Page1 Phone: 360-385-7459 Linda F. Little, Ph.D. Clinical Psychologist Email: LindaFLittlePhD@gmail.com License: PY60468249 Welcome! You have made an important decision to deal with a challenge or change in your life. Before you begin the work this will require, you have the right as a consumer to be informed about the nature and limitations of me as a particular practitioner and of the therapeutic relationship in general. Therefore, it is essential that you take the time to read the following carefully. In our first session feel free to ask me questions about anything that seems unclear. When you have read and understood each page, sign and date the bottom of the last three pages (7, 8 & 9) and bring these signed copies with you to our first meeting. Also please bring completed copies of the Client Registration and Biographical Information Forms and your insurance card(s). I look forward to meeting with you. Psychological Services: Psychotherapy varies depending on the personalities of the therapist and client, the issues being addressed, length of treatment and strategies used. Psychotherapy requires active involvement, honesty, openness, and effort on both our parts. These requirements can feel risky. You might experience uncomfortable levels of feelings like sadness, anger, and anxiety. Therapy can often involve talking about unpleasant aspects of a person s history and behavior. If you wish and are committed, it can also lead to a significant reduction in feelings of distress, better relationships, and problem solving. Success in therapy does require hard work on your part, both during and between sessions. During the first few sessions we will do the following: Discuss your presenting problems. Get to know each other and our individual styles and determine if I can help you with your problems. Discuss any special circumstances (current or anticipated legal actions, medical conditions / procedures, financial concerns, anniversary of traumatic events, etc.) that might affect our work.
Page2 Determine appointment times, frequency of sessions, your unique financial obligation (payment / co-pay). Secure appropriate releases of information, such as for summary records of previous treatment, consultation with collaborative treatment providers (e.g. primary physician). Discuss other recommendations, suggestions, and necessities such as the need for physical or neurological examinations, psychological testing, and psychiatric evaluation for medication. We will decide if we can effectively work together and/or whether another referral would be appropriate. Clients Rights: You have the right to refuse treatment, to change therapists, to receive referral to another therapist, to ask questions concerning your evaluation and treatment, and to raise questions about the therapist, the treatment approach, and the progress made at any time. At any time you wish to cancel therapy or even leave during a session, you may do so. You also have the right to review your records. Both law and the standards of my profession require that I keep appropriate treatment records. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case I will provide the records to an appropriate and legitimate mental health professional of your choice. Your records are kept for seven years after your last session and then your records will be destroyed. You will be charged an appropriate fee for any preparation time required to comply with an information request. Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, unless disclosure is required by law. When Disclosure is required by Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where the client presents a danger to self, to others, to property, or is gravely disabled. When Disclosure may be required: If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain psychotherapy records and/or testimony from your therapist. Emergencies: If there is an emergency during our work together, or in the future after termination, where I am concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychological care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the registration form.
Page3 In some cases it will be useful for me to discuss your situation with others such as your former therapist, attorney or employer/school. If I find this to be true, you will be asked to sign a written consent. You may choose to sign such a consent and to indicate what information is to be disclosed. The authorization for release of information expires 90 days after termination of services, but you may cancel it at any time. You may also choose not to provide your consent. This may lead to a discussion of our continued therapeutic relationship. Health Insurance and confidentiality of records: Disclosure of confidential information may be required by your health insurance carrier in order to process claims. Be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, to the future capacity to obtain life insurance, and might impact your costs for supplemental health insurance. Litigation Limitation: 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 (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.,) your records may not be confidential and may be used in civil suit legal proceedings. I may be legally obligated, by subpoena or court order, to turn over your records and to testify before the court. A subpoena requires your consent to release information. A court order signed by a judge does not. Getting to Know Me: Education and Experience: I received my doctorate in Counseling Psychology from the University of Kentucky in 1981. I then completed a supervised residency with Dr. Robert Harman of the Gestalt Therapy Institute of Kentucky, and Dr. John Crosby both approved supervisors of The American Association for Marriage and Family Therapy (AAMFT). In 1982, I was licensed as a psychologist by the Commonwealth of KY and approved for Clinical Membership in (AAMFT). In the same year, I was hired to establish a Masters Degree Program in Family Studies and Marriage and Family Therapy at VA TECH s Northern Virginia Graduate Center (Falls Church, VA). In 1983 I was licensed as a Clinical Psychologist in VA, and in 1985 I became an Approved Supervisor of AAMFT. Under my leadership VA Tech established the Center for Family Services, a training facility for graduate students seeking either a masters degree or postmasters certificate program to become licensed (marriage and family counselors) and to meet the requirements for Clinical Membership in AAMFT. The Center for Family Services served a secondary purpose of providing low-cost mental health for couples and families in the Washington D.C. Metro area who had no insurance coverage or whose coverage had exceeded it maximum allotment for services. Under my direction the graduate program in marriage and family therapy passed intensive evaluation standards and was accredited by the American Association for Marriage and Family Therapy in 1987. I administered this
Page4 program, served as clinical supervisor from 1985-1991, and taught graduate classes on a regular basis. During this period I was promoted to full-professor with tenure, and received the College s highest honor for outstanding teaching. This program thrives today as does The Center for Family Services (www.nvc.vt.edu/mft/cfs.html). In 1988, I established PIERRS Family Services and PIERRS Inc. (Fairfax VA and later WA State), a woman owned small business, and began a long and satisfying career outside of academia. While providing direct clinical services to individuals, couples, families and working groups throughout my career, I also served as Clinical Director, and Project Administrator for multiple customized national and international Employee Assistance Programs (EAPs) for the following clients: Eastern Air Line Pilots, Air Line Pilots Association; The Drug Enforcement Administration (DEA) U.S. Department of Justice (DOJ); Mobil Oil Corporate Headquarters; and, the US Marshals Service, US DOJ. To provide a wide range of services to these employees and family members, I established, supervised and mentored a national network of over 1200 licensed mental health professionals. Over 125 PIERRS Clinicians, including myself, received and maintained top secret security clearances from DOJ throughout our tenure (1988-2007). My writings have appeared in over 30 professional journals and been translated into five languages. My research findings have been reported in such popular publications as The New York Times, The Atlanta Tribune, The Miami Herald, The Arizona Times, Newsweek, and Cosmopolitan Magazine. Psychology licensure provides that psychologists have passed written and oral examinations administered by the Examining Board of Psychology for Washington State and attests that Psychologists are qualified to engage in the independent practice of psychology. The Washington licensure law provides complaint and discipline recourse procedures for clients. Inquiries about a psychologist s professional qualifications and/or treatment may be directed to the Examining Board of Psychology, Division of professional Licensing, P.O. Box 9649, Olympia, WA 98054. Therapeutic Approach: I am a Gestalt Therapist. I believe that health or dysfunction occurs in the present, and the present is the only time one can change. Clients are encouraged to acknowledge their current existence and to focus on problem resolution. They are facilitated in integrating conflicting desires or priorities, and strengthened in assuming responsibility for who they are. Responsibility leads to maturity, maturity to authenticity, authenticity to self-regulation, and self-regulation to positive behavior change. As a Gestalt Therapist I am systems oriented. Most problems addressed in therapy are related to how the client interacts or did interact with others, and how successful this interaction is or was. Problems between or among people can best be resolved with all persons present and with the focus on present interactions. Couples, family and group
Page5 therapies all provide immediate information on the health of an individual s engagement and how the system of interactions helps or hinders goal accomplishment. In the absence of all players, individuals can still learn the parts they play and decide if they wish to continue playing those parts or if they wish to try something different. As a Gestalt Therapist, I am developmentally oriented. Based on developmental theory of human behavior, I believe that individuals, groups, and organizations go through predictable life stages with accompanying life stage tasks to be accomplished before successful graduation to the next stage. Putting a client s current concerns into a larger life-cycle context can normalize experiences and provide roadmaps for successful functioning in the now. I rely upon psycho-education introducing clients to theories, research findings, and information to increase their knowledge while normalizing their experiences. As a Gestalt Therapist, I am cognitive-behavioral oriented. I call into awareness the outmoded ineffective beliefs (I should could would--ought to), thoughts and attitudes, and focus instead on what is, what it is you want, and what you will do in response. At the end of three sessions, either I or you may choose to enter into or exit the therapeutic relationship. If we decide not to continue, I will work with you to find a therapist to meet your needs. Contacting Me: Office Policies I have a confidential voice mailbox that is password protected only I can access. Follow directions for accessing that mailbox and feel free to leave a message for me. I typically schedule appointments on Tuesday, Wednesday, Thursday or Friday. On the days I am with clients, I will generally return calls by the end of the day. When I am not working, on weekends, and when out of town I may not return your call in a timely fashion. If I do not return your call soon enough and you feel it is an emergency, you should go to the nearest hospital emergency room or call 911. My practice is not designed for emergency services. Please note that I may be away for extended periods of time. During times I am away feel free to leave a message for me, and know that I will return your call as I am able. Fees: My hourly fee is $220 for a diagnostic interview or testing and $165 for a full session for individuals, couples and families. In addition to clinical appointments, I charge conversations lasting longer than 10 minutes, attendance at meetings or consultations with this amount on a prorated basis for all other professional services you may require, such as report writing, telephone other professionals which you have authorized, or preparation of records or treatment summaries. For evaluations that are required for litigation, after the
Page6 diagnostic first hour, all other time spent is billed at $200 an hour. Group sessions are typically $50 per and last 90 minutes. Billing: Unless other arrangements are made if you are not using insurance mental health benefits or Medicare, you will be expected to pay for each session at the time of service. If you have a co-pay it is typically the amount you pay when you see your primary care provider and is to be paid at the time of service. In circumstances of unusual hardship, I am willing to work out a payment plan. Insurance Reimbursement: If you have a health benefits policy, it may provide coverage for mental health treatment by a licensed psychologist. Prior to your first appointment, please contact your insurance carrier to determine what mental health services your insurance policy covers and what is needed from my office in order to secure these benefits for you. I will communicate with your insurance provider. You and I will work out standardized procedures for payment of your fees for services rendered. Appointments: I understand that I am financially responsible for no-show appointments and cancellations within less than 24hours notice. A separate Cancellation / No Show Policy is included at the end of this document and requires your signature. Social Contact: It is not uncommon for us to meet in a social setting such as stores, restaurants, or other public places. If I knew you prior to our therapeutic relationship, I will address you as I had done in the past. I will not engage in a discussion about our therapeutic process. If I did not know you prior to entering into a therapeutic relationship, as a courtesy, I will not initiate social contact to assure your anonymity. However, if you wish to initiate social contact, I will be glad to talk briefly with you, in social settings. Please keep one copy of this document for your information. You are welcome to print out and sign the following three pages (pages 7, 8, and 9) and bring only those to our first appointment. Your signature will signify that you have read and agree to terms herein. Thank you.
Page7 Linda F. Little, Ph.D. Clinical Psychologist 780 McMinn Road Port Townsend, WA 98360-9005 Phone: 360-385-7459 Email: Lflittle@gmail.com NPI: 1063889269 License: PY60468249 Your signature below verifies: I have read Dr. Little s Disclosure Statement and Office Policies Agreement and have had the opportunity to ask questions. I understand I may contact the State Dept. of Licensing if I have any concerns. I understand I am financially responsible for all negotiated charges whether or not paid by insurance (Refer to Cancellation / No Show Policy on the next page). I hereby authorize Dr. Little to release all information necessary to secure the payment of benefits and for the use of this signature on all my insurance submissions whether manual or electronic. I understand that Dr. Little will write to my primary care provider after the initial appointment to assure coordinated care in my behalf. I agree to abide by the terms therein. Signature: Date signed:
Page8 Linda F. Little, Ph.D. Clinical Psychologist 780 McMinn Road Port Townsend, WA 98360-9005 Phone: 360-385-7459 Email: Lflittle@gmail.com NPI: 1063889269 License: PY60468249 Cancellation / No Show Policy for Medicare and Non-Medicare Clients I understand that I am financially responsible for no-show appointments and cancellations within less than 24- hours-notice of the appointment. I understand that no-show and cancelled appointments with less than 24- hoursnotice will NOT be billed to my insurance plan, but the fee for this session, at the standard rate of $165 per appointment, is to be paid directly by me prior to the next appointment. Exceptions: I understand that the fee for appointments under the above conditions will be suspended if we can establish an alternate appointment time during the same week, or If we agree that the reason the session was missed constitutes what we both define as an emergency. Printed Name: Signature: Date:
Page9 Linda F. Little, Ph.D. Clinical Psychologist 780 McMinn Road Port Townsend, WA 98360-9005 Phone: 360-385-7459 Email: Lflittle@gmail.com NPI: 1063889269 License: PY60468249 CONSENT TO RELEASE OF INFORMATION Your insurance may require that I contact your primary care physician as a way of coordinating treatment. If this is the case, I am obligated to notify your physician about services being provided. If this is not required by your insurance, your signature below indicates your authorization for me to exchange information with your primary care physician. Client Signature: Today s Date: / / Therapist Signature: Today s Date / / You may choose to indicate what information is to be disclosed. The authorization for release of information expires 90 days after termination of services, but you may cancel it at any time. You may also choose not to provide your consent. This may lead to a discussion of our therapeutic relationship. LFL Client Intake Information 9