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Barton Goldsmith, Ph.D., MFT, CADC-I
Psychotherapist/Licensed Marriage & Family Therapist, Certified Substance Abuse Counselor
32129 Lindero Canyon Road, Suite 210   Westlake Village, CA 91361
818-521-2922      Barton@BartonGoldsmith.com
 
Informed Consent
Welcome. This patient information form will answer most of your questions about therapy services at my office. Please feel free to ask for clarification or additional information at your initial visit.
What is therapy and how does it work? Therapy is the process of solving emotional problems by talking with a person professionally trained to help people achieve a more fulfilling individual life, marital relationship, or family relationships. The process of change will, in many ways, be unique to your particular situation. Who you are as a person will help to determine the ways in which you go about changing your life. The process of change begins by first clearly defining the problem, and then discussing your thoughts and feelings, understanding the origin of the difficulty and developing new skills and healthy attitudes about yourself and others. As the patient, you have the right to ask your therapist questions about his/her qualifications, background and orientation. The most important factor in the success of therapy is good communication between therapist and patient. In some instances, talking about your difficulties may exacerbate your symptoms, however over time you should see an improvement. In addition, not all individuals benefit from therapy or working with a particular therapist. If at any time during the therapy you have questions about whether or not the treatment is effective, feelings about something I have said or suggested or need clarification of our goals, do not hesitate to bring this up in our session.
Confidentiality: By law and professional ethics, your sessions are strictly confidential. Generally, no information will be shared with anyone without your written permission. If you are seeing another therapist or health professional it may be necessary for me to contact that person so that we can coordinate our efforts. If this is necessary I will ask for your permission. In addition, some insurance companies require periodic updates. I will only provide this information with your permission.
Regarding couples counseling: I employ a "no secrets" policy when counseling couples. Your signature at the bottom of this document states that you understand that if you are seeing me with your partner and information arises through an individual conservation, that information is not bound by the standard confidentiality agreement. This process is therapeutically correct as it does not let either party covertly control the therapy.
The following are additional exceptions to this confidentiality policy.
  • If I am ordered by the court to testify or release records.
  • If you are a victim or perpetrator of child abuse I am required by law to report this to the authorities responsible for investigating child abuse.
  • If you are a victim or perpetrator of elder or dependent adult abuse I am required by law to report this to Adult Protective Services or other appropriate authorities.
  • If you threaten harm to yourself, someone else or the property of others, I may be required to call the police and warn the potential victim, or take other reasonable steps to prevent the threatened harm.
Fees: My current fee is $250.00 for sixty-minutes (1hour) or $195 for 45-minutes. You are expected to pay for the counseling at each session unless other arrangements have been made. Fees may be increased with reasonable notice. If at any time you have financial concerns do not hesitate to discuss them with me. In most cases, financial concerns can be resolved. Please have your check made out to Dr. Goldsmith before your session so we can use our time together in the wisest ways.
Unpaid balances: A credit card needs to be on file and its use is authorized by signatures on this document and on the intake form. If Dr. Goldsmith cannot collect directly from the patient, the card may be charged and all attempts will be made to collect the debt. If there is more than one person in therapy, both are responsible for the charges. Delinquent bills will be turned over to a collection agency. The patient is responsible for the original bill, service charges, collection fees as well as any legal costs that are incurred as a result of the collection process.
Insurance: I do not bill insurance companies directly. I will give you a statement at the end of the month marked "PAID" which you may submit to your insurance company for reimbursement directly to you.
When insurance is utilized for psychotherapy services, patients should be aware of the limits of confidentiality. Typically, insurance companies only require the following information: length of illness, psychiatric diagnosis, dates of service, and the names of persons being treated. Recently managed care companies have been requiring additional information such as family abuse history, alcohol and drug history, treatment goals/interventions, the details of the treatment sessions, and on some occasions, treatment notes. In addition, providers are now required to sign waivers that allow the payers to audit client records. What this means is, if you utilize your insurance benefits for psychotherapy services, you may not have the extent of confidentiality you would otherwise expect.
Cancellations: You will be charged for all missed appointments. You may call my answering service 24 hours a day, seven days a week to cancel an appointment. Frequent cancellations may result in your losing your regular appointment time and having to schedule our meetings based on my availability each week. If you have the type of schedule that makes consistent weekly appointments impossible, we may be able to work out a schedule that meets both of our needs. Periodically I will have to cancel sessions due to mandatory court appearances or medical emergencies. If this occurs I will notify you promptly so that we can reschedule our session. You will not be charged for these cancelled appointments.
After Hours Emergencies: I am not available after my usual business hours for emergencies I do check my messages during weekdays between 9:00 AM and 8:00 PM and I am usually available to speak with you on the telephone (or schedule a time we can talk). There will be a charge for all telephones calls other than brief calls concerning rescheduling appointments, confirming appointments, etc. Leave a message on my voicemail (818-879-9996) and I will call you back as soon as I retrieve the message. For after-hours emergencies or if you need immediate assistance call 911, your medical group, or your primary care physician.
Vacations: I will give you reasonable notice before I go on vacation. If I am going to be out of town or unavailable, a colleague will be on call for emergencies. The name and phone number of this individual will be on my answering machine. If you feel that you will need continuing treatment during this time, I will help you make arrangements ahead of time with another therapist.
Terminating Treatment: You have the right to terminate or take a break from your treatment at any time without my permission or agreement. However, if you do decide to exercise this option, I encourage you to talk with me about the reason for your decision in a counseling session so that we can bring sufficient closure to our work together. In our final session we can discuss your progress thus far and explore ways in which you can continue to utilize the skills and knowledge that you have gained through your therapy. We can also discuss any referrals that you may require at that time.
Psychotherapists are ethically required to continue therapeutic relationships only so long as it is reasonably clear that patients are benefiting from the relationship. Therefore, if I believe that you need additional treatment, or if I believe that I can no longer help you with your problems I will discuss this with you and make an appropriate referral.

Legal Issues: Should any legal issues/disputes arise between the client and the therapist, the client agrees to settle said issues/disputes through mediation and binding arbitration rather than the court system. 
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