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Policies and Consent for Treatment

Rachel Nilsen, Ph.D., Licensed Psychologist


19 West 34th Street, Penthouse Floor NY, NY 10001
26 Court St., Suite 600, Office 1, Brooklyn, NY 11201
703-622-9725



Welcome. I am a psychologist licensed in New York State. My practice is independent, meaning that I am not
associated with any other provider of psychological or counseling services in this suite. I have prepared this
contract to provide you with information about your rights and responsibilities as a client, fees, scheduling and
other details related to my practice. Please read this information carefully before our initial session. We can
discuss any questions you have about the procedures at that time. When you sign this sheet, it will represent an
agreement between us.

Informed Consent and Psychological Services. Psychotherapy varies depending on the problems with which
you are struggling as well as the personalities of the psychologist and patient. By the end of our first few ses-
sions, I can offer some impressions about what treatment approach might be most helpful in meeting your treat-
ment goals. It is important that patients feel that there is a good match between them and the psychologist with
which they are working, and I encourage you to think about and discuss with me this match as we begin treat-
ment. If you feel that you would prefer to see someone else or receive some other form of therapy, I will be
happy to help you set up a meeting with another mental health provider.

Your participation in therapy is voluntary, and you have the right to discontinue and/or request a referral to an-
other therapist at any time. Therapy has been a positive experience for many people who want to address prob-
lems and create changes in their lives. Psychotherapy has been shown to have many benefits, leading to better
relationships, reduction in feelings of distress, and solutions to specific problems. However, therapy often in-
volves discussing unpleasant aspects of your life and thus you may experience uncomfortable feelings such as
sadness, anger, guilt, and loneliness. My role throughout the process will be to help you tolerate and deal with
these emotions. I will be a facilitator and companion on your journey by providing support and challenge as we
work together toward the therapeutic goals. Satisfaction with the sessions will be increased by your commit-
ment to the process, including a willingness to persevere through difficult or uncomfortable feelings, and to par-
ticipate fully and honestly.

Confidentiality. The information you share with me in our sessions is strictly confidential, with exceptions
noted below. This means that what you disclose in therapy will not be shared with anyone other than whom you
designate by written release of information. There are times, however, when I am legally and ethically required
to disclose information with or without your permission: (1) in the event that I believe there is clear and immi-
nent danger to yourself or another person; (2) in the case of abuse or neglect of a minor or senior citizen; and (3)
when the court issues a legitimate subpoena requiring records or testimony, and attempts to block such a motion
have failed. In addition, if you use insurance to subsidize your sessions, I am periodically required by the insur-
ance company to provide information concerning treatment and diagnosis. Lastly, administrative information
may be released to a collection agency, if necessary.

Fees, Payment, and Use of Insurance. The fee is $200.00 per session. Standard session length is 45 minutes.
Therapy is typically conducted weekly but the frequency of meetings is negotiable. Payment for the initial ses-
sion is expected at the time of service. For ongoing psychotherapy, payment is expected weekly. A monthly (or
weekly if desired) statement will be provided to you for your records. If you are using insurance, it is your re-
sponsibility to file your own insurance claims with the statements that I provide. Likewise, you are responsible
for ensuring that your treatment is covered, and knowing the limits of your coverage. Payment can be made by
check, cash or credit card. In circumstances of unusual financial hardship, I may be willing to negotiate a fee
adjustment or payment installment plan.



Cancellations and Emergencies. Your session time is held exclusively for you, thus it is your responsibility to
let me know if you will not be able to attend a session. If you must cancel an appointment, please give me at
least 24-hours notice. I reserve the right to charge for missed sessions if such notice is not given. If I must can-
cel our session due to emergency or illness, I will make every effort to notify you as early as possible and to re-
schedule with you in as timely and convenient a way for you as possible. Should a crisis situation arise during
your treatment, I will make every effort to respond over the phone or offer an emergency appointment.

Contacting Me. If you need to reach me, please call me at 703-622-9725. Messages can be left and will be
returned within 24 hours. If you are experiencing a crisis and cannot wait 24 hours to be contacted, you should
follow any emergency plan we established ahead of time, call 911, and/or visit a hospital emergency room.

Your signature below indicates that you have read this agreement and agree to its terms

_________________________________________ ____________________
Client Signature Date





Demographic Information


Date: __________________

Name: _________________________________________________________

Address:_____________________________________________________
______________________________________________________

Phone: _____________________________(hm) OK to leave message? Yes No

_____________________________(wk) OK to leave message? Yes No

______________________________(cell) OK to leave message? Yes No


E-mail Address: ______________________________________ OK to email? Yes No

Date of Birth: ________________________________________

Age:__________

Gender: Male Female


Racial/Ethnic Background: American Indian/Alaskan Indian Hispanic or Latino
Asian/Pacific Islander White
Black or African American Other:_______________

Occupation:_______________________ Years in current job:___________

Relationship Status: Single Widowed
Married Divorced
Other:_______________

Do you have children: Yes No
If yes, please list names and ages:





Please briefly describe the reasons you decided to contact me and your current struggles:
(You will have time to discuss in detail with me during our initial session)










What goals do you have for therapy (We will discuss and further define as we start working together):

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