Informed Consent for Treatment and My Policies

Welcome to my practice. When you decide to begin therapy, you are making an important investment in yourself. Good information about your prospective therapist will help you decide which therapist is the best fit for you. This form contains information regarding my training, experience, and credentials, as well as my professional services and business policies to help you in your decision. If you have any questions, concerns, or suggestions regarding any aspect of my practice or my credentials, please discuss them with me. I am happy to answer your questions, and I welcome your comments.

There are several different methods I may use, based upon my training and experience. My primary approaches to therapy include: Imago Couples Therapy, Interpersonal/Insight-Oriented approaches, as well as CBT interventions. Your thoughts regarding what works well for you is also very important to the success of your treatment. Psychotherapy is an active and creative process between client and therapist. I view therapy as a collaborative process that works best with an open line of communication. To that end, I would like to have input from you on how you feel you are progressing in therapy, or areas that you feel are not being addressed.

Therapy can have benefits as well as risks. Since psychotherapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings, such as sadness, anxiety, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy has also been shown to have many benefits. Therapy often leads to reduction of symptoms, improved relationships, solutions to specific problems, and can significantly reduce feelings of discomfort and distress. However, there are no guarantees regarding what you will experience.

Training, Experience and Credentials My Ph.D. in Counseling Psychology was awarded from Texas A&M University. I graduated in May 2004. I also hold a Masters degree in Counselor Education from Indiana University. I am a Licensed Psychologist in Maryland (License # 04477) and the District of Columbia. I am a Certified Imago Couples Therapist and am currently being trained in Sex Therapy.

My private practice emphasizes working with individual adults as well as couples. I specialize in relationship issues, women’s mental health issues, and identity development. My goal is to empower my clients to find solutions to the issues that trouble them.

Professional Practice Policies Although the exact length of treatment is difficult to predict, I can provide an estimate of the treatment duration. You have the right to know if other forms of treatment are available. You may end treatment or seek a second opinion at any time.

Fee Information I require payment by cash or check at the time of service and payment is due in full at each session unless another arrangement is made with me. I am an out of network provider of insurance, and am not a member of any managed care plans. I would be happy to provide documentation so that you can submit your own claims to your insurance company, if desired.

Should someone not pay a therapy bill (or make regular payments toward an accumulated balance) in a timely fashion, every reasonable effort will be made to gain his/her cooperation and resolve the situation informally. However, it is within the therapist’s right to engage a collection agency if the balance remains unpaid. In such cases, confidentiality is maintained and only minimal pertinent information is shared with the collection agency (client’s name, dates of service, amount due, and contact information.

There will be a charge of $200/hr, with a 4 hour minimum, for any forensic services (ie. Responding to subpoenas, court and travel time, talking with attorneys, etc.) This amount will be payable in advance. Returned checks will be subject to a $35 fee.

Cancellations I reserve a regular appointment time for you. If you need to cancel or reschedule an appointment, please call (301) 654-1203 as soon as you are aware of your inability to come to session. If you cancel or miss an appointment without providing 24-hour notice, you will be billed for the entire session.

Telephone Calls Please note that I do not answer my phone or return calls after the business hours of 9 am-5 pm on Monday through Friday. I will always try my best to return calls on the following business day. Any calls made after 5 pm Friday, will be returned the following Monday. If you are in crisis and I am not readily available, please call 911 or go to the nearest emergency room of a hospital. Please keep in mind that cell phones and email are not considered secure and confidential forms of communication.

Limits of Practice I have limited my practice to clients who typically do not require 24-hour-care or crisis/emergency care. Therefore, I do not carry a pager. If you feel you have a need for this level of care, please inform me so that I may refer you to an appropriate therapist or facility. If, during our work together, an emergency does occur which requires immediate attention, please call 911 or go to your nearest hospital for assistance. I urge you to inform me of these events as they may impact your therapy. Additionally, I am not in the practice of testifying in court or making court appearances in general. If you feel that you made need these services in the future (ie. Representation for divorce hearing, etc), I may not be the best match.

Confidentiality Confidentiality is an important component of therapy and one that I take very seriously. In general, the privacy of all communications between a client and a therapist is protected by law, and I can only release information about our work to others with your written permission. However, clients should recognize that the law mandates certain information to be released to appropriate authorities when:

1) there are suspicions of child abuse or neglect (or, in some cases, suspected abuse/neglect of an elderly or disabled adult); 2) there are indications that the client might seriously harm him/herself or another person; 3) in rare cases where a court order for information about one’s counseling is issued.

In most legal proceedings, you have the right to request restrictions on certain uses and disclosures of protected health information. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he or she determines that the issues demand it.

In addition, parents may have the right to receive certain information about the treatment of clients under 18 years of age.

I will take all reasonable steps to discuss any possible release of confidential information with you before any action is taken.

From time to time, I may seek consultation from other clinicians with expertise in specialized problem areas. During these consultations, I limit the information communicated, and specifically avoid revealing the identities of my clients. Consultants are also legally bound to maintain confidence.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have. Regulatory Agency The Maryland Board of Examiners of Psychologists (the “Board”) is charged with qualifying, examining, and licensing individuals for the practice of psychology in Maryland. The Board also investigates and acts upon complaints against licensed psychologists and against individuals practicing under the supervision of licensed psychologists, such as psychology associates. Any questions, concerns, or complaints regarding my services may be directed to:

Maryland Board of Examiners of Psychologists 4201 Patterson Avenue, 2nd Floor Baltimore, Maryland 21215-2299 Telephone No.: 410 764-4787 Fax No.: 410 .358.7896

Chevy Chase Counseling is an independent practice and is not affiliated with any other providers or institutions.

Consent I have read the above and fully understand: the nature of the treatment; my treatment alternatives; limits of confidentiality in the counseling/psychotherapy relationship; and the circumstances under which confidentiality could possibly be breached without my written consent. In addition, I have received the HIPAA Notice Form. I have been informed of Dr. Leila Jarrahi’s degrees, credentials, and practice policies. I have also read the preceding information and understand my rights as a client.

I have been informed and understand the scheduling and fee policies. I, the undersigned, agree to be responsible for all fees and charges incurred in receiving counseling services from Chevy Chase Counseling, Leila Jarrahi, PhD, PC. I also agree to pay all expenses incurred in the collection of those fees, should that become necessary.

I understand and agree to the policies described herein. A copy of this document has been given to me for my records. I consent to therapy, including assessment, evaluation, treatment, and/or referral.

______/_____/______Client Signature Date

I, Leila Jarrahi, have discussed the issues above with the client. My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.

______

Leila Jarrahi, Ph.D., PC Date: ______