William
Gaultiere, Ph.D.
Clinical Psychologist,
PSY12036, Christian Soul Care
4000 Barranca Pkwy., #250, Irvine, CA 92604, 949-262-3699
CLIENT POLICIES
Please print out these client policies. After you have read
carefully each of my policies below and agreed to them sign at the
bottom and bring this to your first session. When we meet we
will discuss these policies and I will answer any questions you may
have about them or the psychotherapy services I have to offer you.
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 page me. 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 or a community support service like the New Hope
Crisis Hotline at (714) N-E-W-H-O-P-E.
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: To help you with your struggles we can pray
together, look for insight from the Bible, or I can teach how to use
spiritual disciplines like meditation, breath prayers, fasting, silence
and solitude, and others. I also can offer you healing of
memories prayer. If the help you want primarily has to do
with improving your relationship with God, rather than overcoming
psychological issues, then talk to me about this because you may want
spiritual direction instead of psychotherapy.
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 my website,
ChristianSoulCare.com, 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 $130 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 ______________
|
