Therapy Information Sheet
1. Legal / Ethical (Refer to Intake Paperwork or your therapist for any outstanding questions)
a. Confidentiality. As a client, your confidentiality is extremely important to me. The identifying aspects of our time in therapy is kept private from the outside world.
i. Below are the primary occurrences that requires a break in confidentiality:
1. Child or Elder Abuse – If there is reason for your therapist to believe that you are delivering abuse towards, or receiving abuse as, a minor or elderly individual, specifically an elderly individual who is under your care, the therapist is required to break confidentiality. Your therapist values honesty and will take every measure to include you on the reporting process, up until safety cannot be comfortably guaranteed.
2. Harm to Self or Others – If the therapist believes you are fatal threat to yourself or others, as determined by all of the following criteria being met: 1) Client has identified individual(s) (self or other(s)), 2) has means available to harm said individual(s), and 3) has the plan in which harm would be carried out. Your therapist values honesty and will take every measure to include you on the reporting process, up until safety cannot be comfortably guaranteed.
3. Court Order – Your therapist takes every step to stay out of the legal system, however, it is still possible that a court order would require a release of confidential information. While this is unlikely in most instances, it still remains a possibility. Your therapist will endeavor to keep you informed of any legal involvements surrounding your therapy experience.
4. Release of Information – You are free to access your personal documents and files (your therapist may take up to a week to fulfill this request) and you are free to give your therapist permission to discuss your case with any individual (professional or otherwise) you so choose.
b. Mandated Reporting
i. As stated previously, both Child and Elder Abuse are reportable and merit a break in confidentiality. Areas of abuse include: Physical Abuse, Sexual Abuse, Emotional Abuse, and Neglect. Your therapist values honesty and will take every measure to include you on the reporting process, up until safety cannot be comfortably guaranteed.
c. State and Federal Law obligations
i. As the client, your care, confidentiality, safety, and health are of extreme importance. As with topics of reporting stated previously, your therapist appeals to all State and Federal laws.
d. Therapist Licensure and Supervision
i. Your Therapist is licensed as an LMFT in both Missouri and Kansas. The MFT refers to ‘Marriage and Family Therapist’ and is a subfield of the Mental Health field.
2. Professional
a. Pricing
i. By coming to therapy, you are agreeing to pay for the services provided. Therapy is paid for session by session, with one session only beginning after the previous session has been paid for.
ii. Your Therapist does not accept insurance but will happily send you an invoice or Superbill after any and all sessions (as requested), the latter of which can be submitted to insurance companies with the potential for, but not guaranteed by your Therapist, reimbursement (please contact your insurance company if you wish to utilize a Superbill).
iii. Your Therapist utilizes a 72-hour cancellation policy. Any sessions needing to be cancelled must be done so no later than 72-hours prior to your next appointment. Late cancellation fees are set at the price of the agreed upon session fee.
iv. No-Show. Missing an appointment without contacting your Therapist will result in a late cancellation fee set at the price of the agreed upon session fee.
b. Email and Phone
i. The best way to contact your Therapist is through email. Emailing is to be utilized primarily to address scheduling, rescheduling, and cancellations. However, your Therapist values clear communication and will work to attend to any questions or concerns you have through emails. (contact info provided below)
ii. Your Therapist does not utilize texting but does utilize phone calls as needed. Please communicate through email to schedule any phone calls in advance. (contact info provided below)
c. Public Interaction
i. Your privacy and confidentiality are important, due to this fact, your Therapist endeavors to continuously respect this privacy. If you see your Therapist in public, he will intentionally treat you like a stranger, potentially being more distant than the average stranger. This is to protect your confidentiality in the event of a random encounter. That said, you have every right and full permission to come up to your Therapist and say hello if you would like. Your confidentiality is in your control while in a public setting.
d. Hours
i. Your Therapist endeavors to respond to all emails and voicemails within a 24 hour or sooner timeframe. Your Therapist checks his messages Monday through Friday and is away from Therapy related contact on Saturdays (any time your Therapist takes time off and will be away from his messages for a longer period of time, you will be informed, and options will be discussed at that time). You may at times receive responses from your therapist on Sundays.
e. Legal System
i. If you believe that your current life situation could include involving your Therapist in legal proceedings (court dates, requesting documentation, letter writing, speaking or messaging with non-client individuals involved in cases, custody cases, divorce cases, etc.) please disclose this information as this is often an area that is equal parts important and challenging, and therefore it is important to address early on so that you and your Therapist can best be prepared going forward. If desiring your Therapist’s involvement in legal proceedings, please see excerpt from your Informed Consent below:
1. “For cases with any court/attorney involvement your supervised therapist will bill at an hourly rate of $350/hour plus mileage based on current IRS Standard Mileage rates at the time. This includes court appearances, drive time to and from the requested court appearances, completion of court-requested paperwork, and phone/in-person collaboration with other professionals involved in the case. This will be billed at quarter hour increments (15 minutes) with a minimum time of one hour. Payment must be received prior to the release of the requested records.”
f. Secrets
i. When the therapy process involves multiple individuals (couples, families, multiple households, etc.) it is important to discuss what can and cannot be discussed between individuals. As a guideline, I attempt to not hold secrets between individuals involved in therapy. This is for two reasons: 1) It can easily begin to make therapy a non-transparent interaction if your Therapist is holding secret information, and 2) The more secrets that are present, the more difficult it is to remember who knows what at any given time.
3. Personal Therapy Experience
a. Rights and Responsibilities
i. Responsibilities as Client
1. Scheduling
a. We will endeavor to find a comfortable time to conduct therapy. It is important to inform your Therapist in advance if you will ever need to adjust our scheduled time. This includes adjusting to and from virtual therapy when applicable. Scheduling is on a first come first serve basis.
2. Trying
a. Your Therapist can only offer his best in the therapy room. You get to choose how engaged you are in the process. Your engagement in the room makes a difference, and the level of self-work you apply outside of sessions can have a positive impact the pace of therapy.
3. Benefits and Difficulties
a. You have a right to your needs in therapy. It is not unlikely that we will address difficult or sensitive topics which may at times be challenging. You have the freedom to end sessions early, take breaks, step outside, and otherwise care for yourself during the process. This can include entire sessions being focused on less intense or more intense subjects as needed. The goal is towards your own positive growth.
Below is the contact information for your Therapist. Email is preferred.
Contact Info
913-653-3638
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