CONSUMER INFORMATION STATEMENT
1. Professional Information: I am a licensed psychologist in the State of California. I have been in independent practice since 1982. My work involves helping people with a wide range of problems. I see children, adolescents and adults.
2. BILLING: I will bill you at the end of each month. We will agree on a regular time, at the beginning of the next month, at which you will pay me. Your fee will be ____.
3. CANCELLATION POLICY: Once we have agreed upon a regular time or times to meet during the week, I will reserve that hour for you and you will be responsible for paying for that time. If we are able to reschedule or I am able to schedule another consultation in your hour, I will not charge you for the missed appointment.
4. TELEPHONE: My answering machine is on 24 hours a day. When you call, please leave your name, phone number, time of day, and a brief message.
5. VACATION: When I am on vacation or otherwise unavailable for appointments, I will leave the name and number of someone to call in the event of an emergency.
6. CONFIDENTIALITY: Privacy is a basic right of any individual who seeks psychotherapy. Therefore, all consultations and records are confidential except where prescribed by law, as described in the Consent to Treatment.
I have read, understand, and agree to the policies set forth in this statement.
DatePatient, Parent, or GuardianWitness
Name of PatientPatient's Birth Date
AddressPhone Number Date of Birth