Stacy Berlin, Psy.D. • Telephone (310) 442-6466 Psychologist License #PSY16878

INFORMED CONSENT: PSYCHOTHERAPY OR CONSULTATION

Welcome to my practice. As a licensed California psychologist I, Stacy Berlin, Psy.D., am governed by various laws and regulations and by the code of ethics of my profession. The ethics code requires that I make you aware of specific office policies and how these procedures may affect you. However, many of these policies will be unrelated to our work together. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. The state expects that you will be informed of all possible contingencies that might arise in the course of psychotherapy. Please check to be sure you have read, understood, and discussed all questions with me.

CONFIDENTIALITY is important to help you feel safe in our work together. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. State law and professional ethics require therapists to maintain confidentiality except when there is suspected child, elder, or dependent adult abuse, or a serious threat to harm a reasonably well identified victim or oneself. Even though it rarely occurs in my practice, if the need should arise to release information about you, I will make every effort to fully discuss it with you before taking any action.

EMERGENCIES: My voice mail will be monitored frequently. If you need to contact between sessions, please leave a message and every effort will be made to return your call as soon as possible. However, if you have any doubt of serious harm or you feel you can’t wait for a return call and you need to talk to someone right away, contact or go to the nearest hospital emergency room and ask for the psychologist or psychiatrist on call, or call your physician, or (911) for help.

ABOUT THE RELATIONSHIP WITH THERAPIST: Because of the nature of psychotherapy, the therapeutic relationship is different from most relationships. It may differ in the topics we discuss, or in the goals of our relationship. It must also be limited to the relationship of therapist and client only. If we were to interact in any other ways, we would then have a "dual relationship.” Therapy professions have rules against such relationships to protect us both. I cannot be a therapist to my own relatives, friends, friend’s relatives, people I know socially, or business contacts. I cannot have any other kind of business relationship with you besides the therapy itself. I cannot have any kind of romantic or sexual relationship with a former or current client, or people close to a client. There are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions. A therapist helps you to consider what is best for you.

PSYCHOTHERAPY varies depending on the personalities of the psychologist and client, and the particular problems you bring forward. I use different methods depending on your issues, but I have a philosophical belief in the efficacy of dynamic therapy (defined below). Therapy often involves discussing unpleasant aspects of your life, and you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Other therapies include medication, physical exercise, meditation, and nutrition. For periods of extreme depression or agitation, I will offer a referral for medication. If you have questions about my methods, we should discuss them whenever they arise.

DYNAMIC PSYCHOTHERAPY: Therapy is both a way of understanding human emotions and of helping people with their relationships and their problems. The mature or rational self that functions more or less successfully in the real world is only a part of the total person. The more immature, irrational, or unconscious self functions silently in the background to produce various symptoms and maladaptive behaviors that often intrude into the person's social life, personal relationships, school or work activities, and physical health. In dynamic therapy specific problems are viewed in the context of the whole person. The quest for self-knowledge is one important aspect to changing attitudes and behavior.

Dynamic therapy is based on the insight that our personalities are the result of passing through and solving relationship issues at many developmental stages. At any stage, the way we have reacted to events in our lives may have caused us to get stuck at a certain level of insight or problem solving. While we go ahead and mature in many ways, we may carry within us the parts that didn't have a chance to develop. We can have a mature exterior and be functioning more or less successfully, while internally we may feel vulnerable, confused, depressed, angry, afraid, and childlike. We may not feel able to bounce back from rejection, get past blocks, allow our real feelings to surface, or stay in touch with our desires.

Dynamic therapy is designed to help the client get in touch with her or his unconscious memories, feelings, and desires that are not readily available to the conscious mind. It is designed to help one understand how their unconscious feelings and thoughts affect the ways they act, react, think, feel, and relate. Each client, by expressing their story in whatever ways possible to someone who knows how to listen and to give new meanings back, has the opportunity to learn about herself or himself in a new way.

Dynamic therapy can provide a safe place for people to discover for themselves their own truths. It provides a unique opportunity to re-experience personal history in a new relationship, to see it in a new way, and to make connections between past and current conflicts that illuminate the way one relates to oneself and to others.

Clients are encouraged to talk about thoughts and feelings that come up about therapy or about the therapist. These feelings are important because elements of one's earliest affections and hostilities toward parents and siblings are often shifted onto the therapist and the process of therapy. This phenomenon, known as "transference," offers a rich source of understanding, for it offers the possibility for people to re-experience and rework important feelings arising from the past with the maturity they now possess.

Dynamic therapy aims to help people experience life more deeply, enjoy more satisfying relationships, resolve painful conflicts, and better integrate all the parts of their personalities. Perhaps its greatest potential gift is the essential freedom to change and to continue to grow in relationships.

TERMINATION OF TREATMENT: Dynamic therapy usually takes time to explore the complex layers of feeling and experience that make up a person's own unique relationship history. When the client feels she or he wants to terminate therapy, then a termination date can be set and agreed upon. Clients have the right to terminate at any time but the usual minimal termination for an ongoing treatment process is four to ten sessions and a satisfying termination to long-term work may take several months. Patients have the right to refuse or to discontinue services at any time. The therapist may terminate treatment if prescriptions are not filled (such as seeking consultation, refraining from dangerous practices, coming to sessions sober, etc.), or if some problem emerges that is not within the scope of competence of the therapist.

FEES: My hourly fee is $175, and you are respectfully requested to pay at the beginning of each session. If you cannot afford my fee, a sliding fee scale may be offered. Sessions are scheduled for the same time each week for a minimum of once a week, and we will discuss the frequency together. Once an appointment hour is scheduled, you will be expected to pay your full fee, whether or not you are able to attend, unless you provide 48 hours advance notice of cancellation.

ARBITRATION AGREEMENT: I agree to address any grievances I may have directly with my therapist immediately. If we cannot settle the matter between us, then a joint agreed-upon outside consultation will be sought. If not, an arbitration process will be initiated under the auspices of the American Arbitration Association, which will be considered as a complete resolution and legally binding decision under state law, which in California states as follows: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and your are giving up your right to a jury or court trial as stated in Article 1: “It is understood that any dispute as to medical malpractice that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration." Any arbitration process will be considered as a complete resolution and legally binding decision. The client will be responsible for the costs of this process.
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• OFFICE NOTICE OF PRIVACY PRACTICES •

I may disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. “PHI” refers to information in your health record that could identify you. “Treatment” is when I provide, coordinate or manage your health care and other services related to your care. “Payment” is when I obtain reimbursement for your healthcare. “Health Care Operations” are activities that relate to the performance and operation of my practice. “Disclosure” applies to activities such as releasing, transferring, or providing access to information about you to other parties.

DISCLOSURE REQUIRING AUTHORIZATION: I may disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or a family session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

DISCLOSURE WITH NEITHER CONSENT NOR AUTHORIZATION: I may disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If I have reasonable cause to believe that a child has suffered abuse/neglect, I am required by law to report it to the proper law enforcement agency. Serious Threat to Health or Safety: I may disclose your confidential mental health information to any person without authorization if I reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. Adult and Domestic Abuse: If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, or reason to suspect that sexual or physical assault has occurred, I must immediately report the abuse to the proper law enforcement agency. Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, I must make available, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury if requested. Health Oversight: If the California Board of Psychology subpoenas my records as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed psychologists, I must comply with its orders. This may include disclosing your relevant mental health information. Judicial or Administrative Proceedings: You are required to sign a release for psychotherapy records because you are involved in litigation or other matters with private or public agencies. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony. If you are involved in a court proceeding and requests are made for information about the professional services that I have provided to you and the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform me that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party, where the evaluation is court ordered. You will be informed in advance if this is the case. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings, neither you (patient) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. I do not provide report writing of any kind or court attendance. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the complexities of legal involvement, the charge is $525 per hour for preparation and attendance at any legal proceeding. Payment: If you are required to sign a release of confidential information by your medical insurance. Family therapy: Secrets cannot be kept, yet, discretion is used when disclosing your information to other participants in the treatment. Minors: Clients less than 18 do not have full confidentiality from their parents, yet discretion is used when disclosing your information. Consultation: I may at times speak with professional colleagues about our work without asking permission, but all identities will be disguised. All consultants are also legally bound to keep the information confidential. Electronic communication may compromise confidentiality.

PATIENTS’ RIGHTS: You have the right to request restrictions on certain disclosures of PHI about you. However, I am not required to agree to a restriction you request. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. Upon your request, I will send your bills to another address. You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss the details of the request and denial process with you. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss the details of the amendment process with you. You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor provided authorization. On your request, I will discuss the accounting process with you.

PSYCHOLOGISTS’ DUTIES: I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will date and post a copy of the revisions to my Notice.

QUESTIONS AND COMPLAINTS: If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may discuss it with me. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written notice of your complaint to me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

EFFECTIVE DATE AND CHANGES TO PRIVACY PRACTICES: I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. Revisions to this notice will be posted at the time of revision. I will provide you with a written copy of these revisions upon request. This notice is effective on 08/08/2008.

AGREEMENT FOR PSYCHOTHERAPY OR CONSULTATION: You have read this Informed Consent for Psychological Services and Privacy Practices completely and have raised any questions you might have about it with your therapist. You have received full and satisfactory response and agree to the provisions freely and without reservations. You understand that your therapist is responsible for maintaining all professional standards set forth in the ethical principles of her professional association as well as the laws of the state of California governing the practice of psychotherapy. Your signature below indicates that you have read the information in this document and agree to abide by its terms, and have received a copy of this document.
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• CLINICAL AREAS PRACTICED •

- Anxiety: Fear, Panic, Obsessions, and Compulsions
- Clinical instruction: Consultation and Supervision
- Creativity: Artists, Meaning, and Blocks
- Cultural and Ethnic concerns or "Differentness"
- Depression: Mood or Bipolar disorders
- Eating disorders: Body image, and Self-regulation
- Existential, Religious, and Spiritual concerns
- Gay and Lesbian Concerns: Coming-out and relationships
- Identity: Self-perception, Attachment, and Gender
- Life Transitions: Aging, Career, Health, and Death
- Loss, Grief, Bereavement, and Healing
- Personality concerns, disorders, and resolution
- Relationships: Sex, Intimacy, and Communication
- Substance Abuse, Addictions, and Recovery
- Trauma, PTSD, Abuse, and Dissociation

Stacy Berlin, Psy.D. • Telephone (310) 442-6466 Psychologist License #PSY16878

CLINICAL PSYCHOLOGY

OFFICES: WEST LOS ANGELES AND SAN FERNANDO VALLEY

INFORMED CONSENT: PSYCHOTHERAPY OR CONSULTATION