VIEWS: 3 PAGES: 2 POSTED ON: 12/11/2011
Jill M. Penaloza ATR-BC, CGP 133 Defense Highway, Suite 210, Annapolis, MD 21401 (410) 279-3106 Welcome. I appreciate the opportunity to serve you in group therapy. I am a board certified art psychotherapist with a Masters of Science in Education and Certifications in Art Therapy and Group Psychotherapy. The purpose of this Creative Cognitive Therapy Group for Women is to help you learn, practice and integrate new skills that you can use to improve your quality of life and your relationships. In each session we will combine cognitive instruction with creative expression as a means to accessing and organizing your “whole” brain around new beliefs and behaviors. As the group leader, my goal is to provide a safe and supportive environment in which you, and all group members, can both experience and practice compassion, curiosity, playfulness, empathy, and acceptance. Client Name:________________________________________ Date of Birth:_____________________ Address:______________________________________________ Cell Phone #:__________________ Email Address:_________________________________________ Home Phone #:________________ INFORMATION AND CONSENT ATTENDANCE AND MISSED SESSIONS Regular attendance is very important. Your attendance will directly relate to the effectiveness of the group for all group members. If you miss a session you will be responsible for payment. If several group members have a conflict on the same day we may decide to reschedule that session. If you need to schedule an individual session with me in order to make up for a missed session the cost is $90/hr. PAYMENT FOR SERVICES, HEALTH INSURANCE / MANAGED CARE For a 10 member group the cost per member would be $50.00 ($25 per hour) for each 2-hour session. For a 12 member group the cost per member would be $42.00 ($21 per hour) for each 2-hour session. You will be required to pay $100/$ 84 (10 member/12 member group) for every 2 sessions in advance. No refunds. I do not participate in any insurance or managed care networks. If you will be submitting insurance claims please let me know in advance and I will provide you with an invoice for services. CONTACT OUTSIDE OF APPOINTMENTS Questions and concerns arise that can be addressed in a brief telephone conversation or email. Please feel free to leave me a confidential message at (410) 279-3106 or email me at email@example.com. I will respond as soon as possible. I consider occasional phone calls or emails to be part ordinary treatment and I do not bill separately for them. There may be a charge for extended telephone or email responses. EMERGENCY CARE, URGENT CARE, AND THERAPIST ABSENCE In case of a mental health care emergency requiring immediate action please call your psychiatrist or primary therapist or go to your local emergency room. If I have an emergency and need to reschedule group I will contact you as soon as possible to let you know. CONFIDENTIALITY Group discussions are confidential. No information will be released without your written consent unless mandated by law. By signing this information and consent form you are giving me your consent to share confidential information with your primary therapist and all persons mandated by law. I authorize, Jill M. Penaloza, to communicate with the provider listed below to discuss mental health information for the purpose of coordinating group and individual mental health treatment. My Primary Therapist Contact Information: Name: Address: Telephone Number(s): Email Address: DUTY TO WARN In the event that Jill Penaloza, MS. Ed. ATR-BC reasonably believes that I am in danger, physically or emotionally, to myself/them self or another person, I consent for her to warn the person in danger and to contact the following persons, in addition to medical and law enforcement personnel: Name Telephone Number CONSENT TO TREATMENT I agree to receive mental health assessment, care, treatment, services, and authorize Jill Penaloza, MS. Ed. ATR-BC to provide such care, treatment, or services as are considered necessary and advisable. I understand that I may stop such care, treatment, or services that I receive from Jill Penaloza, MS. Ed. ATR-BC at any time. By signing this Client Information and Consent form I acknowledge that I have both read and understood all the terms and information contained in this consent. _____________________________________________ ___________________________ Client Date
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