Therapy Client Information Sheet

D Gregory Smith, MA, LMHC, LCPC
Licensed Clinical Professional Counselor (MT)
Licensed Mental Health Counselor (WA)
202 S Black Street, suite 502 Bozeman, MT 59715
(406) 596-2013 (MT) or (206) 234-5939 (WA)

~Provider Information Form~

Confidentiality
            You have a right to expect professional confidentiality from me. I may not release information to medical providers, schools, attorneys or other professionals unless you personally request it and you sign a Release Of Information (ROI) form. The duty of a counselor to keep confidential any information given by a client is required by law- except in very specific circumstances. Counselors are required to report to the appropriate authorities/parties information that leads them to believe that:

  • The client presents a danger to him/herself
  • The client presents a danger to the life, health and/or property of another
  • When there is reasonable suspicion of child, dependent or elder abuse or neglect
  • The client is gravely disabled and is judged to be incapable of making self-care decisions

Dual relationships (contact outside of therapy) are discouraged, but often unavoidable in a small town.  It is important to recognize that my primary relationship and concern with you is as your therapist. We will discuss the proper protocol together for your particular situation, circumstances and concerns.

Records and Your Right to Review Them
              Both the law and the standards of my profession require that I keep treatment records for every contact with a client. If you have concerns about your treatment records, please discuss them with me. Because client records can be subpoenaed under law in some instances, I include only information that I believe necessary in your file- I avoid including potentially damaging information- or information that could be misconstrued out of context.
As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. I will release information to any agency/person you specify by a signed ROI unless I assess that releasing such information might be harmful in any way.

When more than one client is involved in treatment, such as in cases of couple and family therapy,I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

Phone Calls and Emergencies
            I try to avoid working over the phone, unless we have pre-arranged to do so. If you need to contact me between sessions, please call my phone and your call will be returned as soon as possible.  Do not email if you need a quick response. If you do call, we will probably work to schedule a face-to-face session in my office if it cannot be handled quickly and effectively over the phone.

I do take emergency phone calls, but there are times that I am unavailable. My voicemail message will direct you to an alternative therapist who is handling my calls, or to the Help Center 586-3333 . They handle my calls in cases when I am unavailable. In addition, you can always call your physician or go to a local emergency room if you are in crisis.

If there is an emergency during therapy- or in the future after termination- where I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to make sure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet.

Billing, Payment and Cancellations
            My fee is $125.00 per 50-minute session, $150.00 for a 70-minute session, payable at the conclusion of the session. Please have checks made out in advance. I do accept debit/credit card payments. I currently accept Blue Cross/Blue Shield of MT and most other insurance. I do not accept Medicare/Medicaid. Arrangements can often be made to negotiate fee and payment in special circumstances.

If cancelling an appointment, please give me as much notice as possible. Cancellations within 24 hours of your appointment will result in being charged for the appointment- with special considerations given for weather, illness or emergency circumstances. I will charge a returned check fee of $35.00, and unpaid accounts will risk being sent to collections.

Consultations
            To provide the best quality care, I occasionally consult with a select few professionals. Consultations are done with the full anonymity of the client preserved- no names or identifying circumstances are used. Please discuss with me any concerns you may have about consultations with other health care providers or professionals.

The Process of Therapy and Scope of Practice
Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness to change your thoughts, feelings, and/or behavior. I will ask for your reaction and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly.

Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in the experience of  discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed.

Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. If you are concerned by this, please bring it to my attention.

During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to, Gestalt, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational.

I do not offer custody evaluation, medication/prescription recommendations or legal advice, as these activities do not fall within my scope of practice. We may, however, discuss options for you to bring up with the appropriate professionals on your own, or with a joint consultation

Professional Qualifications
            I graduated from Seattle University with a Master of Arts in Mental Health Counseling in 2002. I was employed as a therapist and case manager at Seattle Counseling Services from 2002-2007. I have worked in private practice since 2005. I am also a certified Gestalt therapist (Gestalt Institute of Seattle, 2001). I have been professionally licensed in Washington State since 2001 and am a Licensed Mental Health Counselor (LMHC # 60174437). I am a Licensed Clinical Professional Counselor in Montana (LCPC, License #4429).

If you have any questions at all about any of this information, please bring them up with me-  and please keep this sheet for future reference. One copy will be kept for your file.

 

I have read the above Provider Information Form carefully (a total of 2 pages); I understand them and agree to comply with them:

 

Client’s Name (print)  ___________________________________________________________________________

Signature ____________________________________________________ Date ______________________________

Client’s Name (print)____________________________________________________________________________

Signature __________________________________________________________________ Date ________________

Psychotherapist: D Gregory Smith, MA Signature _________________________________ Date ________________


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