Welcome To My Practice.

Below are some forms that need to be filled out. This will give us basic information to begin your counseling.

You will also find an article explaining what to expect in couples therapy which you may find helpful.

Feel free to ask any questions regarding your treatment or progress, and to give us feedback if there is a better way to assist you.

Sincerely,

Eugene Kayser LMFT

Licensed Marriage & Family Therapist

Clincal Member of the

American Assoc. of Marriage & Family Therapists

Kayser Intake Form
Please note that all fields followed by an asterisk must be filled in.
 

By submitting, I acknowledge I have read and understood the Consent Form below. Please enter the word that you see below, and submit.

  

NO-SHOW AND CANCELLATION POLICY -  Your visit has been reserved for you. 24 hours notice is required for cancellation or you will be charged a late cancellation fee of $80.00.

INFORMED CONSENT AND CONFIDENTIALITY STATEMENT

I understand and agree to the following:

  • that treatment offered is voluntary in nature, unless I am under the age of 18.
  • that, within certain limits, information that may be revealed during therapy will be kept strictly confidential, requiring a written authorization from all parties in treatment if any information is to be released to any outside parties, with the exception of my insurance company.
  • that if I reveal information indicating that I may be a threat either to myself or others, my therapist may be permitted and/or mandated by law to reveal this information to other persons or agencies for the safety of yourself or others. This would include instances of suspected child abuse when treating a child under 18 years of age.

  Telemental Health Information -  

  • We may be using certain technological services and tools, such as Facetime and Zoom.
  • Telemental health has both benefits and risks, which you and your provider will be monitoring as you proceed with your work.
  • You can stop work by telemental health at any time without prejudice.
  • You will need to create a private and appropriate space for your sessions.
  • You will need to make a plan for managing technology failures, mental health and medical emergencies.

  • Your provider follows security best practices and legal standards to protect your health care information, but you will also need to maintain your own security and privacy.

PAYMENT IS DUE IN FULL AT THE TIME OF EACH SESSION.  We accept all credit cards and Venmo. Fees are subject to change every six months.

By clicking the Submit button, I acknowledge that I have read and understand this information sheet and informed consent.

 

For an interesting article on how to benefit from Marriage Counseling, click on the link below.

How To Get The Most From Couples Therapy
(Click to download this PDF file)

Eugene Kayser Marriage Therapist

Gene Kayser uses the Gottman Method Couples Therapy system with it's proven techniques & strategies for couples who want to save their relationship. This is a "nuts and bolts" approach based on 40 years of research & treatment.

For a free 20 minute consultation, Call or Text:

(215) 813-8633

If you would like to receive the Couples Guide Newsletter containing articles on relationships, please sign up below.


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