Heart Healer Treatment Center - Brad Gilbert MFT, CSAT, Director

CLIENT INFORMATION

Complete and check preferred method of contact

*Email address may also be used to contact you with information about coming workshops, conferences, or just to send articles on therapy issues. Is this OK with you?

How did you find us?

INFORMED CONSENT

Please note, I am only licensed in the state of California, therefore I may not be able to do teletherapy with you due to state licensing laws when either of us are out of state. Feel free to ask about exceptions 7 days in advance if you are wanting teletherapy while you are out of state.

Fees/Payments

Each 50 minute session is $150.00, 80 minute sessions are 225.00. Clients with insurance are responsible for filling a claim and reimbursement. I will provide a super bill that will provide the necessary information for most PPO insurance plans. However, I must give you a diagnosis for you to obtain reimbursement. For private pay clients I reserve the right to periodically adjust fees and you will be notified of any changes 60 days in advance.

Cancellations & Missed Sessions

Consistency is important in the therapeutic process, but if you need to cancel an appointment, please contact me at least 48 hours prior to the session or you will be responsible for paying for the missed session. (I understand if you are sick, or there is an emergency and you are not able to give a 48 hour notice.) You will be billed $150.00, or 225.00 for 1 ½ hour session.

Please initial below to agree to the above policy and to grant permission for your payment information to be collected upon your first visit.

The Nature of Counseling

The relationship between the client and psychotherapist is unique and special. This means that there can be NO dual relationships (i.e. being friends, attending functions together, bartering for services, etc). This is mandated by the ethical code of my profession.

Our first few sessions together will be an evaluation period as we get to know each other and understand the issues that brought you here. We then discuss treatment options and recommendations. The counseling process can be intense and painful. Sometimes clients feel worse before they feel better.

Group counseling adds another dimension, in that other members may discuss or do something that brings up painful issues for other group members. That is both the gift and the risk of group counseling.

The goal of couples counseling is to help couples improve their relationship. However, separations or divorces do occur despite, or as a result of, couples counseling. When I work with a couple, I will keep no secrets from either partner.

Lastly, referrals to other professionals (doctors, psychiatrists, etc.) may be required, and refusal to comply with my referral may require me to terminate our therapy relationship.

Other Fees/Payments

Most of my professional time is billed at a rate of $150.00 per hour, including preparation of reports or letters on your behalf. Testimony at depositions or in court is billed at $300.00 per hour plus travel expenses. Phone calls in excess of 10 minutes duration will be billed for whatever fraction of an hour.

Payment

Full payment is due at each session. Please pay cash or make out your check to Brad Gilbert before the session begins. Credit or debit card payments are also accepted.

Outstanding Balances

I prefer to run a “payment at time of service” practice to avoid dealing with the extra overhead of billing clients. However, should an outstanding balance arise (i.e. “I forgot my checkbook”, or “I forgot we had an appointment”), the payment must be paid before or at the following session.

There is a $20.00 fee in addition to the original check charge for all checks returned for insufficient funds. After 90 days with no payment or effort to make a payment arrangement, accounts may be turned over to the Retail Credit Association (RCA) for collection, which may adversely affect your credit rating.

Odds & Ends

I generally have coffee, tea and water available. There is a bathroom for your use.

Phone Calls & Messages

I strive to return calls promptly, but there can be unavoidable delays. Please leave your phone number with each call. If you have left an urgent message and I have not answered within two hours, please call the Family Services Life Line at 916-368-3111 to get support until I can reach you. If you have a physical or psychiatric emergency, contact the nearest hospital emergency room. For psychiatric admissions and evaluations, my clients usually use Heritage Oaks Psychiatric Hospital at 916-489-3336.

Confidentiality

Confidentiality will be maintained unless you have signed a written release of information to a specific individual or agency.

The following are exceptions to confidentiality between therapist and client in California:

  1. If you disclose that you are suicidal, and after clinical assessment, it is deemed that there is a serious concern for your safety, your therapist is required to ensure you are safe by calling the police, hospital or family member, etc.
  2. If you disclose that you are homicidal, and after clinical assessment, it is deemed that you are of imminent homicidal threat to an identified potential victim, your therapist is required to and has a duty to warn the potential victim and contact the police.
  3. If you disclose that you have abused any person 65 or older or a dependent/vulnerable adult, your therapist is mandated to report the abuse to Adult Protective Services.
  4. If you disclose that you have abused or neglected a minor (defined as any person under the age of 18), your therapist is mandated to report the abuse or neglect to appropriate state agencies.
  5. If you disclose that you have downloaded, streamed or accessed images of a minor engaged in an act of obscene sexual conduct, including child pornography/child sexual abuse imagery (CSAI), your therapist is mandated to report that disclosure to appropriate state agencies. This means that if you disclose to me that you or anyone you know has viewed child pornography/child sexual abuse imagery (CSAI) or other images of obscene sexual conduct involving a minor, I am obligated by state law to report your disclosure to appropriate state agencies.

Regarding group therapy: All participants are asked to maintain confidentiality, but I cannot guarantee that. By deciding to join a therapy group, you are deciding to take that risk.

Your initials below signify that you understand and agree with the limitations of confidentiality.

Appointments

At the end of our first session, we will make appointments for further sessions.

Notice of Termination

You are not obligated to see me for any specific number of sessions. It is important, however, to give me one session’s notice should you wish to discontinue treatment. What I want to avoid is a situation where you cancel and then do not reschedule without an explanation. A clean ending will be important for the both of us.

Weekends, Holidays, & Vacations

I check phone messages between the hours of 9:00 a.m. – 7:00 p.m. If I am out of town or on vacation, I may have another therapist checking my messages and returning your call if I am unable. If I suspect that you may be calling while I am away, I will advise that therapist of pertinent facts about you.

Therapist Consultation

I may decide that consultation with a colleague will help in your treatment. If I do this, your name will not be used.

Your signature below signifies you are granting permission for such sharing of information.

I understand and agree to the terms specified above:

Client Intake

Please enter the name, age, and your relationship to each person living in your household:

Please enter the name and age of each of your children:

If any of your children do not live with you, where do they live and how often do you see them?

If yes: Please list each one, when you saw them, and why you left (if applicable)

Have you or do you participate in any 12 step program? If so: Which ones, when, and why did you stop attending (if applicable?)

If you are, please list them:

Please list all tranquilizers or anti-depressants you have taken in the past:

Have you ever been hospitalized for psychiatric (emotional) reasons? If so, why and when?

Have you ever thought about or attempted to kill yourself; when?

If yes, please explain:

Have you ever been sexually molested? (Include attempts):

Have you ever been raped? (Include attempts):

Have you ever been a victim of a violent crime?:

Have you ever been involved in a battering relationship? Explain:

If so, what effect has that had on you?

Have you ever had any of the following illnesses?

SUBSTANCE USE

What is your history and current use/abuse of the following substances: alcohol, illegal drugs, prescription drugs, tobacco and caffeine?

PRELIMINARY BACKGROUND INFORMATION

How were you disciplined?

Were you ever physically abused as a child by anyone?

Do you have any of the following symptoms? For each question below, please indiciate the timing that best describes how often each symptom has been an issue for you. If it has only been a problem recently, indicate how long it has been a problem.

CURRENT SITUATION

Please state briefly what is troubling you now.

What would you like to accomplish in therapy?

Thank you for filling out this form. It will be very helpful in your evaluation. Add any additional comments below that you would care to make.

In the next section, there are life circumstances that can cause stress to you or other significant people in your life. They are not necessarily negative, but may be viewed as negative by some people in society. Check the box in the appropriate space if these circumstances have occurred.

You can use the Comments section to give more detail (identify which sibling, etc.) or add other significant people who qualify under these classifications.

Even if the stressors happened before you were born they may have impacted your parents. Do your best. You don’t have to interview your whole family, just fill what you already know about.

You
Mother
Father
Brother
Sister
Spouse/Mate
Children
Stepchildren
In-Laws
Maternal Grandfather
Maternal Grandmother
Maternal Aunt
Maternal Uncle
Paternal Grandfather
Paternal Grandmother
Paternal Aunt
Paternal Uncle
Anorexic
Compulsive Eater
Bulimic
Compulsive Gambler
Workaholic
Interracial Relationship
Affairs
Adoption
Miscarriages
Stillborn Births
Infertility
Drug Abuse
Alcoholism
Mental Illness
Psych. Hospital
Severe Depression
Attempted Suicide
Committed Suicide
Sent to Prison
In & Out of Jail
Sexual Addictions
Victim of Sexual Abuse
Victim of Physical Abuse
Violent to Family
Life Threatening Illness
Chronic Serious Illness
Accidental Death
Victim of Violent Crime
Perfectionist
LGBT
Explosive Behavior
Permanent Disability
Foster Care
Compulsive Spender
Miser

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