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
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.
(Click to download this PDF file)
If you would like to receive the Couples Guide Newsletter containing articles on relationships, please sign up below.
Visit The Relationship Forum to get and give advice on your relationship issues.
If you're struggling with your relationship, this is the place to talk about it!
Our counselors will answer your questions.
And you, our readers, can offer advice from your experience.
