Your Therapist. At an appropriate time, your therapist will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your therapist’s background, experience and professional orientation. Your therapist is a Licensed Marriage and Family Therapist, MFC #45067. Fees and Insurance The fee for service is $100 per individual therapy session for individuals, couples and families. A sliding scale is available upon request and at the discretion of your therapist. Individual Sessions and conjoint (marital /family) sessions are approximately 50 minutes in length unless arranged otherwise in advance. Fees are payable at the time that services are rendered. Please inform your therapist if you wish to utilize health insurance to pay for services. If your therapist/provider is a contracted provider for your insurance company, your therapist/provider will discuss the procedures for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of your specific insurance plan. You should be aware that insurance plans generally limit coverage to certain diagnosable mental conditions. You should also be aware that you are responsible for verifying and understanding the limits of your insurance coverage. Although your therapist/provider is happy to assist your efforts to seek insurance reimbursement, I am unable to guarantee whether your insurance will provide payment for the services provided to you. Please discuss any questions or concerns that you may have about this with your therapist. If for some reason you find that you are unable to continue paying for your therapy, you should inform your therapist. Your therapist will help you to consider any options that may be available to you at that time.
Your Therapist. At an appropriate time, I will discuss my professional background with you and provide you with information regarding my experience, education, special interests, and professional orientation. You are free to ask questions at any time about my background, experience and professional orientation. Xxxx Xxxxxx-Xxxxxxxx, MDiV, MA MFT MFC 45828 Name of Therapist License Type License Number
Your Therapist. Your therapist Xxxxxxxx Xxxx is a fully-qualified Counselling Psychotherapist (PG Cert) with a Master’s Degree (pending April 2021) in Psychotherapeutic Practice. Xxxxxxxx has completed his MA thesis into the issue of vulnerability in professional rugby league. He specialises in integrated practice, meaning that he works across a number of modalities (methods) depending on what works for the client. Xxxxxxxx’s primary modalities are humanistic approaches – Gestalt, Person- Centred and Emotion-Focussed – but from time to time, aspects from other ways of working (such as Neuroscientific, CBT and Existential methods) may be brought in. Remember, although this may sound wordy, complex and perhaps daunting, Xxxxxxxx will explain what these things mean during your initial conversation. Essentially, they’re just ways in which they help you to explain and discover what you are feeling and grow your understanding and acceptance of your experiences. In its simplest form, therapy, or counselling if you prefer that word, are structured conversations – the modalities help to ensure you get something from these encounters. Xxx is an Accredited Registrant of the National Counselling Society. 01
Your Therapist. Whenever you wish, I will discuss my professional background with you and provide you with information regarding my experience, education, special interests, and professional orientation. You are free to ask questions at any time about anything related to your therapy.
Your Therapist. At an appropriate time, your therapist will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your therapist’s background, experience and professional orientation. Note: The therapist should indicate his/her licensure status before the patient completes this form.
Your Therapist. Rose City therapists are Registered Psychological Assistants to the California Board of Psychology operating under the license and insurance of Rose City Center. Each Clinician is under the Primary Supervision of a licensed Clinical Psychologist who is contracted with Rose City to offer weekly supervision, meeting the requirements set forth for Primary Supervisors by the Board of Psychology. Your therapist’s Primary Supervisor is . His/Her phone number is: ACKNOWLEDGING SIGNATURES I have read and understand this Agreement, Informed Consent for Psychological Treatment and for Uses and Disclosures to Carry out Treatment, Payment, and Health Care Operations carefully. I understand and agree to comply with them. I understand that Federal regulations (HIPAA) allow health service providers to disclose Protected Health Information (PHI) from your records in order to provide you treatment services, obtain payment for the services provided, or for other professional activities known as “health care operations”. How, why, and where Rose City might release your PHI is described in the Notice of Privacy Practices. This consent is voluntary and you may refuse to sign it now or revoke your consent later. I consent to the use or disclosure of my Protected Health Information as specified. I understand that I will be receiving the following psychotherapy: □ Individual □ Couples □ Family/Group Patient(s) Name (print) Signature Date Patient(s) Name (print) Signature Date Patient(s) Name (print) Signature Date Parent or Guardian Name Signature Date Clinician Name Signature Date
Your Therapist. I am a licensed Marriage, Family Therapist with certification in EMDR I & II, Somatic Experiencing and am a Certified Bioenergetic Therapist (CBT). Professional organizations of which I am a member are California Association of Marriage, Family Therapists (CAMFT), American Association of Marriage, Family Therapists (AAMFT); San Diego North County CAMFT (SDNC-CAMFT); International Institute of Bioenergetic Analysis (IIBA); Southern California Institute for Bioenergetic Analysis (XXXXX). Please feel free to ask me questions regarding my education, specializations, experience and professional orientation. Fees and Insurance My professional fee has already been discussed with you, as well as how arrangements may be made for payment. A therapeutic hour is 50 minutes in length and fees are payable at the time services are rendered. If insurance will be involved in your payment, then I require your insurance information, and your signature to correspond with your insurance carrier. Insurance plans determine the co-payment and you have confirmed that with me. Please be aware that insurance plans generally limit coverage to certain diagnosable mental conditions and you are responsible for verifying and understanding the limits of your insurance coverage. Although I am happy to bill for reimbursement, I cannot guarantee whether your insurance will provide payment for the services provided to you. You are responsible for your fee and shall be held liable for any unpaid for billed services should your insurance company fail to cover the professional services provided.
Your Therapist. At an appropriate time, your therapist will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your therapist’s background, experience and professional orientation. Note: The therapist should indicate his/her licensure status before the patient completes this form. Your therapist is a: X Licensed Marriage and Family Therapist Licensed Clinical Social Worker Licensed Psychologist Marriage and Family Therapist Registered Intern* Marriage and Family Therapist Trainee* Associate Clinical Social Worker* Psychological Assistant* Registered Psychologist* * If your therapist is a Marriage and Family Therapist Registered Intern, Marriage and Family Therapist Trainee, Associate Clinical Social Worker, Psychological Assistant or Registered Psychologist, his/her practice is conducted under the supervision of a licensed mental health professional. The clinical supervisor’s name, license type and licensure are listed below: Name of Clinical Supervisor (if applicable) License Type License Number Information About This Practice (as applicable) The name of this practice is: Xxxxxx X. Xxxxxxxx, MS, LMFT The individual therapist(s) who operate this practice is: Xxxxxx X. Xxxxxxxx, MS, LMFT Name of Therapist License Type and License Number Marriage Family Therapist, License number 51900 (Note: All therapists are required to disclose information about their fees in advance.)
Your Therapist. At an appropriate time, your therapist will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your therapist’s background, experience and professional orientation. Your therapist, Xxxxxxx Xxxx, is a Licensed Marriage and Family Therapist (LMFT). License number: MFC 45874.
Your Therapist. Your therapist, Xxxxx Xxxxxx, holds a Master’s Degree in Family Therapy and is clinically licensed in the state of Kansas. She is committed to uphold the ethics of the counseling profession, which demand strict confidentiality and the highest regard for the value of your time, finances and person. CONTACT YOUR THERAPIST Your therapist’s telephone number is 000-000-0000. If your therapist is not immediately available, you may leave a message on your therapist’s confidential voicemail.
