Informed Consent to Engage In Marriage Counseling or Psychotherapy with James W. Walkup
I am happy that you have decided to begin your psychotherapy with me. I hope that our work together will give you new skills and tools and self-understanding to deal with your issues. I am a licensed Marriage and Family Therapist in the New York State. To learn more about my philosophy credentials and training go to my website at dr-jim.com. I am a Clinical Member of the American Association of Marriage and Family Therapists.
I believe, a clear understanding about the boundaries of our relationship can help you build trust in me and in the work we are doing. Your fee, unless otherwise indicated, will be $225 per 45 minutes and $75 for each additional 15 minutes. I like to be paid by check at the beginning of each session. I will usually see you for up to two sessions a week. On an annual basis, I may raise your fee. When necessary, I am willing to talk with you by phone. If these conversations last more than five minutes, I will charge at your usual rate in 15 minute increments.
Therapy works best when you have a regularly scheduled time that you expect and plan for. I will charge you for the session if I do not have a 24 hour cancellation. If you have to cancel, I encourage you to reschedule an additional session, to keep up the focus and intensity of your therapy.
Let me know if you anticipate not being able to pay the fee. This will allow us to make a plan for how to deal with this problem. If you have an outstanding balance of more than $600, I will need to discontinue the therapy until payment can be made. I will help you find a referral if therapy if necessary.
On the twentieth of the following month I will submit to you an invoice for the sessions and amounts you have paid. If you have insurance coverage, you can submit this invoice to your insurance company for reimbursement. By signing this document you are giving me permission to give to your insurance company the pertinent information that they request to validate your coverage. This usually includes a diagnosis and a treatment, a description of the problem and subsequent statements about the progress.
I want you to know that my work with you will be strictly confidential unless I am concerned about your harming yourself or someone else. If you tell me about the possibility of a child being abused, I am a mandated reporter and will need to report this to the child protective agency. I can be required by a judge to submit the clinical record to the court. This does not include the notes that I take in a session. This does not often happen and I will seek to protect your records unless you sign a release. If this is required I will write up a summary at the cost of a session.
I usually respond to phone calls within 24 hours but in an emergency call 911 or go to your nearest hospital.
I invite you to come in a spirit of trust and openness. My work with you will be restricted if either of you fears that your statements or my witness will be taken before a court. For this reason by signing this you agree you will not use these clinical records to resolve legal settlements. If you have any concerns about my work, please talk to me about this and if we cannot resolve them together you may file a report with AAMFT.
If you inform me of something that your partner does not know and you and your partner are in marriage counseling with me, I will help you make sense of what this means about the marriage counseling. I will not divulge this to your partner but there may come a time when it is clear that we need to move toward divorce counseling or stop the marriage counseling.
Our work together will be a collaborative process. I look for your input as we progress. Of course there is no guarantee that your work with me will achieve all of the results that you hope for. However, I do hope that you will talk with me about any concerns about the direction of your therapy. Please do this as soon as possible after you recognize those feelings. I ask you not to discontinue your therapy without talking about this for a few sessions since many times, something is about to break open in a new, but anxiety provoking way.
I hope our work together will be quite helpful to you.