Bill Gaultiere, Ph.D., Licensed Psychologist, PSY12036, 949.413.8610
Kristi Gaultiere, Psy.D., Licensed MFT, MFT29887, 949.293.8273
Christian Soul Care, 4000 Barranca Pkwy., #250, Irvine, CA 92604

Please print out these client policies. After you have read carefully each of our policies below and agreed to them then sign at the bottom and bring this to your first session. When you meet with me (Bill or Kristi) we will discuss these policies and answer any questions you may have about them or our psychotherapy services.

Appointments: Your standard appointment time is 45 minutes long. (You can schedule more time). I have reserved that time for you. If you are unable to attend, please let me know at least 24 hours in advance. You will be charged the regular rate for no shows and last minute cancellations, except in the case of an emergency. (This isn’t reimbursable even if you have insurance).

Telephone Calls: If you have a psychotherapy related emergency then you can call the emergency number on our voice mail. If I don’t get back to you soon enough or if you can’t get a hold of me then you may need to call another support person, a community support service, or a crisis hotline like 1-800-NO-SUICIDE.

Record Keeping: I will keep in a locked file a record of information you share with me that includes your intake form, a signed copy of these client policies, a record of your visits and payments, the results from any psychological tests I administer, any written correspondence you give to me, and the notes I take to record my assessments and the progress of your work with me.

Confidentiality: All the information you convey to me, whether in my written record or not, is kept strictly confidential, with the following rare exceptions:

* You report knowledge of sexual, physical, or emotional abuse or physical neglect of a minor or elder.
* You represent a life-threatening danger to yourself or another.
* The court requires disclosure of your records.

You may want for me to discuss your therapy with a previous psychotherapist, doctor, pastor, other professional, or family member. If so, indicate this and I will have you sign a release of information.

Spiritual Help: If you want prayer and encouragement from the Bible to be part of your therapy I can provide this. To help you with your struggles I can teach how to use a variety of spiritual disciplines like meditation, breath prayers, fasting, silence and solitude, and others. I also can offer you healing of memories prayer.

Homework: If you’re motivated to change then you’ll work on your issues between sessions by utilizing support groups, journaling, reading, and spiritual disciplines. On our Soul Shepherding nonprofit ministry website you’ll find articles on Christian psychology and spirituality, Bible verses for specific issues, self-tests (for identifying psychological, relational, or spiritual struggles), and referrals to self-help organizations and support groups.

The Effects of Therapy: As best I can I will tell you if and how I think I can help you. You need to realize that changing may be emotionally painful for you or your family. Also, you may want to keep the fact that you’re in therapy private from certain people who wouldn’t be supportive, like your employer or co-workers.

Feedback: You can help me to help you by telling me what you want from psychotherapy and providing me with feedback along the way on how you feel it’s going.

Length of Therapy: You may wonder how long therapy will take. I am interested to discuss this with you at any time. Whenever you want to terminate your therapy with me you may do so. When you feel ready to end our work together it would be helpful for us to discuss this. At any time I can offer you referrals to other psychotherapists who may be of assistance to you.

Payment: The fee for psychotherapy is $160 per session. Please make out your check out to “Christian Soul Care” in advance. I will give you a receipt, which you may be able to submit to your insurance company for reimbursement. If financial problems arise for you then please discuss these with me.

I have read and I understand the contents of the above material.

Client Signature______________________________________

Date_______________

Parent Signature (If client is minor)______________________________________

Date ______________