Paul F. Schmidt, PhD

mynewlife.com  (502) 633-2860

PERMISSION and INFORMED CONSENT

FOR COUNSELING and LIFE COACHING

CLINICAL SERVICES:  I provide personality testing plus individual and couples counseling.  These services are described on my website above.  The following pages can be accessed on drop-down menus under the main heading of “WORK WITH ME”, where you will see and can download a copy of this “Permission to Treat”.

MEETINGS:   After you’ve returned this form to me, you can set up your first appointment with me over the phone.  The first session will be 75 minutes long, and future sessions will usually be for one hour. 

PROFESSIONAL FEES:   Sessions cost $180 for one-hour appointments on weekdays that start before 5 PM.  $270 is the fee for sessions during evenings and weekends.  The first session costs $270 because it lasts 75 minutes and includes several communications and future privileges.  Costs of personality testing are listed on my website.   

BILLING AND PAYMENTS:   Sessions are paid at time of service by cash, check, or Venmo.  Except for illness or unsafe roads, to avoid the late cancel charge of $90, cancellations need to be sent to me by text or voicemail by end of the day before your session.  All fees are to be paid at time of service, and my services are not eligible for any insurance reimbursement.

CONTACTING ME:  Your fees pay for 15 minutes per week of my spontaneous (unscheduled) time with your phone calls, texting, and emailing while we are regularly working together.  So don’t ask me if you can have your 15 minutes now, just text or call me whenever you like to find out.  I will respond immediately if I can, and at my first convenience if I can’t, almost always within half a day (not if I’m out of town on vacation).  If you feel you are unable to wait for me to return your call, contact your family physician, the nearest emergency room, or the local mental health hotline.

CONFIDENTIALITY:  In general,all our communications including whether you’ve seen me is private, between us.  I will only release information about our work to others with your written permission.  But there are a few exceptions:

v If you sign a release directing me to do so, or if a judge or court order requires me to;

v If I am told that someone has been or may be abused or neglected without it being reported;       

v If you tell me that you or someone else poses a serious threat for physically harming someone, or 

v If you confess to me that you or someone else has committed an unreported crime.

Emergencies:  If I feel that an emergency such as those in the four previous lines above may occur or may have occurred, I will report this.  We will communicate through a private telephone and video conferencing service (Zoom), where our messages and pictures are protected with encryption (scrambled at each end, so they cannot be recorded or intercepted).   

Social Media:  I will not give or receivecontact with you on social media, as it isn’t private enough. Details of this policy are on my website above.    

My possible need to discuss transferring your case:  If I ever believe you need to work with another therapist instead of me, you release me to discuss our sessions with a consulting licensed counselor of my choice, and we both agree to follow the directives of this counselor.

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Now please open this form/document, read it, and call or text me if there’s anything that seems confusing, difficult, or unfair to you.   Of course I won’t give or sell this info to anyone, but by digitally entering the four pieces of information below, you acknowledge that you’ve agreed to these as terms for our working together.  

Your name:                                           Cell phone(s) I can use dto reach you:                                   

Email(s) I can use to reach you:                                                      Today’s date:

Once this information is entered, save this new document with your info on it, and email it back to me as an attachment, to  [email protected].   Then we can set the time for our first appointment, and be ready to go when our first session begins.  Thank you, and I look forward to working with you.

__________________________________                               ___________________________________

Your Signature of agreement                                        (Optional Spouse/Child Signature)

Thanks!