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The Center for Growth and Healing
Psychotherapy Seattle & Kirkland
Executive Director
Wayne E. Carr, Ph.D.
Licensed Psychologist
WA License # PY00002543
(active), NV License # PY0354 (inactive), CA License # PSY14938 (inactive)
Mailing
Address:
15505 79th Ave. NE Kenmore,
WA98028
Phone: 425-488-5496
waynecarr@yahoo.com
,
www.growthandhealing.com
Blog:
www.waynecarrphd.blogspot.com
DISCLOSURE AND POLICY STATEMENT FOR
CLIENTS
Welcome to my
practice. I am pleased to have the opportunity to serve you.
This document
answers some questions clients often ask about my practice. It is important
to me that you know how we will work together to assist you in making an
informed decision concerning my services. I believe that our work will be most
helpful when you have a clear idea of what we are trying to do. I encourage
questions at any time, as they are helpful in solidifying the therapy process.
This brochure
will answer the following in a general way:
·
What the risks and
benefits of therapy are
·
What the goals of
therapy are and what my methods of treatment are like
·
How long therapy might
take
·
How much my services
cost and how I handle money matters
·
Other areas of our
relationship
After you read
this brochure we can discuss, in person, how these issues apply to your own
situation. This brochure is yours to keep as a later reference. Please read all
of it and mark any parts that are not clear to you. Write down any questions you
think of, and we will discuss them at our next meeting. When you have read and
fully understood this brochure, I will ask you to sign it at the end. I will
sign it as well and make a copy, so we each have one.
PARTIES TO THE PROFESSIONAL RELATIONSHIP
Wayne E. Carr,
Ph.D. rents office space at several locations. The other practices of the
professionals at these locations are separate and independent from one another.
Therefore, this agreement is solely between you and Wayne E. Carr, Ph.D., a
licensed psychologist practicing independently.
PSYCHOLOGICAL TREATMENT AND RESULTS
Effective
psychological treatment requires openness, an attitude of collaboration, and
your willingness to invest both time and effort between sessions in working
toward personal change. The success of treatment can not be guaranteed because
the outcome depends significantly upon your actions. I will utilize my
experience and education to work with you, and will perform my services in a
professionally competent manner. In turn, your efforts will enhance the speed
and effectiveness of this process.
I encourage you
to ask about the procedures, goals, results and possible side effects of
psychotherapy. Psychotherapy may be very beneficial for some individuals while,
at the same time, there are risks. The risks may include the experiencing of
intense and unwanted feelings, including sadness, anger, fear, guilt, depression
or anxiety. It is important to remember that these feelings and experiences may
be natural and normal and are an important part of the therapy process, and are
usually a sign of psychological integration and healing. Other risks of therapy
might include reliving unpleasant life events, facing unpleasant thoughts and
beliefs, changes in one's personal life style, and alteration of an individual's
desire or ability to deal effectively and harmoniously with others in
relationships, in or out of the family. It is also important to note that
therapy is only one force working to shape behavior and attitudes in a person's
life. These other forces can affect outcome, making it more difficult to reach
the desired outcome. Throughout the therapy process, I encourage you to
discuss, and work on, these experiences. Not dealing with them is often what
brings people into therapy. And dealing with them increases the likelihood of
achieving a satisfactory outcome.
APPROACH TO TREATMENT
I have been a
practicing psychologist since 1996. My basic approach to therapy can best be
described as Integral and "Humanistic". Humanistic means therapeutically &
creatively using authentic contact, feelings and awareness in the “here and
now”. I have integrated many different approaches from a variety of
disciplines (for example, Gestalt, Primal, Transpersonal, Integral,
Marriage & Couples counseling, Child Counseling, Cognitive-Behavioral, Stress
Management, Practical Problem Solving, and “Radical Honesty”) I will try to find
and continually adjust the most appropriate combination of interventions to
most effectively reach the goals of therapy we have decided on. When dealing
with couples relationships or families I use a "systemic" approach, meaning that
the relationship or family constitutes a unique system which in and of itself
becomes a separate “client" which must be looked at and healed.
The
Integral approach: Dr.
Carr stresses that it is important to work on all levels of the self, as
well as of the whole self, for complete healing and full functioning.
This includes the cognitive level (thinking), the emotional level,
the primal level (assessing the limbic system in the brain), the body
level, the behavioral social level and the spiritual energetic
level. What levels and problems you want to work on is up to you
In our initial
contacts, I will be describing how the appropriate types of therapy work and I
encourage you to ask any questions you may have regarding your treatment.
Please fell free to ask about the strategies I am using or the expected outcome
of therapy. In all cases, appropriate professional boundaries are respected
and maintained.
In regards to
spiritual matters, Dr Carr respects all the great wisdom traditions,
religions and sects (including non-religious positions etc.) He believes they
all come in several versions: A “toddler” version, a “child” version, an
“adolescent” version and an “adult” version. One tends to pick the version of
appropriate to their developmental level and needs. As we grow we tend to move
up the religious or spiritual developmental scale and change versions.
Initial
_________
GOALS OF
THERAPY
The goals of
therapy are mutually determine by both the client and the
therapist. I believe that problems can be identified, and solutions defined, in
a straightforward and understandable manner. The length of therapy, and the
approaches that I employ, will depend on your particular needs and goals. On the
last page is space for you to list some possible goals that we can
discuss during the next session. They can be specific and general, short term
and long term. How do you ultimately want your life to be? Be honest; discontent
is not a bad thing.
Initial _________
FREQUENCY OF
APPOINTMENTS
Weekly
appointments are usually
appropriate unless you are in crisis, in which case it may be suggested
that you temporarily come two to three time a week. Toward the end of therapy,
it may be appropriate to come every other week or as needed.
Homework and THE starting OF a
weekly “practice”
Dr. Carr is
serious about the giving and the client doing of weekly homework. An
example of homework might be the reading of an article, studying a handout,
listening to a CD or to a talk on Dr. Carr’s web site
www.healingmedia.net , or the
practice of an agreed upon new behavior such as the expressing of a
feeling to someone, or the increased awareness of boundaries during
interactions with someone. Dr Carr will always ask you about your homework.
Dr. Carr will
also ask you to take up an agreed upon weekly discipline or practice such
as controlled breathing, mediation (or prayer), relaxation, yoga, swimming or
exercise (class or at home), support group, journal writing, nature walks, time
together with one’s spouse etc.
Initial _________
Weekly
group therapy (optional but highly recommended)
You will
probably be invited to attend a weekly group therapy meeting if it fits your
schedule. It is strongly recommended that you attend. The group allows us to
practice what we have learned and to get crucial feedback and support! The group
meets one night per week for two hours and payment is whatever you
can comfortably afford. (e.g.: $10-$60) (No charge to those who have current
financial difficulties)
Initial _________
You may be
asked if you are willing to bring your spouse or other family members in for
several sessions
A relationship
is an entity in and of itself and it must be looked at as such. It is
much less effective to teach one person to “dance” while the other person gets
no dance lessons. A therapist can see and point out the subtle interactions with
two or more present that would otherwise be missed! Keep in mind the 90-10
rule: Usually when we blame someone for something that has upset us 10% is
really them and 90% is our own stuff that has be triggered!
Initial _________
USE OF THE "PRIMAL” EMOTIONAL RELEASE ROOM (OPTIONAL)
When it appears that old rage and anger,
as well as, old deep sadness are beginning to surface, Dr. Carr may suggest use
of the primal room downstairs. The primal room is relatively soundproof
with no windows. It has mattresses on the walls and floors. It has various
blankets, pillows, bats and punching bags they can be used for release work. It
also has a sound system that can play emotionally appropriate or evocative
music. The lighting and temperature is also adjustable. Clients can release
pent-up feelings that have been held back for many many years. The effect is
often a huge sense of release and freedom such as they have never felt. Clients
are often initially not aware of how much deep pain, emotion and knowledge
they have stuffed and numbed sense childhood.
The use of the primal room is part of the
process of working on all levels of the self. Use of the primal room is
never mandatory and always optional. It is totally okay for a client to say they
don't want to, or are not ready to explore that possibility in themselves.
Plenty can be done without use of the primal room depending on the goals of
therapy worked out between the client and the therapist.
“Primaling” allows us to fully access the
limbic system and brainstem where the actual painful
memories are stored. Your can talk about your problems (using the
cortex) for decades and centuries and never access the part of the
brain where the pain is actually stored. This unconscious pain
unconsciously drives many of our current thoughts and behaviors without our
realizing it. The conscious cortex is usually clueless about this process
and tries to make sense of what is gong on by rationalizing. Only trying to
change our thoughts will have limited results. Deep feelings, thoughts and
behaviors have to be changed on their own neurological level. “Trickle
up” and “trickle down” is very limited.
PLEASE USE WEB PAGE, BLOG, BOOKS, CD’s , TAPES & HANDOUTS AS MUCH AS
POSSIBLE
Feel free to
access my web site:
www.growthandhealing.com ,
www.healingmedia.net , and
www.waynecarrphd.blogspot.com for
therapeutic articles and charts and to listen to self-help talks by various
people. (Handouts are yours to keep and study) I also have a lending library
of self-help books and tapes. Borrowers are responsible for their prompt return
after a two week period. DR CARR IS VERY SERIOUS ABOUT RETURNING BOOKS
ON TIME SO OTHERS CAN USE THEM!
Two-Week
Borrowing Agreement:
Sorry to ask for a deposit. Nothing
personal, this process keeps books available for other client to borrow and
keeps me from losing several books a year. Everyone, including myself, gets
absent-minded at times. (Most people, most likely including yourself, are very
good at returning books in any case)
A deposit check will be held
by Dr. Carr for the price of the book or item (new) plus a $10
restocking fee. If the book or item is not returned within one month, the
book is yours and the check will be cached to repurchase another book.
Any deposits will be immediately returned when the book is returned within the
month period.
An additional check deposit will be
asked for out-of-print books. The amount of that deposit will very
depending on the rarity of the book. That check will also be cached after one
month if the book is not returned. These agreements, of course, can be altered
under extenuating circumstances, after talking to Dr. Carr.
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PLEASE GET
UPDATES AND HELPFUL INFORMATION BY BEING ON THE EMAIL LIST!
You will be
asked at the bottom if you want to be place anonymously on Dr. Carr’s Growth and
healing email list to receive valuable updates, schedule
changes, and helpful information for your personal growth and development.
Your information and email address will not be shown or given out without
your permission.
Initial _________
ENCOUNTERING RESISTANCE and
Pain IN THERAPY
It is not
unusual during the course of therapy that some painful feelings from the past
come up. This is part of the process. When painful feelings come up, some
people want to run the other way as far as they can. At this time a client can
think of all sorts of reasons not to come to therapy. The best clue to go by is
to notice if a desire to avoid comes at a time when the therapy is being most
successful and effective in revealing painful material.
Another issue to
look at is something called "transference" in which case you notice you began to
react to and resist the therapist in the same way you reacted to or resisted one
(or both) of your parents. When transference happens it is something to be
worked through instead of acted out.
Therapeutically
it is better to become aware of, and work through this kind of resistance than
to escape into avoidance. This working through can actually be a caring and
gentle process. This does not mean doing therapy when you hit an impasse or a
desire to run away will be easy. As emotional “frostbite” thaws and feeling is
regained it will sometimes require the bearing of pain for a while. You will not
bear this pain alone though.
In addition,
some people want to quickly discontinue therapy as soon as they feel better, or
as soon as their relationship starts going smoothly. It is much wiser to first
more firmly establish the necessary skills and tools to continue to maintain the
improvement over a long period of time and for when you hit a "bump in the road"
or get hit by a “rainstorm". It's almost a guarantee that you will hit bumps in
the road that will catch you off guard.
Don't get
trapped by the “leak in the roof syndrome” which goes as follows: “When my roof
is leaking I can't fix it; when my roof is not leaking I don't need to fix it.”
You need to make sure the holes in your relationships and coping skills are
fully "patched up" before the next "rainstorm". You also need to make sure you
have enough tools in your "tool belt" to patch things up during a rainstorm.
If you feel the
urge to run or avoid, just let Dr. Carr know so we can discuss what may be going
on . We all use the “ostrich method” at times but it has its limitations.
Initial
_________
The role
of pain
Pain is the
body-mind’s message ‘pay attention to me” and “something needs
attention”. It plays an important role in life. Unfortunately we live in a
society that is very phobic toward pain. When pain is intense enough it causes
us to let go of our old coping skills and risk trying new ones. If you always
take the edge off your pain with alcohol of another drug of choice, you will
keep your old coping skills. A therapist role is sometimes to help you through
this healthy suffering. An hour of healthy suffering an prevent months of
unhealthy suffering. Keep in mind there is plenty of room for joy,
excitement and discovery during therapy as you learn to see through new
eyes.
Initial _________
Denial and
defenses (EVERYONE HAS A SHADOW)
No matter who
one is and no matter how good a childhood one remembers, we all carry a
reservoir of unfinished hurt, anger, pain etc. inside of us. Most of this
painful material is kept from consciousness by defenses, rationalizations and
justifications. We all have disowned parts of ourselves referred to as
“shadow”. Everyone has a shadow whether or not you are aware of it. Your shadow
shows up in your relationship & behaviors and makes your repeat the same
mistakes over and over in its attempt to heal. Our conscious mind is just the
tip of the iceberg that goes deeper than we imagine.
Initial _________
COMMITMENT
asked for
I believe that
serious psychotherapy requires a commitment on the part of the client
beforehand that when painful feelings are encountered the client will
stay the course until he/she gets over any painful humps. I like the saying
"the truth will make you free, however first it may hurt a little bit." You have
to decide how deep you want to go and then go there. The deeper you go the more
rewards you will reap and the more courage and commitment your will need. It is
my job to supply the support, patience, encouragement and expertise. Again, you
will not be lost and alone in this journey.
You can’t judge
progress, the extent and effectiveness of therapy in one or two session. If one
intervention or therapy style is does not work with you another will be tried.
Not everything will bring instant results. During the course even the best
therapy there must be occasional plateaus and setbacks. Be aware if you
have any tendency to jump to conclusions.
At the beginning
of therapy, goals will be mutually determined and a commitment to these
goals will be discussed. Also, realize the goals of therapy may change during
the course of therapy as you progress. As one gets the lost parts of one’s
self back one tends to want all of one’s self back. This can go way beyond
just “figuring something out”
Some problems
can be solved in days, some deep wounds require years to completely heal. You
can still experience rapid relief and change even if the total wound may needs
years to totally heal.
Is it totally
another matter if therapy is no longer necessary given one’s goals, or is truly
not being productive, or if, after discussing it during a session, it is
determined there is not a good match. In this case, after an Exit Session,
therapy can be discontinued and a referral can be made if necessary.
Please don’t
wait to discuss any reservations or concerns you have. There are many, many
different approaches, techniques and interventions that can be used with you.
After being informed of the ones that would be appropriate, you can pick the
ones you fell most comfortable with.
Initial _________
SPECIFIC
EXIT SESSION requested at
completion or termination of therapy
If you decide
you want to discontinue therapy Dr. Carr asks you to commit to attending a
final exit session to discuss any final issues and allow for full “closure”.
This will allow for 1) a review of the total progress in therapy 2) a
discussion of what may still need work and how 3) a completion of any processes
needing completion, 4) allow us to express final feedback 5) allowing us to
check out any unchecked out assumptions 7) the expression of appreciations and
goodbyes 8) Other possible referrals.
Initial _________
MY AVOIDANCE
OF “PSEUDO PROFESSIONALISM”
“Pseudo professionalism”
can be great hiding place for "control freaks" and others who are afraid to be
authentic and human. It is the creation of an appealing professional looking yet
hollow façade.
Real
professionalism is a
genuine value, and necessary to run a business, but it's only valuable to the
extent that it helps us be more genuinely trustworthy more genuinely human and
more able to relate to each other. It is a necessary but not sufficient part of
good therapy. Good therapy is a combination of art, skill, experience,
training, intuition, knowledge, professional integrity, and outrageous
creativity. It is by no means the mere following of cookbook procedures, the
giving of diagnoses and the filling out of forms.
Unfortunately,
in our society the façade or image of professionalism often supersedes,
and is more important than, real substance and expertise. Pseudo
professionalism is also often misused to maintain a power differential between
"professional" and client. This kind of social sickness over emphasizing the
importance of façade, has led to a society where most people have difficulty
distinguishing between their own self-image and façade and their real authentic
self.
As a
professional therapist, part of my job is to undo some of this damage, so that
people can get in touch with their authentic self.
Initial _________
GREENLAKE OFFICE
BUILDING OR OFFICE IN PRIVATE HOME?
THE
THERAPEUTIC ADVANTAGES OF RECEIVING THERAPY IN DR. CARR’S OFFICE IN HIS
PRIVATE HOME
(For those of you in the Kenmore area)
Some people may
feel squeamish about seeing a psychologist in a private home. Dr. Carr’s office
in his private home, although not providing a standard “clinical” façade,
actually can be more conducive to doing therapy by providing a relaxed, safe,
supportive and ‘homey” atmosphere. It is just as professional, just less formal.
It’s easy to get used to. A fair number of therapists in this country have
offices in their home. If you want to see Dr. Carr in a more “formal” setting
(which I respect) you are welcome to see Dr. Carr at his Greenlake office. Of
course, whatever location you live closest to should be the major factor in
deciding.
Initial _________
BASIC HELPFUL
DEVELOPMENTAL MODEL USED:
As adults, almost all of us have parts of ourselves that
are still stuck at stages further down on the developmental ladder that need
help catching up with the rest. We all have a “center of gravity” some place
along this oversimplified scale.
1st tier
Pre- rational
1. infant Stage Survival
oriented (Pre- conventional)
Me
and not me.
2. Toddler Stage Rule oriented
Conformist stage - Order Driven.
Me and other me's.
Rational
3. Child Stage Success oriented
(Achiever Stage) “Mental”
Me
and You and I'm going to win
4. Adolescent
& young adult Stage Relationship oriented
(Pluralistic Stage)
Me and You. I know how you feel. I know how you feel about
me.
(Most of the world’s adult population’s “center of gravity”
is from Infant to Adolescent stage.)
“2nd tier” Rational moving to “trans-rational”
5. Adult Stage “Philosophically” (or
perspective) oriented (Integrated or Integral Stages) (Paradigmatic to Post
Paradigmatic)
Me and you and we
are both part of something greater.
Trans-rational
3rd tier
The sixth stage may have only a very few representatives
6. Elder Stage Transcendental (Holistic Stage) “Global
Mind” When I see you I
see me.
Initial _________
GOOD THERAPY
INVOLVES BOTH RE-GRESSION AND PRO-GRESSION:
As we climb our
developmental ladder we must both reach for new higher rungs
on the ladder and go back and help the parts of ourselves (often disowned) still
stuck on the lower rungs catch up with the rest of us. Progression
involves risking, reaching out, trying new behaviors & ways of being, building a
support network, getting nourishment, accomplishing, maintaining boundaries,
getting new perspectives. Regression involves fully feeling, experiencing
and re-owning and re-parenting the parts of ourselves still
in the infant, toddler, child and adolescent stage (our “shadow”). Both need a
base of safe caring support to work fully. We can rarely do this
totally for ourselves at first; we all need each other.
Initial _________
CONFIDENTIALITY
All information
you disclose is considered confidential, and will not be released without a
Release of Information form signed by you. The law requires disclosure
of confidential information, and reporting to authorities, in three situations:
suspected abuse of children or incapacitated adults, threatened harm to self or
others, or if individuals are gravely disabled and not able to care for
themselves. In some instances, confidential information can be subpoenaed by
court order.
Additionally,
the law allows me to provide information about your care, without your
permission, to the extent that a recipient needs to know the information, to:
·
Any other health care
providers reasonably believed to have provided you with previous healthcare
services, to the extent necessary for them to provide continuing health care
services to you, unless you have instructed me in writing not to disclose this
information;
·
To any other
individual, if I believe reasonably that disclosure will avoid or minimize
danger to health and/or safety of you or this other individual, although I am
not necessarily obligated to do so;
·
Any of your immediate
family member or other individuals with whom I believe you to have a close
personal relationship, if made in accordance with good professional practice,
unless you have instructed me in writing not to disclose this information.
Confidentiality
law does not cover sessions with two or more persons, e.g., couples or families,
but it does apply when one of these persons is seen individually. On all
occasions in which confidentiality is an issue, I will attempt to meet the
ethical, clinical and legal responsibilities I have to you.
Initial _________
IF YOU EVER
FEEL SUICIDAL:
If you feel like
hurting yourself or ending your life, my role is to supportively help you
through this period (and you will get through it). I will want to be in
contact with you several times a week. You are important so please reach out
for help and lean on me for a while. I will set up a special arrangement for
you.
Initial _________
ETHICAL AND
PROFESSIONAL STANDARDS
Psychologists
offering service to the public must be licensed by the State of Washington. A
licensed psychologist has a doctoral degree from an accredited university,
supervised pre- and post- doctoral experience, and has passed a national written
examination and an oral examination given by the Washington State Examining
Board of Psychology. I received my doctoral degree from the University of
Nevada Reno in 1982, and have met all the other requirements for licensure in
the State of Washington.
I have no
financial arrangements with any individual or any agency regarding referrals to
or from me. I do not pay any fees for the referral of patients to me, nor do I
accept fees for patients whom I refer to other professionals.
As a licensed
psychologist and member of the American Psychological Association, I am
accountable for my work with you. If you have any questions or concerns about
the quality of my services, or any administrative matter (such as fees, etc.),
please discuss them with me first. I am committed to providing
the highest
quality professional service, managed in a fair manner. If, after discussing
your concerns with me, you feel that I have been unresponsive to your concerns,
you may contact the Department of Licensing, P.O. Box 9646, Olympia, Washington
98504, and (360) 753-0776.
Initial _________
SUPPORTIVE
HUGS AND LIMITED SUPPORTIVE AND THERAPEUTIC TOUCHING WITH PERMISSION FROM
CLIENT
When Dr. Carr
feels it may be therapeutic, supportive and appropriate, he may offer a gentle
(non-full-bodied) hug or a hand on the shoulder. During a great many sessions
touch is not offered. He will clearly ask for your permission prior to
any touching, at which point you are entirely free to say you would not
like that. There is no pressure agree and you can change your mind at any time.
It is also OK for you to ask for a hug or a supportive hand on the
shoulder and Dr. Carr will comply if he feels it is appropriate.
Touching is not
necessary for successful therapy to occur. Sometimes touch, when done at the
wrong time, can interfere with the client’s experience. For some people with
trust issues, physical-sexual abuse issues, boundary issues, or saying "no"
issues, therapeutic supportive touch may be experienced as too overwhelming or
intrusive and in this case is not initially appropriate.
Any kind of
touching is only done with clear permission and of course, is only in
appropriate (nonsexual) areas. It is Dr. Carr's clear intention to
acknowledge and respect your boundaries without shame or guilt on your
part.
With
permission, touching may
be offered during the session as a means of: 1) providing support while crying
2) providing something to push against, or hold on to, in emotional release
work, 3) helping provide awareness of muscular blockage of emotions and
breathing. 4) Saying goodbye. Please discuss this further with Dr. Carr if you
have any questions or reservations.
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APPOINTMENTS
Individual
therapy sessions are 45-50 minutes in length. It is important to be on
time because your appointment will not be extended beyond the scheduled time
because of your late arrival. Your appointment time is held exclusively for
you. If you are unable to keep your appointment for any reason, you must give
at least 24-hour advance notice to cancel. OTHERWISE, YOU WILL
BE CHARGED THE FULL AMOUNT FOR THE TIME RESERVED FOR YOU. INSURANCE DOES NOT
PAY FOR LATE CANCELLATIONS OR MISSED APPOINTMENTS.
PLEASE KEEP
DR. CARR UPDATED. Also,
if Dr. Carr misses an appointment (on very rare occasions) the next scheduled
appointment is on him (no charge).
If your life
circumstances change and you can make appointments for awhile please give Dr.
Carr a call; don’t just drop off the map. Try not to be shy about
discussing any changes that have happened. If I can't get a hold of you for
awhile, I worry about you.
Initial _________
EMERGENCIES
In the event of
an emergency outside normal office hours, you should first attempt to reach me
at 425-488-5496. This number should be reserved more urgent issues. If you
are unable to reach me through one of these sources, please contact one of the
following: Crisis Clinic 206.461.3222 or toll free 1.800.244.5767, Emergency
services at 911; or proceed to your local hospital emergency room as
appropriate.
Initial _________
PAYMENT POLICIES
Payment for
services provided to you is expected at the time of service. You are expected
to pay for all services you receive, whether or not insurance will eventually
pay for a portion of the charges. Full payment of the charges is expected with
each visit unless you have left in this office your insurance form with benefits
assigned to me. Any other arrangements should be made on an individual basis
with me. My fee for psychotherapy is $145.00 per 45-50-minute session.
For people with difficulty paying this amount there is a sliding scale
from $145 down to $60 in some circumstance. There will be a $20 fee for
returned checks. You may have additional charges for:
·
legal expenses,
including testimony, billed at $250 per hour
·
Extended time in
psychotherapy sessions
·
In-hospital serviced
·
Administration, scoring
and interpretation of psychological tests
·
Books, pamphlets and
other learning materials
·
Reports, letter or
telephone calls on your behalf to attorneys, physicians, agencies, employers,
state disability, etc.
·
Telephone conversations
with you
·
Travel time to any
location outside my office
Some of the
above charges are not covered by insurance plans. No reports will be released
on your behalf unless your account is current. A retainer fee for court or
other legal purposes must be paid prior to commencing any evaluation or
treatment. Over a long period (years), Dr. Carr may adjust his fee’s in
accordance with current billing practices of Psychologists and Inflation.
If you run out
of money or are having financial problems while you are in a temporary crisis,
Dr. Carr will probably see you at no charge or a differed payment plan
can be worked out. Feel free to discuss you options during a time of crisis.
Initial _________
INSURANCE REIMBURSEMENT
Many, though not
all, medical plans cover psychological services when your work with a Licensed
Psychologist. I recommend that you check with your insurance company to see if
you are entitled to receive any benefits under your plan. I will also have the
lady and does my billing check this for you, and get back to you the next day.
What
you are responsible for
You are
responsible for the insurance any yearly 1) deductible amount left, 2)
the insurance co-payment as well as for the 3) difference between
what the insurance company is billed for and the percentage of that
billed amount that the insurance company actually pays. 4) If other
arrangements have been made, then you are responsible for payment according to
those other arrangements. Feel free to discuss any arrangements with Dr. Carr.
5) Please read below for your responsibilities when insurance checks are mailed
directly to you.
Initial _________
When
insurance checks are mailed directly to you
Some insurance
companies, like Premera Blue Cross, will sometimes mail the checks to cover the
session fees directly to you (the client) instead of to me (the
provider). This is more often done for providers who are "out of network". When
the insurance checks are mailed to you, it may be easier for you to pay for each
session and then wait for the reimbursement check to be sent to you. If this is
not possible, you must remember to forward or bring the insurance check
sent to you to Dr. Carr's office the week you get it.
Initial _________
OVERDUE
ACCOUNTS
You are
responsible for your account and are expected to pay for all services you
receive. Accounts overdue 90 days or more may be turned over to a collection
agency or to an attorney. You will be responsible for attorney's fees and
costs, or collection agency fees in the event that your account becomes
delinquent. Accounts overdue more that 30 days will be assessed a 1.5-%
interest charge each month (18% per year).
Initial _________
SPECIAL NEEDS
If you have
special needs of any kind (including financial), please discuss these with me.
AGREEMENT TO PARTICIPATE IN SERVICES
(Your Copy. Dr Carr’s copy follows this page)
If you have any
questions, please feel free to discuss them with me prior to signing this form.
Your signature indicates that you have read, initialed, understand, and
agree to these policies, and accept responsibility for payment of fees in
accordance with these terms and conditions. Your signature also indicates that
you have received your own copy of this office policy agreement.
________________________________
________________________
Client
Signature
Date
________________________________
________________________
Wayne E. Carr,
Ph.D.
Date
I CONSENT TO BE
PLACED ON DR. CARR’S GROWTH AND
HEALING MAILING LIST TO RECEIVE UPDATES SCHEDULE CHANGES
AND HELPFUL INFORMATION FOR MY PERSONAL GROWTH AND DEVELOPMENT. I understand my
information and email address will not be shown or given out without my
permission.
Signature:
_______________________________________________________ Date _______________
Please initial
one: I do ________, do not _________ explicitly
wish to have the option of supportive or therapeutic touch
offered during a session:
Signature:
_______________________________________________________ Date _______________
Please list some
possible goals of therapy we can discuss during our next session (see
page two):
1)
____________________________________________________________________________________________
2)
____________________________________________________________________________________________
3)
____________________________________________________________________________________________
4)
____________________________________________________________________________________________
5)
____________________________________________________________________________________________
6)
____________________________________________________________________________________________
PLEASE TEAR OFF,
SIGN & GIVE THIS PAGE TO DR. Carr
NEXT SESSION
AGREEMENT TO PARTICIPATE IN SERVICES
If you have any
questions, please feel free to discuss them with me prior to signing this form.
Your signature indicates that you have read, initialed, understand, and
agree to these policies, and accept responsibility for payment of fees in
accordance with these terms and conditions. Your signature also indicates that
you have received your own copy of this office policy agreement.
________________________________
________________________
Client
Signature
Date
________________________________
________________________
Wayne E. Carr,
Ph.D.
Date
I CONSENT TO BE
PLACED ON DR. CARR’S GROWTH AND
HEALING MAILING LIST TO RECEIVE UPDATES SCHEDULE CHANGES
AND HELPFUL INFORMATION FOR MY PERSONAL GROWTH AND DEVELOPMENT. I understand my
information and email address will not be shown or given out without my
permission.
Signature:
_______________________________________________________ Date _______________
Please initial
one: I do ________, do not _________ explicitly
wish to have the option of supportive or therapeutic touch
offered during a session:
Signature:
_______________________________________________________ Date _______________
Please list some
possible goals of therapy we can discuss during our next session (see
page two):
1)
____________________________________________________________________________________________
2)
____________________________________________________________________________________________
3)
____________________________________________________________________________________________
4)
____________________________________________________________________________________________
5)
____________________________________________________________________________________________
6)
____________________________________________________________________________________________
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