Kibel Consultation

Practice Forms

CLIENT INFORMATION

Welcome to Kibel Consulting. I am eager to explore ways to increase clarity, courage and connection for you and your family. The therapy process requires that we collaborate to deal with the problems, concerns or worries that have led you to seek consultation. I expect to partner actively with family members to support each other. This calls for significant involvement on your part and sometimes may involve experiencing some uncomfortable feelings, engaging in difficult interactions, or facing difficult aspects of your life. My intention, however, is to provide a safe and protected space in which we are clear about each other’s expectations and tackle any concerns as they arise. This document is intended to provide clarity regarding client services. Please read the following and feel free to discuss any questions with me.

PHONE CALLS: My practice number is (408) 680-7205. When I am not available my voice mail will record your message. I will always return your call as soon as possible but tend to do private practice calls in the evenings. For emergencies, call 9-1-1, go to the nearest emergency room or call the Suicide and Crisis Hot Line at (255) 278-4204. A message can be left on my voice mail at any time.

CONFIDENTIALITY: The information discussed in therapy is confidential and cannot be disclosed to anyone. The exceptions to this rule are:

  1. If there is evidence of child, elder, or dependent adult abuse.

  2. If I learn that there exists a serious threat to the client’s life or the life of another.

  3. If you sign a release of information as part of your insurance form, or you are referred by an EAP or Managed Care Company that requests information.

  4. If you sign a release for the therapist to share information with specific others.

  5. If there is a court order for the therapist to appear or to produce documents.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for canceling an appointment or the full session fee will be charged. My full fee is $120 per hour. If you are using your insurance benefits to pay for therapy, your insurance company will not pay for missed sessions or for late cancellations. Occasional emergencies will be excepted.

FEES: Sessions are 50 minutes in length. Payment is due at the end of each session unless other arrangements are made. Fees will be reviewed every January 1st. I will provide itemized bills with diagnosis and procedure codes to submit to insurance as needed.

I have read and understood the above information and consent to treatment.

 

This authorization, to release confidential information, shall remain valid for one year from the date listed below, unless revoked or otherwise modified in writing.