CASSANDRA A. ERICKSON, Ph.D.

OFFICE ADDRESS:
2020 West 86th Street, Suite 100
Indianapolis, Indiana  46260
(317) 875-9555 or 767-5775

EDUCATIONAL BACKGROUND

Ph.D.   Purdue University - Marriage and Family Therapy
             Completed:  May, 1990
             Major Professor:  Fred P. Piercy, Ph.D.
             Dissertation:  Professional ethics among family therapists in the context of
             clinical training:
             A multi-wave critical incident study

M.S.     Purdue University - Family Studies
             Completed:  August, 1987
             Major Professor:  Charles R. Figley, Ph.D.
             Thesis:  The relationship of source and satisfaction
             of social support to negative perceptions of support received

B.A.     Purdue University - Psychology
             Completed:  December, 1984

PROFESSIONAL EXPERIENCE

Family Therapist  (1989-present)
Private Practice
Indianapolis, Indiana
 Therapist in private practice providing individual, marital, and family therapy.  Specialization in treating survivors of traumatic events presenting with or at risk of developing symptoms of Post-traumatic Stress Disorder.  Extensive work for Sheriff’s, Prosecutor’s, and IPD’s Victim’s Assistance Programs.  Approved by U.S. Marshall’s Office to provide therapy for members of the Witness Protection Program.  Clinical Membership of the American Association for Marital and Family Therapy (AAMFT).  Licensed Marriage and Family Therapist in Indiana.

Family Divorce Negotiator  (1989-1990)
Catholic Social Services
Indianapolis, Indiana
 Part-time family therapist/negotiator involved in negotiating visitation rights and schedules between divorced parents.  Clients were court-ordered and extremely conflictual.  Maintained collateral contact with attorneys, judges, and other agencies for continual assessment of welfare of child(ren) and other current family issues and circumstances.  Also provided family therapy related to individual, marital and family issues (e.g., divorce adjustment).  Supervisor:  Richard Kramer.

Family Therapist in training  (1987-1989)
Purdue University
West Lafayette, Indiana
 Full-time graduate student in the Marriage and Family Therapy Doctoral Program at Purdue University—the top Family Therapy Program in the country in research, theoretical and clinical training.  Provided individual, marital and family therapy for clients presenting with a wide range of concerns:  divorce, substance abuse, marital conflict, suicide, violence, homicide, juvenile delinquency, parenting issues, child sexual abuse, extramarital relations, relationship enhancement, etc.  Live- and case-supervisors:  Supervisors in training and MFT Faculty.

Research Assistant  (1986-1989)
Purdue University
West Lafayette, Indiana
 Part-time graduate research assistant for Dr. Charles Figley, Professor of Family Studies and international expert on Traumatic Stress.  Conducted research in the areas of satisfaction with social support and skills for beginning therapists.  Assisted in compiling and reviewing manuscripts for several edited volumes.  Administratively assisted with manuscripts and books reviews for three professional journals.  Supervisor:  Charles Figley, Ph.D.

Rape Victim Advocate  (Jan.-Aug., 1986)
Planned Parenthood Association
Lafayette, Indiana
 Rape Victim Advocate for Tecumseh Area Planned Parenthood Association (TAPPA).  Provided crisis counseling and intervention for rape victims.  Trained in providing support, information, and assistance through the medical and legal procedures following a rape.  Supervisor:  Jill Strand, M.S.

Planned Parenthood Counselor  (Jan.-May, 1986)
Planned Parenthood Association
Lafayette, Indiana
 Counselor for Tecumseh Area Planned Parenthood Association (TAPPA).  Counseled clients on problem pregnancy, rape, sexual dysfunctions, sexually transmitted diseases, and family and relationship problems.  Researched literature on sexual dysfunctions and developed counseling procedures and referral list for use by TAPPA.  Trained and supervised new interns and counselors.  Supervisor:  Linden Foster, M.S.

Teaching Assistant  (1985-1986)
Purdue University
West Lafayette, Indiana
 Part-time graduate teaching assistant for Marriage and Family Relationships course (CDFS 350).  Developed and team-taught upper-level undergraduate course, created instructional and evaluation materials, supervised undergraduate discussion group leaders.  Supervisors:  Charles Figley, Ph.D. and Kathleen Gilbert, Ph.D.

ADDITIONAL EXPERIENCES AND TRAINING

EMDR Training, Level II  (June, 2003)
Arlington Heights, IL
     Advanced training in the application of Eye Movement Desensitivation and Reprocessing (EMDR), with general advanced training and focus on application to specific problem areas and populations.  17 Hours.  Facilitator:  Kay Werk, MSW, LISW

EMDR Training, Level I  (November, 2002)
Columbus, OH
     Experiential training in the application of Eye Movement Desensitization and Reprocessing (EMDR), or bilateral hemispheric stimulation, for use with a wide range of clients and situations.  17 Hours.  Facilitator:  Kay Werk, MSW, LISW

Ad Hoc Reviewer  (1985-1997)
Purdue University
West Lafayette, Indiana
 Reviewed and edited manuscripts submitted for publication in the Journal of Traumatic Stress and the Journal of Psychotherapy and the Family.  Supervisor:  Charles Figley, Ph.D.

Residence Hall Counselor  (1986-1988)
Purdue University
West Lafayette, Indiana
 Part-time residence hall counselor for graduate dorm.  Acted as intermediary between management and 80 residents through availability for individual personal counseling and securing resident acceptance and observance of administrative rules and regulations.  Supervisor:  Ruth Petzold, M.S.

Child Sexual Abuse Training  (May-Aug., 1986)
Hendricks County Department of Public Welfare
Indianapolis, Indiana
 Received 10 hours of training through the Hendricks County Sexual Abuse Treatment Program on the treatment of and networking involved in child sexual abuse.

Rape Victim Advocacy Training  (January, 1986)
Planned Parenthood Association
West Lafayette, Indiana
 Received 10 hours of training in rape crisis intervention through the Tecumseh Area Planned Parenthood Association (TAPPA).

Traumatic Stress Treatment Training  (June, 1986)
The Family Institute of Chicago
Chicago, Illinois
 Received 6 hours of training in treating trauma victims and their families through the Center for Family Studies/The Family Institute of Chicago.
 

CONTINUING EDUCATION

Conferences (1990-present)
     Attended many of the Annual Conferences for the American Association for Marriage and Family Therapists, and the Indiana Association for Marriage and Family Therapists.

Workshops (1990-present)
     Attended many workshops throughout the years, including such topics as:  hypnosis and metaphor in therapy, legal and ethical issues in practice, child custody evaluations, etc.

PROFESSIONAL LICENSE & CERTIFICATION

Licensed Marriage and Family Therapist (#35001395)
     Licensed and certified as a Marriage and Family Therapist in the State of Indiana.  Met the requirements for certification and licensure, and passed the State Examination in 1998—the first year licensing was available in Indiana.

PROFESSIONAL AFFILIATIONS

Clinical Member, American Association for Marriage and Family Therapy (since 1986)
Member, Indiana Association for Marriage and Family Therapy (since 1986)
Affiliation, Society for Traumatic Stress Studies (since 1986)

PROFESSIONAL NOMINATIONS

Chosen as the “Featured Practitioner” for publication in the 
   Indiana Association for Marriage and Family Therapy
   Bridgebuilder, Winter, 1991, 9(2)

Nominated for Outstanding Young Women of America in 1994
Nominated for International Who’s Who in Medicine in 1995
Nominated for Who’s Who of American Women in 1995

PROFESSIONAL PRESENTATIONS

Erickson, C.  (April, 1990).  Ethical issues in professional relationships.  Presentation at the Annual Meeting of the Indiana Association for Marriage and Family Therapy.  Indianapolis, Indiana.

Erickson, C.  (March, 1990).  Identifying and dealing with troubled teenagers.  Presentation to teachers and administrators at Northcentral High School.  Indianapolis, Indiana.

Erickson, C.  (November, 1989).  Introduction to post-traumatic stress disorder.  Presentation to school social workers and family unit staff at Catholic Social Services.  Indianapolis, Indiana

Gilbert, K. and Erickson, C.  (November, 1987).  The development of a family definition of the event:  Information exchange among family members after a catastrophe.  Presentation at the Annual Meeting of the National Council on Family Relations.  Atlanta, Georgia.

Burge, S., Gilbert, K., Kishur, R., Harris, C., and Erickson, C.  (November, 1986).  Systemic recovery from traumatic events.  Presentation at the Annual Meeting of the National Council on Family Relations.  Dearborn, Michigan.

Erickson, C.  (September, 1986).  A theory of traumatic stress recovery.  Presentation at the Second Annual Meeting of the Society for Traumatic Stress Studies.  Denver, Colorado.

Erickson, C.  (August, 1986).  Introduction to research, theories and treatment of traumatic stress.  Invited presentation for the Case Conference of the Indianapolis Institute for Marital and Family Relations.  Indianapolis, Indiana.

Erickson, C.  (July, 1986).  Post-traumatic stress disorder and anxiety:  The effects on the individual and the support system.  Invited presentation for the Workshop on Treating Traumatic Stress.  South Bend, Indiana.
Erickson, C.  (February, 1986).  Understanding family interaction in working through a traumatic event.  Roundtable for the Annual Meeting of the Indiana Council on Family Relations.  Indianapolis, Indiana.

PUBLICATIONS

Articles/Chapters

Ben David, A. and Erickson, C.A.  (1991).  Ethnicity and the therapist's use of self.  Family Therapy, 17(3), 211-216.

Figley, C.R. and Erickson, C.A.  (1990).  The psychology of traumatized families.  In F.W. Kaslow (Ed.), Voices in family psychology (Vol. 2, pp. 33-50).  Newbury Park, CA:  Sage Publications.

Erickson, C.A.  (1989).  Negative perceptions of social support:  The influence of source and satisfaction.  Family Perspective, 23(2), 85-97.

Erickson, C.A.  (1989).  Rape and the family.  In C.R. Figley (Ed.), Treating stress in the family (pp. 257-289).  New York:  Brunner/Mazel.

Young, M.B. and Erickson, C.A.  (1988).  Cultural impediments to recovery:  PTSD in contemporary America.  Journal of Traumatic Stress, 1(4), 431-443.

Book Reviews

Erickson, C.A.  (1989).  (Review of Handbook of behavioral family therapy - edited by Ian Falloon).  The American Journal of Family Therapy, 17(1), 85.

Erickson, C.A.  (1988).  (Review of Families in transition:  Primary prevention programs that work - by Lynne Bond & Barry Wagner).  The American Journal of Family Therapy, 16(4), 374.

REQUIREMENTS FOR LICENSURE AND CERTIFICATION
1998

Requirements for State Licensure
  Doctoral degree from accredited marriage and family therapy
    program
  Two years and 1000 hours supervised clinical experience 

Material Tested in State Examination
  Joining/assessment/diagnosis   
  Designing treatment
  Conducting course of treatment
  Establishing and maintaining appropriate networks
  Assessing outcome
  Maintaining professional standards   

Required Knowledge for State Examination
  Family studies
  Family and marital development (family life cycle)
  Family stress theory
  Family diagnosis
  Gender studies
  Cross-cultural studies (e.g., ethnicity, class, minorities,
    relocated populations)
  Communication theory
  General systems theory
  Second Order family therapy (Post-Modernism, Constructivism,
    Social Constructivism, cybernetics)
    human sexuality/sexual function and dysfunction
    family and cultural belief systems
    health care delivery systems, community systems, and self-
      help groups
  In-patient systems
  Major models of family therapy:  Behavioral, Cognitive
    behavioral, contextual (Nagy), Experiential, Integrative,
    Intergenerational (Bowen), Network, Psychodynamic/Object-
    relations, Psychoeducation, Strategic (Haley et. al.),
    Strategic (Watzlawick et.al.), Structural, Systemic
    (Milan, Solution-focused, Narrative, Ericksonian
  Human development--geriatrics and child development
  Premarital counseling
  Marital dysfunction
  Content areas: divorce/child custody, remarriage/
    stepfamilies/single parenthood, sexual abuse, family
    violence/physical abuse, depression/suicide, grief/loss,
    substance abuse/addition, child & adolescent behavior
    disorders, psychosomatic disorders, eating disorders, gay
    and lesbian issues, learning disabilities/attention
    deficit disorders, HIV disease
  Family therapy outcome literature
  Major models of individual psychotherapy
  Personality theory
  Major family assessment tools
  Research methodology sufficient to critically evaluate
    assessment tools and research literature
  History of family therapy field
  Professional and ethical standards
  Literature on the influence of the therapist’s personality,
    life experience, and family of origin on the therapy  
    process
  Individual psychopathology
  Individual diagnosis (DSM/ICD)
  Basic psychodiagnostic testing
  Statutes and case laws relevant to clinical practice
  How social, political, economic, and geographic factors
    influence individual and family functioning
  How biological factors interact with psychosocial factors in
    individual and family functioning     

NEW CLIENT INSTRUCTIONS FOR PAPERWORK

Welcome.  Please read the instructions below for what to do with the paperwork prior to arriving for your appointment.

Please PRINT OUT the following from the links on www.DrErickson.net:
2 Informed Consent Forms
1 Adult Personal Data Inventory Form per adult
1 Child/Adolescent Personal Data Inventory Form per
  child/adolescent
1 Health Insurance Claim Forms(s) (HCFA-1500) per client
1 Assignment of Benefits Form
1 Credit Card Pre-Authorization Form (optional)

INSTRUCTIONS
- Please read the Informed Consent Form, then keep one copy
  for your records and have all adults sign a copy to bring to
  Dr. Erickson
- All clients should fill out an Adult or Child/Adolescent
  Personal Inventory Form (as best you can)
- If we have discussed reimbursement through your insurance,
  fill out and sign, where indicated, one Health Insurance
  Claim Form for each adult/child in therapy, and the
  Assignment of Benefits Form provided
- If you intend now or later to make payment by credit card,
  fill out the Credit Card Pre-Authorization Form

UPON ARRIVAL FOR YOUR APPOINTMENT
- PLEASE BRING all the forms identified above to your first
  appointment
- When we meet, you will also be given a copy of the
  Consumer’s Guide to Marriage and Family Therapy brochure
- PAYMENT
  - if paying by check, please write your check in advance for
    the amount due (if known) to “Dr. Cassandra Erickson”
  - if paying by credit card, please have your credit card
    ready for swiping and authorization at the end of the
    session

I look forward to meeting you soon and will be glad to answer any questions you may have!
Cassandra Erickson

INFORMED CONSENT FOR THERAPY
                          Client #:  ____________                Updated: 3/26/04

     This Informed Consent Form is intended to provide sufficient information for you to make informed choices about entering and continuing therapeutic treatment. 

INFORMATION ABOUT THERAPY

THERAPIST’S EDUCATION AND TRAINING
     Your therapist, Cassandra A. Erickson, Ph.D., L.M.F.T., is a Marriage and Family Therapist in private practice.  She obtained her doctorate from Purdue University—one of the leading institutions in research, theoretical and clinical training in her field.  She is a Clinical Member of AAMFT—the American Association for Marriage and Family Therapy—and a Licensed Marriage and Family Therapist in the State of Indiana.  A copy of her Curriculum Vita (professional “resume”), with more detailed education and training, is available upon request.

WHAT TO EXPECT – BENEFITS AND RISKS
 There are benefits and risks in seeking individual, marital or family therapy.  Some of the potential benefits of therapy include developing your ability to handle or cope with your relationships and providing you with greater insight into your personal goals and values.  In working to achieve these benefits, however, you may address issues or make changes that you may experience as distressing.  These risks of therapy include, but are not limited to:  feelings or circumstances becoming worse before they get better; changes in your emotional state, such as feelings of depression or anxiety; the possibility of hallucinations or dissociations; changes in perception or behavior; and changes in occupational, social, or personal relationships.  This Informed Consent form contains information about other potential risks as well (e.g., leaving therapy, confidentiality, etc.).

MEASURING PROGRESS
 To achieve the greatest progress in therapy, your therapist will work to provide the best and most appropriate therapy for you and your family.  You can facilitate this process by maintaining motivation, complying with recommendations and policies, and communicating openly and honestly.  The length and frequency of sessions as well as the duration of treatment varies significantly, and can be discussed at the beginning and throughout the course of therapy.
     Because success or satisfaction with treatment cannot be guaranteed, you are requested to inform your therapist if you do not feel satisfied with your progress.  You and your therapist may then be able to work through the issues, modify treatment, or negotiate a new therapeutic contract.  In some instances, this may mean making an appropriate referral or terminating therapy.  You may choose to leave therapy at any time; however, leaving therapy is best accomplished in consultation with your therapist. 

ALTERNATE TREATMENT OPTIONS
 You may also elect to pursue alternative options for treatment.  These options may include self-help groups, community based clinics, psychotropic medications, physical exams, psychiatric hospitals, emergency services, and other mental health professionals who may offer different training, techniques, specialties, personalities, and theoretical approaches.  Some of these options will have similar risks and benefits to those outlined above.
PRIVACY POLICIES AND PROCEDURES

RIGHTS OF CONFIDENTIALITY
 Your therapist pledges to uphold privacy and confidentiality concerning your treatment process and records as outlined by Indiana Statute and the Federal HIPAA Privacy Regulations.  She will do everything within her power to protect the physical records of treatment and the information contained therein, including safeguarding their use, transportation and storage.  Your therapist has posted a Notice of Privacy Practices in the Waiting Room for your review.  This Notice describes the current and more detailed outline of the uses and disclosures of your protected health information, including when authorization is required and when it is not; your rights regarding this information; and how your health information is safeguarded by your therapist.  Some of this information is summarized below.  You are encouraged to review this Notice of Privacy Practices and may request a copy of the current Notice at any time.

STANDARD USES AND DISCLOSURES
Generally, your health information may be used and disclosed during the normal course of providing and receiving payment for your care. Your voluntary agreement to seek treatment provides this permission by law.   These standard uses and disclosures include:  1) therapist’s consultation with peer professionals, supervisors, attorneys, accountants, etc. (identifying information is not disclosed); 2) information about the cost of care and maintenance of treatment required by third-party payers (e.g., Insurance/Managed Care companies, State agencies, etc.); 3) completion of necessary billing, banking, and collection activities; 4) data collection, research and information for monitoring Managed Care providers by State agencies or to satisfy reporting requirements; 5) phone calls, voice messages, electronic transmissions, written correspondence, and mailings sent to the addresses and phone numbers provided, unless specific alternate instructions are given; and 6) disclosures made during the course of therapy involving a client’s partner, family, or other third parties, in which statements made in individual or group sessions may, of necessity or inadvertently, be repeated to others, unless the handling of that disclosure was previously and clearly agreed upon with your therapist.  Your signature represents your understanding and consent to these standard uses and disclosures of your health information to provide and receive payment for your care.

USES AND DISCLOSURES WITH AUTHORIZATION
 For uses and disclosures of your health information other than during the normal course of business operations and providing treatment, your therapist is required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below (see “Uses and Disclosures Not Requiring Authorization”).  If you request or are asked to provide written authorization for the release of any information regarding your treatment or records, you must submit a written, signed, and dated request for release specifying the content or material to be released, to whom, and the purpose of the release.  Your therapist can provide an Exchange of Information form to sign.  You may specify or limit the scope of information to be released at any time, and it will expire one year, if not otherwise specified, from the date of your signature. 
     Your signed consent may be required for the release of diagnostic and treatment information to any third-party payers.  Your written permission also will be obtained if you or your therapist were to request audio or videotaping of treatment.  Any information included in your records from another source (e.g., physician, therapist, family member, etc.) will not be released without a signed authorization from that source.
You may revoke an authorization, in writing, at any time (see Notice of Privacy Practices for exceptions). If you do wish to revoke an authorization, your written revocation must include the date of the authorization, the name of the person/organization authorized to receive the information, your signature, and the date of the revocation.

USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION
(LIMITS TO CONFIDENTIALITY)
The use and disclosure of your health information and rights of confidentiality may be limited by law under the following circumstances:  1) therapy with minors, which requires parental consent; 2) equal access of a minor’s records to both custodial and non-custodial parents if requested, unless a court order states otherwise; 3) threat of bodily harm or death to yourself or others; 4) information is revealed concerning child or elder abuse or neglect; 5) a crime has been committed; 6) information is required by a coroner or medical examiner; 7) information is required by a National security or intelligence Agency, such as for protection of the President; 8) a judge issues a court order for a court appearance or release of records following a hearing showing good cause; 9) you are involved in certain processes of litigation (e.g., child custody, lawsuit, mental health status); or 10) therapy and/or evaluations are court ordered.  Under some these circumstances, your therapist may be required by law to release requested information about the treatment process and results, and/or to inform the intended victim(s), their families, and appropriate law enforcement authorities. 

RIGHTS REGARDING YOUR HEALTH INFORMATION
You have several rights regarding your health information:  1) You have the right to request, in writing, how you would like your therapist to restrict the uses and disclosures of your healthcare information. Your therapist will consider this request, but is not legally bound to agree to the restriction. 2) You have the right to ask, in writing, that your therapist contact or send you information at an alternate address or by an alternate means, such as contacting you only at work.  You may specify how you prefer your therapist contact you when you fill out the Personal Data Inventory form at the beginning of therapy.  Your therapist will agree to this request as long as it is reasonable to do so. 3) You are generally entitled to inspect and copy your records; however, your therapist is permitted by law to withhold all or any portion of your records a) in order to permit her to freely record diagnostic and therapeutic information regarding your treatment, or b) if she believes with reasonable certainty and in her professional judgment that seeing these records may be detrimental to your physical or mental health. You will be responsible for any costs associated with copying, mailing, and time incurred by your therapist in responding to your request to inspect or copy your records.  Prior to their release, your therapist may require, at her discretion, a 50-minute session or longer to review your records with you, to be charged at the current rate.  Your therapist is required by law to retain possession of treatment records for a minimum of seven (7) years. 4) If you believe there is a mistake or missing information in the record of your health information, you may request, in writing, that your therapist correct or add to the record.  Your therapist may deny your request for an amendment under certain conditions outlined in the Notice of Privacy Practices.  5) You have a right to request, in writing, an accounting of disclosures—a list of what disclosures have been made of your health information—other than instances of disclosure for national security purposes; for treatment, payment or operations purposes; to law enforcement officials or correctional facilities; or for which you have given your written authorization. 6) You have a right to receive a paper copy of the Notice of Privacy Practices, which outlines information in this section in more detail.
    
COMPLAINTS ABOUT PRIVACY PRACTICES
 If you believe your privacy rights have been violated, or if you disagree with a decision made about access to your health information, you may discuss or file a formal complaint directly with your therapist.  You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services.  You will not be penalized for filing a complaint.

ADDITIONAL INFORMATION

CONTACTING YOUR THERAPIST
 Since your therapist is often in session during the weekdays and not in the office on weekends, she may be difficult to reach directly.  To contact her, please leave a detailed message with your full name and phone number on her confidential voice mail, at (317) 875-9555 or 767-5775.  She checks messages often and will return your call as promptly as possible.  Whenever possible, please be specific with your message or request, and let her know if you would like a return call.  If you leave a message at any source you may have for your therapist (e.g. cellular phone, e-mail, etc.), she cannot assure she will get the message in a timely fashion.

HELP FOR EMERGENCIES
 If you feel you need to reach your therapist urgently, you should leave a message specifically stating that it is urgent.  Your therapist will do her best to return your call promptly; however, in the event that she is unable to call or see you as soon as you need, you may choose to contact an alternate source of support, including the following 24-hour Crisis Lines:
     St. Vincent’s 24-hour StressLine - (317) 338-4800
     Crisis & Suicide Intervention Hotline – (317) 251-7575
     Gallahue 24-hour Crisis Service  - (800) 662-3445
     Midtown 24-hour Crisis Clinic - (317) 630-8485

CONSUMER’S GUIDE TO MFT
 Your therapist will provide a brochure from the American Association for Marriage and Family Therapy (AAMFT) entitled A Consumer’s Guide to Marriage and Family Therapy.  This brochure provides additional information relevant for you to make an informed choice regarding your decision to seek therapy.  Specifically, it outlines the theoretical perspective of the field of Marriage and Family Therapy (MFT), reasons and circumstances appropriate to seeking therapy (e.g., signs of distress), training requirements and qualifications of an MFT, and information on finding and choosing a qualified therapist.

FINANCIAL POLICIES AND PROCEDURES

SESSION FEES
 The fee for individual, marital/relationship, or family therapy services is $     per 50-minute session, payable to Cassandra A. Erickson, Ph.D.  Therapeutic services delivered over the phone are subject to the same hourly rate as regular sessions and will be billed on a pro-rated basis.  Please inform your therapist should these fees pose a hardship at any time so you may jointly negotiate alternative arrangements.  Fees are re-evaluated and subject to change every six months.

PAYMENT POLICY
     Payment in full is expected at the time of service, unless alternate arrangements are mutually agreed upon.  Payment is accepted in the form of cash, check, or credit card—including Visa, Mastercard, American Express, and Discover. Debit cards from your checking or savings account are accepted, although a check is preferred since there are additional merchant fees applied when using debit cards. 
     When making payment by check, please have your check written before the start of the session, whenever possible.  All checks returned for non-sufficient funds (NSF) may be automatically forwarded by your therapist’s bank to CheckBack Electronic Check Services.  Your signature below authorizes CheckBack to electronically debit your account for the face amount of the check and the State allowable processing fee.  The debit entries will be shown on your bank statement and your original check will not be returned.  Returned checks are subject to a $20 returned check fee.
     Payment by credit card requires that you provide your credit card at the time of service to obtain your signature and authorization.  You will be asked to sign a Credit Card Pre-Authorization form so your signature will be on file for future charges.  Your signature below also represents pre-authorization to use your credit card to charge for fees and services. 

INSURANCE REIMBURSEMENT
     If you have medical insurance that provides coverage for mental health outpatient services and choose to use these benefits, your therapist will work to help you receive your maximum allowable benefits.  Your therapist has chosen not to participate in any managed care insurance plans, including HMO’s and PPO’s, since the extraordinary amount of time and paperwork required takes away from client care.      
     Your therapist will provide, upon request, a receipt for each session or a monthly statement of services to help you process your insurance claim for reimbursement.  You therapist will gladly answer questions relating to your insurance; however, as the insured you must realize that:
1) Your insurance is a contract between you, your employer and the         insurance company—your therapist is not a party to that contract.                
2) Your therapist’s fees are generally considered to fall within the        acceptable range by most companies, called “Usual, Customary, and           Reasonable” (UCR).  Some companies pay a percentage of the UCR for a given area, while others reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard and cost of care in this area.
3) Insurance contracts do not necessarily provide coverage for all services or all types of providers.  Some insurance companies arbitrarily disallow coverage for certain services (i.e., marital counseling) and types of providers (i.e., non-psychiatrists).
4) Your insurance company will require that your therapist include on any statement of services a Procedural Code(s) from the CPT-4 Manual and a Primary Diagnostic Code, or ICD-9-CM Code, from the DSM-IV (Diagnostic and Statistical Manual for Psychiatry, 4th edition).  You may discuss the use of these codes, but all final diagnostic decisions must be left to your therapist’s discretion.
5) You therapist will discuss with you the diagnosis to be submitted to your insurance company and may require your signature on an Exchange of Information form.
6) If your insurer requests a report from your therapist in order to process your claim, this will be charged at the regular hourly fee.
7) It is your responsibility to contact your insurance company to verify eligibility, benefits and reimbursement policies, as well as to mail and track your reimbursement.

ASSIGNMENT OF BENEFITS
     Payment in full is expected at the time of service unless your therapist has agreed to accept direct payment from insurance, called an “assignment of benefits.”  If your therapist accepts payment directly from your insurance company, you will be asked to sign a generic HCFA-1500 insurance form (or one provided by your insurance company, if available), and an Assignment of Benefits form.  You will be responsible for payment in full for your portion of the fee not covered by your policy, including your annual medical or separate mental health deductible.  You will also be responsible for any portion of the balance due that is denied by the insurance company, regardless of the circumstances (e.g., misquoting by an insurance representative, unexpected change in benefits, etc.).

CANCELLATION POLICY
 The time for which your appointments are scheduled has been reserved for you.  You are required to give notice of cancellation at least 24 hours prior to a scheduled appointment.  If you do not give 24-hour notice or fail to show for a scheduled appointment without prior notification, you will be charged the full session fee.  Exceptions can be made in the event of an emergency; however, you are asked to call as soon as possible to inform your therapist of the circumstances.  Your therapist will provide an appointment card so you can verify the times and dates, unless the appointment is made over the phone or you decline to receive one.

OTHER FEES
 Your therapist may charge different fees for some services.  The fee of $175 per hour applies to services other than those that are directly related to your therapeutic process as outlined above.  These services include: conducting negotiations, performing evaluations, providing written reports, or consulting with other professionals at your therapist's discretion.  The fee of $225 per hour applies to services related to the court process, including testifying, consultation with your attorney or other professionals, travel time, and taking your therapist’s deposition.
     Any additional fees for testing and assessment will be discussed at the time your therapist makes the recommendation.

DELINQUENT/DEFAULTED BALANCES
 You are responsible for making any payments due in a timely manner.  Your account will be considered delinquent if a balance remains after two months from the date the fee is assessed, and will be charged interest at a rate of 1.5% per month (18% APR).  If you anticipate difficulty in paying your balance, please discuss the situation with your therapist to work out a repayment schedule that will not cause undue hardship for either party.
 If your balance remains delinquent for more than four months and you have not attempted to make satisfactory arrangements with your therapist, the account will be considered defaulted.  Once your balance due has defaulted, it may be forwarded to a collection agency and you will be responsible for all court costs, attorney fees, interest, and related damages or expenses associated with pursuing payment of the balance.

CONSENT FOR TREATMENT/ACCEPTANCE OF POLICIES

     Your therapist has attempted to answer your questions about treatment satisfactorily.  If you have further questions or concerns, your therapist will do her best to answer them or find answers for you. 
     Your signature represents a statement that you have read and understood the information above and as outlined by your therapist, have received a copy of this Informed Consent form, have been made aware of your rights and the privacy practices of this office, agree to comply with fees and policies, agree to read the brochure provided, and consent to the therapy process as described above.  You have the right to withdraw your consent for treatment at any time.

____________________________________________   __________
          Client Signature                     Date

____________________________________________   __________
          Client Signature                     Date

____________________________________________   __________
          Client Signature                     Date

____________________________________________   __________
                  Parent/Guardian Signature                Date

 INFORMATION & INFORMED CONSENT FOR EMDR,
Eye-Movement Desensitization & Reprocessing
                                   Updated:  3/25/04

What is EMDR?
Eye Movement Desensitization and Reprocessing, or EMDR, is a powerful new psychotherapy technique which has been successful in helping people suffering many forms of emotional distress, including trauma, anxiety and panic, fears and phobias, loss, disturbing memories, etc.  EMDR is considered a breakthrough therapy because of its simplicity and the fact that it can bring quick and lasting relief.

EMDR therapy uses bilateral stimulation—including right/left eye movement and tactile or auditory stimulation—which repeatedly activates the opposite sides of the brain, releasing emotional experiences that are “trapped” in the nervous system.  This assists the neurophysiological system, the basis of the mind/body connection, to free itself of blockages and reconnect itself.

Who discovered EMDR?
In the late 1980’s, psychologist Francine Shapiro, Ph.D., observed that particular eye movements reduced the intensity of disturbing thoughts in some clients.  Dr. Shapiro decided to study this effect scientifically, and in 1989, reported in the Journal of Traumatic Stress her success using a method she called EMDR to treat victims of trauma.

How does EMDR work?
Currently, there is not enough known about brain function to be able to explain with certainty how EMDR or any other therapy produces its effects.  It is believed, however, that negative life experiences or traumas may upset the biochemical balance of the brain’s physical information processing system, thereby preventing the information from being processed and resolved in a healthy, adaptive way.  The result is that the thoughts, feelings, beliefs, and memories (smells, sights and sounds, etc.) associated with the disturbing experience are, in effect, stored or “trapped” in the nervous system and are often suppressed from consciousness.  The distress, however, lives on in the nervous system where it causes disturbances in the emotional functioning of the person.

EMDR is considered an effective technique for “unlocking” the negative memories and emotions stored in the nervous system, thereby helping the brain to successfully process the experience.  EMDR unblocks the brain’s information processing system in three possible ways:  1) it may tap into the same mechanisms used in learning and memory now identified with REM sleep, 2) the rhythmic intervention of EMDR improves communication between the brain hemispheres, unblocking the processing that is manifested as phase discrepancies between equivalent areas in the brain’s hemispheres, or 3) EMDR may initiate an orienting reflex change in neurophysiological functioning leading directly to desensitization.

In an EMDR session, the therapist works gently in guiding the client to revisit the traumatic incident.  When the memory is brought to mind, the feelings are re-experienced in a new way.  EMDR makes it possible to gain the self-knowledge and perspective that will enable the client to choose their actions, rather than feeling powerless over their re-actions.  This process can be complex if there are many experiences connected to the negative feelings.  The EMDR therapy sessions continue until the disturbing memories and emotions are relieved.
What are the advantages of EMDR Therapy?
When used in conjunction with other traditional methods of therapy, EMDR can help move people more effectively and quickly from emotional distress to peaceful resolution of the issues or events involved.  Treatment with EMDR helps in eliminating even the most difficult emotions—the memory remains but the negative response is neutralized.  The positive, long-term results of EMDR therapy affect all levels of the client’s well-being—mental, emotional and physical, so that their responses return to normalcy and health.  To date, more than half a million people have benefited from EMDR therapy.

What problems are helped by EMDR?
Studies to date show a high degree of effectiveness with the following conditions:

     Depression                    Loss/injury of a loved one
     Anxiety/panic attacks         Car/work accidents
     Phobias/Fears                 Fire
     Post-traumatic Stress         Assault/violent crimes
     Physical abuse                Robbery
     Sexual abuse                  Rape
     Bad Temper                    Natural Disasters
     Low Self-Esteem               Injury
     Relationship problems         Illness
     Worrying/brooding             Witness to violence/trauma
     Trouble Sleeping              Childhood trauma

Who can be helped by EMDR?
EMDR can help many different people suffering from many types of experience or disturbance, such as those listed above.  Research has shown EMDR to be effective for children, adolescents, and adults of many different backgrounds and nationalities.  EMDR may also be helpful for people in specific professions, such as police, emergency workers and firefighters, and can be used to enhance performance or reduce performance anxiety of athletes, actors, musicians, students, public speakers and executives.

Are there studies that show that EMDR is effective?
Research studies show that EMDR is very effective in helping people process emotionally painful and traumatic experiences.  In fact, EMDR is the most thoroughly researched method in the treatment of Post-traumatic Stress Disorder and trauma.  Studies consistently show that treatment with EMDR results in elimination of the targeted emotion—the memory remains, but the negative response is neutralized. Several important research studies conducted on EMDR include the following:
Chemtob, C.M., Nakashima, J., Hamada, R.S. & Carlson, J.G.  (2002).  Brief
  Treatment for Elementary School Children with Disaster-Related Posttraumatic
  Stress Disorder:  A Field Study.  Journal of Clinical Psychology, 58, 99-112.
Shapiro, F.  (1999).  Eye movement desensitization and reprocessing (EMDR) and
  the anxiety disorders:  Clinical