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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

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INFORMED CONSENT
HIPPA DOCUMENT

INFORMED CONSENT

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%3cdiv contenteditable%3d%27false%27 unselectable%3d%27on%27 class%3d%27unselectable%27%3eTERRI BENSINGER LEVY PH.D
1801 BUSH ST. SUITE 110 SAN FRANCISCO%2c CA 94109 LICENSE PSY 13141 415-441-6773 drtbensinger@hotmail.com
PSYCHOTHERAPY INFORMATION DISCLOSURE STATEMENT
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy%2c you have certain rights that are important for you to know about because this is your therapy%2c whose goal is your well-being. There are also certain limitations to those rights that you should be aware of. As a therapist%2c I have corresponding responsibilities to you.
My Responsibilities to You as Your Therapist I. Confidentiality With the exception of certain specific exceptions described below%2c you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me%2c or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992%2c I may legally speak to another health care provider or a member of your family about you without your prior consent%2c but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with
whomever you chose%2c and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you.
You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act %28HIPAA%29. This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically %28for example%2c sending bills or faxing information%29%2c it will be done with with special safeguards to insure confidentiality. If you elect to communicate with me by email at some point in our work together%2c please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs%2c they are%2c in theory%2c available to be read by the system administrator%28s%29 of the internet service provider.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
1. If I have good reason to believe that you will harm another person%2c I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim. 2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult%2c or if you give me information about someone else who is doing this%2c I must inform Child Protective Services within 48 hours and Adult Protective Services immediately. If you are between the ages of 16 and 18 and you tell me that you are having sex with someone more than five years older than you%2c or sex with a teacher or a coach%2c I must also report this to
CPS%2c even though at age 16 you have the right to consent to sex with someone no more than five years older than you. I would inform you before I took this action. 3. If I believe that you are in imminent danger of harming yourself%2c I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this%2c and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety%2c I would call the crisis team. 4. If you tell me of the behavior of another named health or mental health care provider that informs me that this person has either a. engaged in sexual contact with a patient%2c including yourself or b. is impaired from practice in some manner by cognitive%2c emotional%2c behavioral%2c or health problems%2c then the law requires me to report this to their licensing board at the WA Dept. of Health. I would inform you before taking this step. If you are my client and a health care provider%2c however%2c your confidentiality remains protected under the law from this kind of reporting.
II. Record-keeping. I keep very brief records%2c noting only that you have been here%2c what interventions happened in session%2c and the topics we discussed and homework given to do between sessions. If you prefer that I keep no records%2c you must give me a written request to this effect for your file and I will only note that you attended therapy in the record. Under the provisions of the Health Care Information Act of 1992%2c you have the right to a copy of your file at any time.. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.
III. Diagnosis If a third party such as an insurance company is paying for part of your bill%2c I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis%2c I will discuss it with you.
IV.Other Rights You have the right to ask questions about anything that happens in therapy. I%27m always willing to discuss how and why I%27ve decided to do what I%27m doing%2c and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns%2c and can request that I refer you to someone else if you decide I%27m not the right therapist for you. You are free to leave therapy at any time.
V. Managed Mental Health Care If your therapy is being paid for in full or in part by a managed care firm%2c there are usually further limitations to your rights as a client imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions available to you%2c to decide the time period within which you must complete your therapy with me%2c or to require you to use medication if their reviewing professional deems it appropriate. They may also decide that you must see another therapist in their network rather than me%2c if I am not on their list. Such firms also usually require some sort of detailed reports of your progress in therapy%2c and on occasion%2c copies of your case file%2c on a regular basis. I do not have control over any aspect of their rules. However%2c I will do all that I can to maximize the benefits you receive by filing necessary forms and gaining required authorizations for treatment%2c and assist you in advocating with the MC company as needed.
VI. My Training and Approach to Therapy I have a Ph. D. in Clinical Psychology from the Wright Institute in Berkeley California earned in 1990. I was trained in multiple modalities including both individual and system therapies.I did post doctoral work in a family therapy clinic where I became deeply interested in the power of our family stories. The most effective work I%27ve experienced with clients over the years combines a dedicated awareness to one%27s individual story with a variety of strategies that are undertaken to move forward into a more satisfying experience of living. The work of facing painful feelings is supported by mindfulness techniques. It takes courage to come to therapy and most of us don%27t do so unless there is a fair amount of emotional discomfort. Since it%27s human nature to attempt to go around pain rather than face it and take it on%2c it seems counter intuitive to delve into places in ourselves that hurt. Using cognitive therapy strategies and mindfulness calming techniques is very helpful and allows meaningful changes. To sustain the growth and gains made in therapy I incorporate ongoing practices that are encouraged between sessions.
The other important piece of the work I do involves the focus on resilience. This means that it%27s equally important to look at whats right with the picture as it is to identify what%27s wrong. People are endowed with true strengths of all kinds. It%27s never the case that clients are without something quite essential inside of themselves to assist in a profound way with their own healing and growing. The work is to discover these aspects and put them to use in solving challenges. The following types of issues can be supported and helped using the tools just summarized%3a Depression Anxiety Relationship difficulties
Substance dependence Obsessional difficulties Low Self Esteem Parenting challenges Work Life balance tension Stress management Sleep difficulties Anger challenges Low coping strategies and many other issues
VII. INFORMATION FOR CLIENT PARTICIPATION * Payment for the sessions is expected for each meeting. My fee for a 50 minute session is %24195.00. If we decide to meet for a longer session%2c I will bill you prorated on the hourly fee. * Payment methods can include%3a Personal check%2c Paypal%2c Venmo or Cash. * Sessions are 50 minutes in length. * My cancellation policy is as follows%3a Clients usually have a specific time slot that I hold as their time weekly. If you cancel your appointment one week in advance I don%27t charge for the session. * If you%27d like to use your health insurance I will provide you with a form to submit to your carrier at the end of four sessions or a year- end super bill if that is preferable. All insurance carriers need a diagnosis with the corresponding code. As mentioned earlier in this document%2c I am happy to discuss the diagnosis if you should choose to use your insurance. * Schedules can be challenging for those who travel for work. I believe in the power of creative scheduling and have navigated complicated schedules with success. Having said that%2c there is no substitute for consistency in the work. Like anything%2c you get the value from the time you put in. If you are engaged
in making your meetings as regular as possible you will get the optimal benefit.
Complaints If you%27re unhappy with what%27s happening in therapy%2c I hope you%27ll talk about it with me so that I can respond to your concerns. I will take such criticism seriously%2c and with care and respect. This is a collaborative process and I%27ve leaned deeply important and helpful ideas and ways of looking at the work from clients%27 willingness to come forward with what they are thinking and feeling.
If you have any further questions after having read this disclosure document please feel free to ask.
%3c/div%3e

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

PRIMARY CLIENT INFORMATION

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TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

TERRI BENSINGER LEVY PSYCHOTHERAPY PRACTICE

1801 Bush St Suite 110 San Francisco CA 94109-52954155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127

1801 Bush St Suite 110
San Francisco CA 94109-5295
4155050127