Confidentiality

Your Background Information

Please provide me with all of the background information that follows in advance of our first session. The more you tell me about yourself, the better I will be able to help you.

Please Note:
You must be 18 or older.

Form required for e-mail clients only.  Other clients can review history verbally in the first session.

If you have a history of violence or are on anti-psychotic medication, I cannot work with you through e-mail or phone therapy. In-person therapy would be the best choice for you.

IDENTIFYING INFORMATION: Name, age, sex, marital status, address, phone, and any other identifying information that you wish to include.

EMERGENCY CONTACT: The name, address, and phone number of someone I could contact in case of an emergency.

HEALTH: Any serious health problems you currently have or have had in the past which might influence our work together or my understanding of your personal life.

ADDICTIONS: Degree to which you use alcohol or other drugs.

VIOLENCE: Whether you are seriously considering either suicide or violence against another person.

SUICIDE ATTEMPTS: Whether you have ever attempted suicide.

THERAPY HISTORY: Whether you are now in therapy or ever have been in
therapy. (If you are in therapy now, your face-to-face therapist has a "veto power" over our relationship and you may share our e-mail with him or her to facilitate the decision.)

OTHER NEEDED INFO: Any other information that I should have if I'm going to be able to help you.

I usually respond within 48 hours. If you haven't heard from me in 48 hours, please re-send your letter. (On weekends, please allow 72 hours...)

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PRINT THIS OUT, SIGN, AND RETURN THIS TO ME BY POSTAL MAIL along with your background information and first payment:

By signing below I agree to the following terms and conditions:

1) I have read the sections on confidentiality, privacy, and fees and agree to the terms specified in those sections.

2) I agree that when engaging in telephone or e-mail therapy, we are meeting in Pennsylvania and will abide by the laws of Pennsylvania

3) The information that I have provided regarding my background and treatment history is truthful and complete.

Signature: __________________________________

Date:_____________