If you're a new client, please complete the following form and bring it to your first therapy session.
New Patient Information and Informed Consent
The following describes information for new clients who desire individual, child, adolescent, couple, family or group psychotherapy services from me. Please read this information carefully and feel free to discuss any questions you might have with me. We will have an opportunity to go over this information, including your comments, questions and concerns in our first session, and throughout our work together.
1. I have a Ph.D. and M.A. in Clinical Psychology and a M.A. in Clinical Art Psychotherapy. I am licensed in the State of California as a Marriage, Family Therapist, License #23916. I am a Board Certified and Registered Art Psychotherapist, ID# 07351. I am a Senior Candidate at the Los Angeles Institute and Society for Psychoanalytic Studies.
2. I am licensed by law and equipped by training to provide psychotherapeutic services to the individual to mature and grow within relationships and to provide explanations and interpretations of the psychosexual and psychosocial aspects of relationships within marriage and family. I use psychological methods and techniques, (including verbal, visual, writing, play, and drama), in a professional relationship to assist a person or persons to acquire greater human effectiveness or to modify feelings, conditions, attitudes and behaviors which are emotionally, intellectually or socially ineffective or maladjusted. My theoretical perspective is a combination of Psychodynamic, Object Relations and Family Systems. When the word therapy is used in this document, it refers to all therapeutic methods and techniques including Art Therapy. There are many different theoretical orientations to the practice of therapy, many which are very helpful to clients. You always have the option of considering an alternative approach. I will try to help you explore your choices.
3. A licensed Marriage, Family and Child Therapist may use hypnosis and psychological tests in treatment as provided by law. A Registered Art Psychotherapist may use diagnostic art evaluations and visual projective testing. A Psychoanalytic Candidate may conduct Psychoanalysis under supervision.
4. As a non-medical therapist, I do not prescribe medication.
5. Art Therapy and Verbal Therapy are often used to reach similar goals. They do differ in some respects, for this reason, I have included a more detailed explanation of Art Therapy at the end of this document.
Confidentiality and Records
6. Consultations, test results and disclosures between a licensed therapist and a client will be held in confidence, subject to state and/or federal law. I must comply, however, with subpoenas or the directive of a court order to disclose information. Also, the normal confidential relationship between therapist and client does not apply to the disclosure of child and/or elder abuse and neglect or threats to the physical well being of other persons.
7. From time to time, I consult with other professionals to seek information or input, which may be helpful to my cases. In such instances, I will make every effort to preserve the confidential identity of my clients.
8. Notes in regard to our sessions are required by law. I do keep a written record of the theme(s) of the therapy sessions, treatment plan, treatment progress, telephone calls, consultations and any other matters that are directly related to your therapy with me. The written material and any artwork produced is kept in a locked file cabinet and is considered confidential unless a subpoena is issued from the court or you sign a release to a named person or institution. Seven years after our therapy work is terminated I can dispose of your file by shredding all of the material recorded or drawn.
9. According to law you have a right to view your records. I have the discretion of providing you with a summary, full file access and/or parts of the file. My decision will be based on the purpose and therapeutic importance.
Confidentiality and Technology
10. I use a voice mail system in the office. Therefore the telephone does not ring; rather, my pager/cell phone receives your call (always set to “silent”). Thus, your call is recorded through a digital process. The confidentiality of digital technology may or may not be secure. If I am available, I will return your call immediately. If I am not available I will I return your call at my first free time.
11. Generally, I do not pick up phone messages after 8:00 P.M., on the weekend or on holidays. Should you have a crisis it is suggested that you go to the nearest emergency room or hospital for crisis intervention. I will return calls at my first available time on the next business day. You are always welcome, at any time, to leave me a message.
12. I often use my mobile phone (digital) to return calls. I sometimes use a computer to write reports, to write letters, to maintain notes of our sessions (as required by law), to transmit information to other professionals and/or institutions or persons that are important to our work together, to prepare billing statements and/or other forms of written communication that may be part of our work together. I use a fax machine to transmit many of the documents described above.
13. I cannot guarantee that your right to confidentiality is fully protected when electronic means are used. I will make every effort to obtain state-of-the-art products to protect and secure your confidentiality, however, it is not clear if material transmitted electronically is truly secure.
Appointments and Course of Therapy
14. In order for therapy to proceed most effectively, unless otherwise indicated, I will meet with you twice a week for 45 – 50 minutes. I expect that you will keep each appointment except in the cases of illness, prearranged vacation, or an emergency. I will begin on time and end on time, except in cases of an emergency. Under normal conditions, neither of us will cancel an appointment with one another. It is optimum that we meet at each scheduled appointment unless prior arrangements have been made. You have a right to not use the scheduled sessions, however, you are still responsible for the fee.
15. It is impossible to predict the length of therapy. In some cases, I can estimate an approximate timeframe. The variables of the work you do in the process of therapy itself make it impossible to predict an exact outcome. From time to time, we will assess and reassess the goals and progress of your treatment. I encourage you to bring this up for discussion at any time.
16. If I will be out of town and unavailable, a colleague will cover for me and return your call in a like manner. I will make every effort to tell you of such instances ahead of time.
Fees and Insurance
17. You are held responsible for the fee for all scheduled appointments. If you need to cancel an appointment, you are still responsible for the charges. If you desire, I will try to schedule a make up time within two weeks. If you do not have the time or I do not have any time available, you will be the held responsible for your regular fee. I appreciate 24 hours advance notice to any changes to our scheduled appointments. If I am able to fill your canceled time you will not be charged.
18. The fee for individual therapy is $200 per 45–50 minutes session. My fee for conjoint (couples) and/or family therapy is $300 per 75-minute session. I have a limited number of low fee hours available. This can be discussed in session. Payment is expected at the time of service.
19. If your health insurance provides benefits for outpatient mental health services, I will provide you with a statement at the end of each month so that you can submit your claim for reimbursement.
20. In most instances, I do not charge for short telephone calls (2-3 minutes). If telephone calls become a frequent or a part of the treatment process I do charge at your regular fee.
Termination of Treatment
21. Ideally, we will mutually decide when it is time to end our work together. This is often referred to as the termination phase of therapy. There are times when we must terminate because of things beyond our control, like financial reverses or moving out of town. Other possible reasons for termination might include your inability to follow a course of treatment or my inability to continue to be helpful to you. In most cases, it is appropriate for us to set aside a time for formal termination where the process of your work in therapy can be reviewed and you can have ample opportunity to experience the ending of the therapeutic relationship.
I am delighted to welcome you as a client of my practice. I encourage you to ask me any questions that come up about the structure of our professional relationship or your treatment.
Your signature below means you have read the above information, and consent to treatment with Claudia Eskenazi, Ph.D., L.M.F.T., A.T.R.-B.C.
Your decision to begin therapy is significant. You are making a commitment to understand or change something about yourself or your life. Participating in psychotherapy can result in a number of benefits to you, including a better understanding of your personal goals and values, improved interpersonal relationships, and resolution of the specific concerns that brought you to therapy. Working towards these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, but more often it will be slow and frustrating. Remembering unpleasant events in therapy can bring on strong feelings, such as, anger, depression, fear, confusion (and so on). Attempting to resolve issues between marital partners, family members, and other individuals can also lead to discomfort and result in changes that were not originally intended. There are many different types of therapy and psychotherapists that can assist you with your problems or concerns. If you are not committed to this treatment or should you decide you would like to investigate an alternative therapeutic approach I will be pleased to discuss your concerns with you and help you find what you’re looking for. When you commit to treatment, I commit to help you in the most appropriate and professional manner. A discussion about the therapeutic process you have committed to undergo is always appropriate.
I have read the above and I understand it. My therapist has given me an opportunity to discuss and ask any questions that I have in regard to the structure of therapy and my treatment. I agree to comply with the above structure and consent to treatment, unless noted and initialed otherwise on this document. I further understand that I am ultimately, the responsible party for all debts incurred in my therapy.
Patient(s) Signature Date
Parent(s) or Legal Representative’s Signature Date
Therapist’s Signature Date
plete this form to authorize release of psychotherapy information:
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