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Over One Million Copies in Print
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Phone and Live Internet VideoCam Counseling
You can work with Don wherever you live, on vacation, a trip or away on business . . . ANYWHERE in the world. Take advantage of phone counseling or sessions live over the internet with videocam using Skype, Yahoo, iChat, or other providers. 
For an appointment call 925 256 8282 or email Don at Don@DonElium.com
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Regions include United States, South America, South Africa, United Kingdom, Canada, Japan, Romania, Costa Rica, France, Italy . . .
Before the first appointment, please provide the following info
Don Elium, MA MFT Walnut Creek, CA 94596 Don@DonElium.com
Hello!
Yes, this is rather long. It is my attempt to keep clerical office matters as brief and accurate as possible while maximizing the productivity our "in session" time. Please take the time to read all items, and please respond to SECTIONS 2 and 3.
Please note the scheduling policy:
• Rescheduling requires a 24 hour notice by phone or email or you are charged for the session. PLEASE CALL as soon as possible to give us time to make changes. I will do the same. This reduces scheduling issues/extra phone calls and makes our therapy sessions a priority and focused on the needs that you are coming to address. If you need to changed the appointment if you come during that same week there is no charge for the missed appointment.
• Counseling Fee and How To Pay:
Payment is to be made by Credit/Debit Card
Name on Card
Number on Card
Exp. Date
Security code on the back
This information is kept confidential.
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Length of Session: 50 minutes
Fee: $150 for individual counseling per session
Fee: $175 for couple counseling per session
I apologize for the sometimes brief sounding language used in each item---short sometimes isn't very personal, but in this case will help focus and shorten clerical matters. Please bring any concerns you have with any item of the policy on the phone before the first meeting or at the beginning of the first session.
I look forward to working with you soon,
Don
Don Elium, MA MFT 925.256.8282
2168 Norris Road, Walnut Creek, CA 94596
www.DonElium.com
Email: Don@DonElium.com
Skype: donelium
Yahoo: donelium2@yahoo.com
(can also use iChat and other services if needed)
There are three Sections: 1. Policy 2 Confidential Agreements 3. Personal Information
______________________________________________________________________
1•SECTION ONE: •Psychotherapy Office Policy of Don Elium, MA MFT•
______________________________________________________________________
• 50 Minute Sessions
Each session will end promptly at the end of fifty minutes. A double session (two 50 minute sessions in a row= 100 minutes, one hour and forty minutes of time) as well as two session or more per week can be arraigned at your request when needed.
• Payment by check or cash or credit/debit card
Please write you check before the session and make check payable to Don Elium, MA MFT. Hand the check or cash to me to start our session. Payment in full is expected. You will receive a bill that can be submitted to your insurance company for their payment to you. A $10 charge for the first check returned by the bank. If a second check is returned, subsequent payments must be money order or cash.
• Fee
If one returns to psychotherapy, upon completion, before 30 days from date of ending, the fee remains the same. If after 30 days months, the fee will change to the current rate of that time. Fee for individual Phone Counseling is $150 per 50 minutes. Fee for couple Phone Counseling is $175 per 50 minutes. Payment by debit/credit card.
• Rescheduling requires a 24 hour notice by phone/email or you are charged for the session.
PLEASE CALL as soon as you know you need to change the session day or time to give us time to make changes BEFORE 24 hours. I will do the same. This reduces scheduling issues/extra phone calls and makes our therapy sessions a priority and focused on the needs that you are coming to address. If you need to changed the appointment, call less than 24 hours, and if you come for a session during that same week there is no charge for the missed appointment.
• Late? 20 minute waiting period
If you are late, I will wait twenty minutes before assuming you are not available. If you call within twenty minutes, the remainder of the fifty minutes will be your session. If you do not call, there will be a charge for the session.
If I am late, please wait ten minutes before assuming I am not available and email or leave a phone message. If I am not available within twenty minutes, there is no charge for that session nor the following one. This is a very rare event, but can happen.
On occasion the prior session to yours may run over time. I will call and alert youas soon as I can if this is the case. When we start you will receive your full time.
• Emergencies
I am not immediately available in an emergency. I will return your call as soon as I can. Please know your emergency resources in your area as well in your personal network of friends, churches, and organizations. When you call, please tell me clearly that this is an emergency and leave your phone number twice (2 times) If you are in crisis, you can schedule an additional session during the week. If immediate attention is required, Contra Costa Crisis line is available 24 hours a day at 800.833.2900, for medical emergencies or police, dial 911. Note the following point regarding returning phone calls.
• Phone Calls Returned Weekdays
Phone calls are returned each weekdays from 9am to 6pm. Phone calls received after 4pm on Friday, will be returned the following Monday before noon. For Holidays, the phone message will list special changes when they are applicable.
• Phone and Email communication
For scheduling matters, phone or email is okay. Please make sure that the email address you use is okay to contain confidential psychotherapy communications.
• Confidentiality and Exceptions
All information in psychotherapy sessions is strictly confidential unless there is a signed release from the client.
Exceptions are 1) Report of child abuse or 2) Report of elder abuse. Licensed marriage and family therapists are required by California State Law to report these situations to Child Protective Services. More information available upon request. 3) Intent to harm self or other. Immediate report to the appropriate police department, and in the case of threat to harm other, a call to the intended victim (if possible), is required by California State Law. 4) A direct court order from a sitting Judge (not a lawyer). No permission is required to break confidentiality under these four conditions 5) written permission from client to talk with designated person, persons, organizations.
• Don Elium, MA MFT
I am Licensed Marriage, Family, and Child Counselor Lic. #28381 and a member of the California Association of Marriage and Family Therapist.
Talk with you soon!
Don Elium, MA MFT
925.256.8282 DonElium@mac.com
www.DonElium.com
______________________________________________________________________
2•SECTION 2: •CONFIDENTIALITY AGREEMENTS
______________________________________________________________________
Confidentiality is MOST important to this office.
Before are several items that will help to protect your rights to privacy.
PLEASE copy the form below to a new email (or paste in a WORD docutment and attach) & send before first session to Don@DonElium.com, OR print out on paper, fill out, and bring to first session. This will help make our session time more productive and efficient.
EMAIL, INTERNET COMMUNICATIONS, PHONE, FAX, & MAIL
I give Don Elium, MA MFT permission to communicate with me through:
#1. the following email address,
confidential information can be sent here:
#2. the following phone numbers, confidential information can be left here:
cell __________________________
phone________________________
work_________________________
other________________________
#3. the following fax number, confidential information can be sent here:
#4. the following mailing address, confidential information
can be sent here by US Mail, Fed-Ex, UPS, or other:
Street:___________________________
City:_______________________ State__________ Zip ______________
#5. If a client calls my office and leaves a number that is different than the above, I will return that call and ask for you but not leave any other information other than, "I am returning their call."
I give Don Elium, MA MFT permission to communicate with me through the above channels and, where applicable, through any number I leave for him to reach me:
Signature of Client (if using paper)
Signature Printed (type/print full name)
NOTE: Don Elium, MA MFT Psychotherapy Office observes strict confidentiality in all therapeutic matters. All electronic records, email accounts, and/or other electronic communications are password protected. All computer and internet networks have firewalls and passwords to protect from unlawful or accidental entry. All phone message systems are private and password protected--- Don Elium, MA MFT
__________________________________________________________________________
3•SECTION 3: •PERSONAL INFORMATION REQUIRED FOR PSYCHOTHERAPY•
__________________________________________________________________________
According to your preferred method of communication with this office as agreed in Section Three,
PLEASE copy the form below to a new email (or paste in a WORD docutment and attach) & send before first session to Don@DonElium.com, OR print out on paper, fill out, and bring to first session. This will help make our session time more productive and efficient.
(for couples psychotherapy, have each person fill out the same form below.)
Personal Information Required For Psychotherapy for Adult Clients
A. Name:
B. Address:
C. Home Phone:
D. Work Phone:
E. Cell Phone:
F. Is it okay to leave messages of any kind on the above numbers? ____yes ____no (if not, which numbers are preferred for messages of any kind)
G. Date of Birth:
H. Birthplace:
I . Maiden Name:
J. Social Security Number:
L. Marriage/Relationship/Significant Other Status:
M. Married before? ____yes _____no If so, how long? _______ Children__________ How many?________ Ages _________
N. Stepchildren? ____yes ____no, If so, how many?_____ Ages _________________
P. Current Spouse Name:
Q. Birth Date:
R. Current medications, of any kind, prescribed by M.D. (medical doctor)_______________________________________________________________
S. Are you currently in counseling with another therapist other than our sessions?
T. History of any psychiatric hospitalizations:
U. History of any substance/alcohol problems:
If for any reason, you can't fill out any section or item, we can finish them during the first session. Responding before the first session, with as much as possible, helps us more quickly focus on your personal life concerns.
Thanks for sticking with all the items of the paperwork. I look forward to meeting with you soon.
Sincerely,
Don
Don Elium, MA MFT
925 256-8282
Member California Association of Marriage & Family Therapist
Accredited as a provider of Continuing Education by the
Board of Behavioral Sciences, State of California, Approval No. PCE 3717
Marriage & Family Therapist License # # MFC28381
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Copyright 2010, Don Elium. All Rights Reserved.