Client Information Sheet

Meryl H. Brownstein, M.ED, LPCMH

1407 Foulk Road, Wilmington, DE 19803 // 302-475-7555

CLIENT INFORMATION SHEET

Welcome to my office.  I am a licensed professional counselor of mental health in the state of Delaware and Pennsylvania and am Board Certified by the National Board of Certified Counselors.  I received a Masters degree in counseling from the University of Massachusetts in 1983 and have worked as a therapist for over twenty five years in the state of Delaware.  I have been a member, in good standing, of the American Mental Health Counselors Association for the past ten years.  In addition to my private practice, I facilitate workshops and lectures on mental health issues throughout the community.

I offer the following services:  individual, couple, family and group therapy and am also available for consultations to schools and industry. In addition I provide professional supervision for other psychotherapists.  I have experience working with diverse populations in both short term solution focused therapy as well as in longer term, in depth psychotherapy.

In many instances, you have been referred here through a friend, family member, physician, or other health professional because of an existing problem or difficulty.  I would like to encourage you to take an active part in your treatment by sharing information and asking questions.  The following information is designed to answer some common questions that people often ask.  It is not comprehensive or all inclusive and if there is anything that is not addressed below, please feel free to ask.

HOURS:  I generally have hours in the mornings, afternoons, and evenings to try to accommodate varied schedules.  I see patients by appointment only.

APPOINTMENTS, FEES, CANCELLATIONS:  Each session is generally 50 minutes long.  My fees for individual therapy are $175.00 for the initial evaluation and $165.00 for every subsequent session. For couples work, I charge $175.00 for every session. Some sessions are scheduled for more than 50 minutes for more intensive work.  The necessity for an extended session will be discussed with you within the context of your treatment.  The fee for an extended session will be adjusted accordingly.  A fee is also charged for telephone consultations that exceed 15 minutes and for reports that require more than 15 minutes to write.

Payment of fees and /or co-payments under your specific insurance plan is made at the time of the session.  In general, it is my policy to charge for appointments missed without notification or cancelled with less than 24 hours notice.  If, however, you miss an appointment without 24 hours notice for a reason totally beyond your control, discuss this with me and I will, usually waive the fee. Note that insurance companies do not pay for missed appointments.TELEPHONE ACCESSIBILITY: You can reach me through my voice mail while I am with patients any time of day or evening.  I will return your call as soon as possible usually responding within twenty four hours. I do not check messages on weekends.  If this is a true emergency you try my cell at 302-598-2883, or you can call one of the emergency numbers below or call 911.

  Crisis Intervention Service: 577-2484 or 1-800-652-2929

Mobile Crisis Unit: 577-2484 (New Castle County)

   1-800-345-6785 (Kent and Sussex Counties)

 CONTACT:  761-9100 (New Castle County)

1-800-262-9800 (Kent and Sussex County)

Emergency Rooms and Psychiatric Units of Delaware Hospitals. (Wilmington Medical Center, St. Francis, Rockford, Meadowood etc.

Please use these numbers if you cannot wait until I am able to get back to you.

MEDICATION: If there is the possibility that medication may be indicated as a part of your treatment, I will discuss this with you.  Following this discussion, if it seems advisable to obtain a psychiatric consultation to ascertain the advisability of medication, I will refer you to one of my colleagues for an assessment.  Even though you may consult with a psychiatrist for a medication evaluation, you will probably be continuing your treatment with me.  The psychiatrist and I will work in close collaboration if medications are used to supplement your treatment.

CONFIDENTIALITY:  A crucial, foundational dimension for the practice of psychotherapy is the development of a trusting relationship between therapist and client.  Such trust requires, the privacy and confidentiality of all information you share with me.  Be assured that I will do my utmost to respect, protect, and guard the confidential nature of our sessions.  This means that I will make every effort to safeguard records and files and that I will disclose confidential information only with your written consent.  There are however, certain legal exceptions and limitations to the pledge of confidentiality.  This means that under certain legally defined situations I am required to report information revealed during the course of therapy to other persons or agencies without your written consent.  These situations include:

1. If you reveal information to me about physical or sexual abuse or neglect of a child, a disabled person or an elderly person, I am required by law to report this to the appropriate authority.

2. If you threaten suicide, I am required by law to report this to appropriate authorities and, if possible to notify persons close to you.

3. If you threaten bodily harm or death to another person, I am required by law to warn the intended victims and notify the appropriate law enforcement agencies.

4. If a court of law issues a legitimate subpoena, I may be required by law (i.e. court order) to provide the information described in the subpoena.  (Note:  If you choose to use confidential information on your behalf on a court proceeding, such as custody or divorce proceedings, the opposing attorney(s) also has a right to your records.)

5.  If you are using health insurance for reimbursement, you have probably already signed a “release of information.”  This means the insurance company can request information from me, including diagnosis, type of therapy, dates of treatment, fees charged, and treatment progress and outcome.  This information is transmitted either by telephone, fax or US mail.

6.  If your co-payments and/or direct payments become delinquent, and every effort made to collect the payment from you is unsuccessful, I will be forced to turn your balance over to a collection agency.  This measure is distasteful to me as I’m sure it is to you and will only be used as a last resort. 

TREATMENT:  Each therapy session is generally 50 minutes long.  The goals for our work together are usually determined within our first few sessions and we will periodically review and refine them.  You and I will mutually agree on how often we will meet: once a week, once every two weeks, or whatever schedule we mutually decide is best.  We will terminate treatment, hopefully because both of us agree that your goals have been satisfactorily met.  You always have the right to terminate at any time; however, it would be in the best interests of your therapy to discuss openly with me your concerns if you are thinking about ending the treatment.

Participating in therapy can result in a number of benefits to you including alleviation of psychological distress, improved interpersonal relationships, a better understanding of your personality patterns, and the resolution of specific concerns that led you to seek therapy.  Working toward these benefits, however, requires effort on your part and may result in your experiencing varying levels of discomfort.  Remembering, discussing, facing, and resolving events and situations in therapy can bring on strong feelings of anger, sadness, fear and depression.  Attempting to resolve issues between marital partners and family members can lead to potential discomfort and may result in changes that were not originally intended.  In other words, meaningful change is often accompanied by the need to undergo some distress.  Hopefully my therapeutic knowledge, skills, understanding, and support will make this process more easily manageable and constructive in outcome.  I will always do my best, but obviously there is no guarantee.

CONSULTATION WITH COLLEAGUES:  It is customary for colleagues to consult one another from time to time on some cases.  This form of consultation with other psychologists is often standard practice in this field and provides for a higher quality of service.  Please be assured that if I were ever to seek consultation about your case, all confidentiality will be respected.  In the end, it is the client who benefits by getting the expertise of two professionals instead of one.  Please feel free to discuss this with me if there are any concerns about this matter. 

ELECTRONIC COMMUNICATIONS:  Please be aware that email communications with me are not HIPPA compliant which means they can be subject to wiretapping by an unauthorized third party.  If you wish to correspond with me about private information, please do it by phone.  I will gladly respond to appointment requests, or other benign communication but I will not email clinical information to you and would advise you to do likewise.

VACATIONS AND OTHER INTERRUPTIONS IN TREATMENT:  On occasion, I will take some time away from my practice, usually in the summer and around the Christmas holidays.  I will let you know well in advance when this will occur and will offer you the opportunity to consult with another therapist during these times if you so choose.  During these times another psychologist will be covering for me and you will be given information about that psychologist prior to my leaving.

REPORTS: From time to time, clients ask me to write a report for them.  In appropriate situations, I am happy to do this.  I put a lot of time and thought into the reports that I write.  I therefore, have to charge for the time I put into this endeavor. I will prorate the charge based on the time it takes me to write the report.  For example, if it takes me 30 minutes, I will charge 1/2 of my hourly fee.  I will discuss this with you if ever this comes up.

I am hopeful that most of your questions have been answered here.  If you have any other questions or concerns, please feel free to discuss them with me during our sessions.

With best wishes for your good health,

Meryl Brownstein, M.Ed. LPCMH

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I have read the information in this Client Information and Office Policy disclosure statement.  My signature indicates that I understand the information, agree with the conditions of therapy that are either stated or implied here and agree to comply.  I understand that I have a right not to sign this form and can choose to discuss any concerns about treatment with Meryl Brownstein.  

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