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INFORMED CONSENT FORM

Hello and welcome to my therapy practice. Please read, sign and click submit at the bottom of the page.

BENEFITS AND RISKS OF PSYCHOTHERAPY

The process of psychotherapy can offer substantial and life changing benefits, including the reduction of negative symptoms—among them stress, anxiety or depression—as well as an increased capacity for intimacy and self acceptance, greater self awareness and sense of well-being, enhanced flexibility of response to life circumstances, and an enriched emotional and relational life.

Psychotherapy is unique among healing professions in that the therapeutic relationship which develops between the therapist and client often plays a contributing role in the treatment and outcome of the work, as does the motivation and engagement of the person seeking help. For these reasons and more, every course of therapy is different and the outcome is likewise variable, and may be helpful to greater or lesser degrees. 

Additionally, the process of healing and growth often involves confronting difficult or painful feelings, or even periods when it might seem that things are getting worse. I approach therapy as a collaborate process, and I welcome conversation about your concerns and the course of our work at any time.

APPOINTMENTS

Individual sessions are generally 50 minutes, on a weekly basis. I do work with individuals less frequently once we have worked together for a period of time. Therapy is most effective if we are able to meet consistently.

Most couples sessions are 75 minutes. I see couples weekly or every other week, depending on a variety of factors—what I think is clinically advised while taking into account the cost, scheduling, or other considerations.

CANCELLATION POLICY

Cancellations made with less than 24 hours prior to your appointment are charged at the full rate of the session.

I recognize this may feel unfair, especially if the reason for cancellation is unavoidable or beyond your control. Like anything else in our work together, I am open to discussing this policy at any time, and especially encourage you to let me know if you find it is impeding your participation in any way.

PAYMENT

I request payment at the time of our sessions, unless other arrangements are made. I prefer using Zelle for processing payments, though Venmo or a bank issued or personal check are also fine.

INSURANCE AND FSA/HSA

I am not on any insurance panels, though I can write a statement for you to submit to your insurance company for reimbursement. I would be considered an out-of-network provider. I can also write statements (which do not require a diagnosis) for Health Savings Accounts or Flexible Spending Accounts.

COUPLES THERAPY

When I work with couples, if either partner communicates with me privately I still hold the couple relationship as my primary focus, and cannot hold secrets in the relationship. If you disclose information privately which is uncomfortable for you to tell your partner, I will work to support you in sharing that information with them. If you are unwilling to do so, it may be necessary for me to terminate our working together.

PHONE AND EMAIL CONTACT

Cell phone: 510-206-1444
Voicemail only: 510-548-4950
Email: jeffcohenMFT@gmail.com

I try to return all calls within 24 hours. You are welcome to use my cell phone anytime. If there is something of a timely nature, please call or text rather than email. I will assume it is all right for me to leave confidential messages on your phone unless you tell me otherwise.

Please be aware that my email is not encrypted, and that confidentiality with email can be easily compromised. For this reason I suggest using email only for scheduling and logistics.

CONFIDENTIALITY

The information disclosed by you in sessions and the written records of those sessions are held in strict confidence, unless you provide written permission for me to release information about your treatment to specific people. If you participate in couples or family therapy, I will not disclose information unless all involved parties provide their written authorization to do so.

There are exceptions to confidentiality, however. Therapists are required by law to report instances of suspected child, dependent adult or elder abuse; this includes sex with a minor if you are over 18. Therapists may also be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or their property, or when a patient is dangerous to him or herself. Other exemptions occur if you make your own mental or emotional state an issue in a legal proceeding, or under clauses invoked in the HIPPA or the USA Patriot Act.

Further, I may occasionally consult with other mental health professionals about our work together, though your identity will remain anonymous and your confidentiality will be fully maintained.

TERMINATION OF THERAPY

You may initiate ending therapy at any time, without any obligations other than those you have already incurred. The termination process is an integral part of therapy and is often a rich part of the work, but how this happens—for instance, over one session or many—will be as individual as the course of your therapy. If needed, I will assist you in finding another clinician with whom to work.

LITIGATION LIMITATION

Because the therapeutic process involves self-disclosure regarding matters of a confidential nature, it is not my policy to testify in any legal proceedings involving you, as it would breach that confidentiality and possibly my neutrality in your treatment. I would discourage your from bringing your mental or emotional state into a legal proceeding. If I am required to participate in court matters on your behalf, I charge my full hourly rate for all time spent therein, including preparation and transportation time.

Please print a copy for your records. If there is anything you would like to discuss before signing please let me know.

 

 

 

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