marital/couples therapy, I am permitted to use information obtained in an individual session that you may
have had with me, when working with other members of your family. Please feel free to ask me about my
“no secrets” policy and how it may apply to you. Please initial acknowledgement and acceptance here
______________________
PHONE TIME
Sessions are 50 minutes in length. If you would like additional phone time with me beyond in-session
visits you understand you will be charged for phone time at the rate per hour in accordance with my fee.
You understand that if you would like to speak with me on the telephone, I am available to speak with you
in 15 minute increments charged according to my full fee. Telephone consultations between office visits
are welcome. You may leave a message for me at any time on my confidential voicemail. Please know
that I cannot guarantee or be responsible for confidentiality of information passed electronically. If you
wish 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 an urgent need to speak with me, please indicate that
fact in your message. In the event of a medical emergency or an emergency involving a threat to your
safety or the safety of others, please call 911 to request emergency assistance. Please initial
acknowledgement and acceptance of these policies here_____________________
FEES & CANCELLATION POLICY
Your fee is based upon a 50 (individual) to 60 (couple) minute therapy session, or enrollment in a therapy
group. Payment is due at the beginning of each session to avoid distraction before you leave. My current
individual hourly fee is $155-$175 (sliding scale) per individual session and $175-$195 (sliding scale) per
session for couples. Group fees vary. Payment is due each session and it’s your responsibility to keep your
appointments or to cancel with at least 48 BUSINESS hours in advance, or you will be charged your full
regular fee 48 BUSINESS hours does not include Saturday or Sunday times. I will provide you a
confirmation of your cancellation, so if you do not receive a confirmation from me, it means I did not
receive your message, and you are still responsible for your apt. time.
Please understand your regularly scheduled appointment is reserved exclusively for you, and no one else is
given that time. If you think you are going to be ill, or miss your appointment for any other reason, please
let me know in advance of the notice required, in order to avoid the fee that will be charged. The only
exception to this policy is death of an immediate family member or serious life threatening emergency.
If you do not provide me with at least 48 BUSINESS hours notice in advance for regularly scheduled
sessions, or 72 BUSINESS hours for extended sessions (2 or more clinical hours) you are responsible for
payment in full for the missed session. If you have scheduled an extended session and cancel with less than
SEVEN DAYS in advance you understand you will be charged the full amount of the session.
Please indicate here if you would like a billing statement for your services _________________________
If you have a balance and default on payment to me, you will be responsible for all collection and legal
fees, including interest. Please initial acknowledgement of all these policies here ____________________
Women’s Group enrollments require a 6 month commitment with payment due up front unless other plans
are made. If you have to miss (due to vacation, illness, or overbooking), payments are still due and/or non
refundable if already paid. Please initial acknowledgement of these policies here ____________________
Other group enrollments require an eight (8) week commitment with payment due up front unless other
plans are made. If you have to miss (due to vacation, illness, or overbooking), payments are still due and/or
non refundable if already paid. Please initial acknowledgement of these policies here
____________________
Fees will be reviewed annually and may be raised. When you go out on vacation please give me at least
two weeks notice. I will inform you well in advance of my vacation schedule.
Please initial acknowledgement of these policies here ____________________
RETURNED CHECKS
There will be a $20 fee for any returned check.
CREDIT CARD AUTHORIZATION FORM + BILLING POLICY
Name:
__________________________________________________________________________________
(as it appears on card)
Billing Address for this card:
_______________________________________________________________ Zip Code: ___________
Card Type: (Please Circle One) Visa / MasterCard / American Express / Discover
Credit Card Number: ____________________________________________________________________
Expiration Date: ______________________________________________ CCV Code: ______________
(3 digits on back of card)
• Your credit or debit card will be charged in the case of a delinquent balance (15 days after an account
statement requesting amount due has been sent).
 There will be a 4% convenience fee.
• I understand and accept all of the terms regarding this billing policy.
• I give my permission for Joanna Intara Zim, LMFT to bill my credit card for services rendered, and for
appointments missed or group sessions missed where payment is due.
Signature: ___________________________________ Date:_______________________
INSURANCE
If you have insurance you will be reimbursed by the insurance company for any services paid to me. You
understand that I will not bill insurance for you and that I can submit upon your request an invoice to me,
for all services rendered so that you may submit to your insurance company for reimbursement. You
understand that you are responsible to ensure that I am paid in full for any and all services provided. You
understand that insurance companies will not reimburse for missed sessions or sessions cancelled outside
the 48 or 72 hour cancellation policy. Please initial acknowledgement here _____________
COACHING V. PSYCHOTHERAPY
Joanna Intara Zim, M.A., L.M.F.T. (38453), is trained as a Psychotherapist and a Coach. If your work with
her as a psychotherapist requires coaching work, she and you will discuss to make an appropriate referral
for your situation. Coaching and Psychotherapy work are different work.
DISCONTINUING SESSIONS
Leaving therapy is an important decision, and effectively ending the therapeutic relationship is an important
part of the therapeutic process. Please discuss any plan or desire to discontinue therapy to allow enough
time for effective termination.
TELEMEDICINE CONSENT FORM
I ________________________________hereby consent to engaging in telemedicine with Joanna Intara
Zim, LMFT as part of my psychotherapy. I understand that “telemedicine” includes the practice of health
care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive
audio, video, or data communications, including email. I understand that telemedicine also involves the
communication of my medical/mental information, both orally and visually, to health care practitioners
located in California or outside of California. I understand that I have the following rights with respect to
telemedicine:
I have the right to withhold or withdraw consent at any time without affecting my right to future care or
treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be
entitled.
The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I
understand that the information disclosed by me during the course of my therapy is generally confidential.
However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited
to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable
victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand
that the dissemination of any personally identifiable images or information from the telemedicine
interaction to researchers or other entities shall not occur without my written consent.
I understand that there are risks and consequences from telemedicine, including, but not limited to, the
possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my
medical information could be disrupted or distorted by technical failures; the transmission of my medical
information could be interrupted by unauthorized persons; and/or the electronic storage of my medical
information could be accessed by unauthorized persons.
In addition, I understand that telemedicine based services and care may not be as complete as face-to-face
services. I also understand that if my psychotherapist believes I would be better served by another form of
psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can
provide such services in my area. Finally, I understand that there are potential risks and benefits associated
with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my
condition may not be improve, and in some cases may even get worse.
I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
I understand that I have a right to access my medical information and copies of medical records in
accordance with California law.
I have read and understand all the information provided above. I have discussed it with my psychotherapist,
and all of my questions have been answered to my satisfaction
Client Signature __________________________________ Date _______________________
Therapist Signature _______________________________ Date ______________________
BACKGROUND INFORMATION
1. What are your major areas of concern?
________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2. Have you received any counseling/therapy in the past?
Yes
No
Where? ____________________________________________________________________________
What did you seek treatment for? ___________________________________________________
____________________________________________________________________________________
What has your experience been like in groups? ______________________________________
____________________________________________________________________________________
3. Do you have any medical problems?
Yes
No
If you answered yes, what are they? _________________________________________________
_____________________________________________________________________________________
4. List any medications you are currently taking: _____________________________________
Do you feel the need for medication? ________________________________________________
Prescribing Physician: _______________________________________________________________
Would you like me to contact your psychiatrist to coordinate your treatment? __________
5. List the names and ages of the members of your immediate family:
Name
Age
Name
Parent
Child
Parent
Child
Spouse
Child
Other
Child
Brother
Sister
Brother
Sister
Age
6. I was referred by: __________________________________________________________________