New Client Intake Form

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Statement of Understanding and Consent to Treatment

Welcome. I want you to be fully informed about the legal and ethical boundaries of the therapeutic process. Please read this document thoroughly and discuss any questions with me.

Confidentiality
The information disclosed in therapy is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse and neglect, when a client makes a serious threat of violence towards a reasonably identifiable victim, or when a client is dangerous to him/herself or the person or property of another.

Psychotherapist-Client Privilege
The information disclosed by you, the client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between a therapist and a client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the client is the holder of the psychotherapist-client privilege. If a therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, a therapist will assert the psychotherapist-client privilege on a client’s behalf until instructed, in writing, to do otherwise by a client or client’s representative. You should be aware that you might be waiving the psychotherapist-client privilege if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the psychotherapist-client privilege with an attorney.

Risks and Benefits of Therapy
Psychotherapy is a process in which we may discuss a variety of issues, events, and experiences for the purpose of creating positive change. Psychotherapy is a collaborative effort between a client and a therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participating in therapy may result in a number of benefits to a client, including, but not limited to, reduced stress and anxiety, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. There is no guarantee that therapy will yield any or all of the benefits listed above. Participating in therapy may also involve some discomfort and risks, including remembering and discussing unpleasant events, feelings and experiences, and worsening of symptoms.

Confidentiality and Couples / Family Therapy

If you are participating in couples or family therapy, please be aware that, in most circumstances, the law prohibits me from disclosing confidential information and records regarding the unit of treatment’s services unless all identified patients provide written authorization to release the information.

No Secrets Policy

I utilize a “no-secrets” policy. This means, when I determine it is clinically appropriate or necessary to do so, I am able to disclose information I obtain from one member of the couple, or a participating member of the family therapy unit, (i.e. the “treatment unit”) with the other member(s) of the treatment unit. This policy also applies to information a member of the treatment unit shares with me outside of couples / family sessions (e.g., via email, text, etc.) and information I obtain during individual session(s) with a member of the treatment unit (should we agree to hold individual sessions in furtherance of your couples / treatment goals). I find that this policy facilitates effective communication with and between couples and family therapy patients. It also helps me to avoid potential problems which may arise when a therapist is perceived to be “keeping secrets” from other members of the treatment unit.

Private Payment
You agree that therapy services will be rendered for $150 per session and that each session is approximately 50 minutes in length. All fees for service are due at the end of each session unless otherwise negotiated. In the event of non-payment, you authorize release of outstanding account balance information for collection purposes.

You will be emailed an electronic invoice that can be paid using your credit card, Health Savings Account Card, Debit, PayPal or Venmo. Save your credit card information to file and your card will be charged automatically after each session.

Client Litigation
I will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, are parties. It is my policy to decline communication with your attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in a legal matter. I will generally not provide records or testimony unless compelled by a court order to do so. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, you agree to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my usual and customary hourly rate of $150.00.

Therapist Background and Qualifications
My theoretical orientation can be described as social constructionist including the use of Narrative Therapy, Solution Focused Therapy and Expressive Arts. I obtained a PhD in Psychology with a research focus on resilience after trauma and have been practicing since 2009 as a Marriage and Family Therapist – first as an Intern and then I was licensed in CA in 2015. My background includes: working with individuals, couples and families who have struggled with communication, conflict, violence, sexual assault, trauma, anxiety, depression, chronic health issues, work- related challenges, gender, racial/ethnic and cultural oppression, LGBTQI+ and immigration/refugee struggles. I am a certified domestic violence and sexual assault treatment provider and trainer.

Clinical Consultation
Clinical consultation is an important component of a collaborative and sustainable psychotherapy practice. As such, I regularly participate in clinical, ethical, and legal consultation with clinical professionals. During such consultations, I will not reveal any personally identifying information regarding you, the client.

Records and Record Keeping
I may take notes during session. These notes constitute the therapist’s clinical and business records, which by law, a therapist is required to maintain. You may ask for a copy of these notes at any time.

Cancellations
Any appointment scheduled is time set exclusively for you. Should you need to cancel any scheduled appointment, you must do so at least 24 hours in advance in order to avoid the cancellation
fee of: $150 (full cost of session). You may text, call or email: margaretslaska@gmail.com to cancel, however, you will be charged the full fee of $150 if you do not provide notification of cancellation within 24 hours.

Consent to Treatment
I am requesting services from Margaret Slaska, PhD, LMFT and I understand that this is a business of psychological and relational treatment. If for any reason you do not believe I can meet your needs, I will offer referral resources.

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the new law which took effect Jan 1, 2022, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Telehealth Consent

I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the [Informed Consent Form or Statement of Disclosures] I received from my therapist also apply to my Telehealth services.

2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.

3. I understand that miscommunication between myself and my therapist may occur via Telehealth.

4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.

5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.

6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and refer me to in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who can provide such services.

7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.

9. I have discussed the fees charged for Telehealth with my therapist and agree to them [or for insurance patients: I have discussed with my therapist and agree that my therapist will bill my insurance plan for Telehealth and that I will be billed for any portion that is the patient’s responsibility (e.g. co-payments)], and I have been provided with this information in the [Informed Consent Form or Name of Payment Agreement Form].

10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance.

I have read and understand the information provided above, have discussed it with my therapist, and understand that I have the right to have all my questions regarding this information answered to my satisfaction.

Email *

Your Name *

Date of Birth *

YYYY

Address *

Zip code *

Phone number *

May I leave a message on your home or cell regarding appointments? *

Yes

Other:

Place of Employment

Do you have any children? If yes, please include their names and ages.

Emergency Contact Person (Name, Address and Phone number) *

Reason(s) for coming to therapy:

Have you been to therapy in the past? If so, what it a helpful experience?

Do you have any form of disability, chronic pain or medical conditions? *

Have you experienced any recent changes in eating, sleeping, mood, concentration, weight gain/loss? *

What is your level of alcohol or drug use? *

Have you had any thoughts currently, or in the past, of wanting to do anything to hurt yourself or someone else? *

Have you had any recent problems with the police? *

When was your last physical exam? Any concerns? *

What medications are you currently taking? *

Have you had any recent hospitalizations? *

Do you see or hear things others might not? *

Is there anything else you would like me to know before your first appointment?

I confirm that I have read this document and agree. *

YYYY

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