Dr. Beth Gadomski Psychologist, CA License PSY 23658

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1 page 1 of 7 Welcome to my practice. I look forward to our work together. You may have many questions as you begin work with a psychologist who is new to you. In an effort to answer some of those questions, please take the time to read this document prior to our initial session. If you have any questions or need additional clarification, please feel free to discuss any concerns with me directly. Once you are comfortable with the information presented here, please print and sign the Acknowledgment of Notifications Form. By signing this form, you are indicating that you have reviewed this document and that you are aware that this agreement will be enacted once we begin working together. QUALIFICATIONS I received my doctorate in clinical psychology from Alliant International University s California School of Professional Psychology in San Francisco, CA, in My dissertation research focused on ethnic-racial and subcultural identity, which continues to be an area of expertise and interest. I completed my postdoctoral fellowship at the University of California, Berkeley, Counseling and Psychological Services, which then led to a staff position. Afterwards, I served as a psychologist at Stanford University s Counseling and Psychological Services for five years before leaving to pursue a private therapy practice. EVALUATION AND BEGINNING THERAPY During our first few sessions, you can expect that we will be discussing what is bringing you to therapy at this time, what you hope to gain from your time in therapy, and how you feel about the therapeutic relationship that is developing between us. If I believe that I am not an appropriate treatment provider for your specific situation, or if you feel that there is not a good fit between us, then I may provide you with referrals to other clinicians who may better suit your needs. After this initial evaluation time, I will be able to offer you some first impressions about what our work would include and what a potential treatment plan would look like if we continue working together. You should consider this information carefully, as therapy involves a large commitment of time, money, and energy; therefore, it is essential that you feel comfortable with the therapist you select. ENDING THERAPY / TERMINATION Concluding our work together will ideally be a mutual process comprised of us determining together when it will be best for you to end treatment, whether follow-up options will be beneficial to you, and how you will know when it may be appropriate to return to treatment after ceasing our work. If engaging in this termination process is not possible for you, I suggest you allow for at least two final sessions so that we can conclude your treatment in a way that is both healthy, as well as respectful of the time and energy you have devoted to the therapy process. If during our work together I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you. If appropriate, I may terminate treatment and give you referrals that may be of help to you. If you request and authorize in writing, I may talk to the psychotherapist of your choice (with your permission only) in order to help with this transition. If at any time you want another professional's opinion or wish to consult with another therapist, I will

2 page 2 of 7 assist you in finding someone qualified. You have the right to terminate treatment at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer. I reserve the right to terminate treatment unilaterally and immediately if you verbally threaten or harass, physically threaten or harass, or commit violence towards me, my office, or my family. I may also choose to terminate services if you fail or refuse to pay for services after a reasonable amount of time. BENEFITS AND RISKS OF PSYCHOTHERAPY Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I will ask for your feedback and views on your therapy and its progress. During the initial evaluation and the course of therapy, remembering unpleasant events, feelings, or thoughts may result in your experiencing considerable discomfort, strong feelings, anxiety, depression, insomnia, etc. It is possible that I may challenge some of your assumptions or perceptions, suggest new ways of thinking about your experience, or recommend different ways to respond to situations in your life; this may cause you to feel upset, angry, or disappointed. Attempting to resolve issues that brought you into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions to change behaviors, employment, substance use, schooling, housing, identity, or relationships. Change can sometimes be quick and easy, but more often it can be gradual and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. SESSIONS I will usually schedule one 45-minute or 75-minute session per week at a mutually agreed-upon time, unless we determine another frequency/duration of treatment. If you are late to an appointment, we will end on time so as not to run over into someone else s appointment time. Once an appointment time is scheduled, that time is reserved specifically for you. If you need to reschedule or cancel an appointment, I require a minimum of 48 hours notice. Your full fee will be charged for sessions missed without sufficient notice. If you are acquiring statements from me to submit to your insurance company, please be advised that most insurance companies do not reimburse for missed sessions. FEES Individual sessions are $165 for 45 minutes and $275 for 75 minutes. Couples and partners sessions are $205 for 45 minutes and $340 for 75 minutes. Please note that a 75-minute meeting is required

3 page 3 of 7 for the initial couples/partners appointment, the cost is $340. An annual fee increase will occur every January; I will remind you of this in advance of that date. PAYMENT SCHEDULE Your full payment is expected at or before the time of our session. This payment schedule may be adjusted pending prior agreement. Should you neglect to provide your full payment during our session, a grace period will be allowed with no late fee if payment is received by 6:00 pm the next business day. After 6pm on the next business day, there will be a $20 charge for late payments made within the same week, and a $30 charge the next business week. Should you experience continued delays with fees, we can discuss strategies to rectify this pattern. I proudly work as an Associate and Independent Contractor with Keely Kolmes, Psy.D. As a result, all checks are to be made out to Dr. Keely Kolmes or payments made via PayPal to Payments can be made by cash, check, or credit card. Should a check be returned due to insufficient funds, you will be responsible for all associated costs and fees. ADDITIONAL FEES For other professional services lasting over fifteen minutes outside of our scheduled sessions, you will be billed on a prorated basis. These services may include telephone conversations or communications lasting longer than fifteen minutes, extensive coordination of care, consulting with other professionals with your permission, report writing, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Should this coordination of care by or telephone with other professionals require more than 15 minutes of time per week (outside of your session with me), you will be charged $45 for each additional 15-minute increment. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time and services even if I have been called to testify by another party. Because of the difficulty of legal involvement and the interruption to my regular practice, I charge $450 per hour for preparation and attendance at any legal proceeding. I will provide bills/receipts for legal proceedings at the end of each session and expect to be paid upon receipt unless otherwise agreed upon. LATE PAYMENTS I do not permit clients to carry a balance of more than two sessions and if you are unable to pay this balance, we will discuss whether it makes sense to pause your care or develop another strategy so that you can avoid incurring additional debt. Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments. In the event there is an outstanding balance on your account for more than 90 days, I reserve the right to utilize a collection agency to facilitate financial reimbursement for services rendered. Please

4 page 4 of 7 note that relevant client information will be provided to the collection agency as necessary for the purpose of obtaining reimbursement. CANCELLATION POLICY Therapy is most effective when attended regularly. Please make every effort to attend your sessions in order to maximize therapeutic benefits. Should you need to cancel a session, please inform Dr. Beth Gadomski as early as possible. If you cancel your appointment less than 48 hours before your scheduled session, you will be required to submit full payment. On occasion, reasonable exceptions to this policy will be made in the event of illness (impacting you or your family) and unexpected life events, which will result in a one-time waived cancellation fee. INSURANCE I am an out-of-network provider, as I do not currently accept insurance. I will be able to offer you a monthly invoice for counseling sessions, which may be submitted for partial or full out-of-network reimbursement from your insurance company. Please contact your insurance company to obtain details regarding your out-of-network benefits prior to your first session. I will not be fiscally accountable, should your insurance company be unable to reimburse your therapy costs. Please remember that my services are provided and charged to you, not your insurance company, so you are responsible for payment. Fees you pay for therapy services that are not reimbursed by insurance may be deductible as medical expenses, if you itemize deductions on your tax return. HEALTH INSURANCE AND CONFIDENTIALITY OF RECORDS Your health insurance carrier may require disclosure of confidential information in order to process claims or invoices. Only the minimum necessary information will be communicated to your insurance carrier, including diagnosis, the date and length of our appointments, and what services were provided. Often the billing statement and your company's claim form are sufficient. Sometimes treatment summaries or progress toward goals are also required. Unless explicitly authorized by you, Psychotherapy Notes will not be disclosed to your insurance carrier. While insurance companies claim to keep this information confidential, I have no control over the information once it leaves my office. Please be aware that submitting a mental health invoice for reimbursement carries some risk to confidentiality, privacy, or future eligibility to obtain health or life insurance. CONTACTING ME Due to the nature of my work, I am often not immediately available by telephone. Should you need to contact me between sessions, please leave me a voic message at I check my voic daily and will generally return your message within one business day, with the exception of weekends and holidays. Please leave a voic message, if you need to reach me; I do not return missed calls or text messages. You may use my address only for administrative purposes such as scheduling, rescheduling, or canceling appointments. is NOT an appropriate forum for discussing clinical issues that are better raised during our sessions.

5 page 5 of 7 In an emergency situation, please contact me via telephone only. If I am going to be away from my practice and/or unavailable to respond to messages during a prolonged absence, I will let you know in advance and will provide you with the name of a colleague who will be covering for me. If an emergency situation arises and you are unable to reach me or you need to talk to someone right away, dial 911 or go to your nearest Emergency Room (San Francisco General Hospital Psychiatric Emergency, , 1001 Potrero Ave., San Francisco, CA). The Suicide Prevention/Crisis Line can be reached at TALK ( ) and the San Francisco Suicide Prevention line can be reached at (415) CONFIDENTIALITY OF ELECTRONIC COMMUNICATIONS Forms of electronic communication, such as texts, s, voic s, and faxes, can be easily accessed by unauthorized individuals, which can compromise your privacy and confidentiality. Please notify me at any time during your treatment, if you would like to avoid or limit the use of any or all of these methods of communication. DUAL RELATIONSHIPS Therapy never involves sexual, business, social or any other dual relationships that could impair my objectivity, clinical judgment or therapeutic effectiveness, or could be exploitative in nature. It is possible that during the course of your treatment, I may become aware of other preexisting relationships that may affect our work together, and I will do my best to resolve these situations ethically, but this may entail our needing to stop working together, depending upon the type of conflict. Please discuss this with me if you have questions or concerns. CONFIDENTIALITY During therapy, my ability to help you will largely depend on how open and honest you can be about yourself. In order for you to feel free to talk openly with me, and so that your right to privacy is protected, the law makes it my duty to keep client information confidential. This means that, in most situations, I cannot release information about you, your attendance in counseling treatment, the content of our sessions, or your written records to anyone else without your permission. If you ever want me to share information about your treatment with someone else (for example, with your physician), I will ask you to sign the Release of Information form, available on my website, which allows me to exchange information about your treatment with others. EXCEPTIONS TO CONFIDENTIALITY There are some situations where I am permitted or required to disclose information without your consent, and it is important for you to be aware of these situations prior to engaging in psychological services. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. These situations are briefly noted here; you will read about them in more detail in the HIPAA Notice of Privacy Practices document that is also available on my website.

6 page 6 of 7 If I believe that you are unable to keep yourself safe, either because you are threatening serious harm to yourself or because you are unable to engage in basic activities of daily life, I am permitted to reveal information about you to others in order to ensure your safety. In urgent situations, I may also contact the person you designated as your emergency contact on your Client Information Form. If you threaten to harm or injure another person, I am required by law to take steps to inform the intended victim and appropriate law enforcement agencies. If I reasonably suspect that any child, elderly person, or dependent adult is being abused or neglected, the law requires that I report this to the appropriate county agency. If you report instances where you downloaded, streamed, or accessed through any electronic or digital media depictions in which a child is engaged in an act of obscene sexual conduct, I am required by law to report this to the appropriate county agency. If a court of law orders me to release information, I am required to provide that specific information to the court. If you have been referred to me by a court of law for therapy or testing, the result of the treatment or tests ordered may have to be revealed to the court. If you are involved in, or become involved in, any kind of lawsuit or administrative procedure (such as worker s compensation), where the issue of your mental health is involved, you may not be able to keep your treatment information private. In couples, partners, or relationship therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the partners or among family members. I will use my clinical judgment when revealing such information. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. In order to provide you the best treatment I can, there will be times when I may seek consultation from another licensed mental health professional. In these consultations, I make every effort to avoid revealing your identity. The consultant is also legally bound to keep the information confidential, although the exceptions to confidentiality apply to them as well. Similarly, when I am away or unavailable, my practice will be covered by a licensed therapist. I may inform this on-call therapist about your situation to facilitate the appropriate support, should you require it in my absence. RELEASE OF INFORMATION Considering all of the above exclusions, upon your request and with your written consent, I may release limited information to any person/agency you specify, unless I conclude that releasing such information might be harmful to you. If I reach that conclusion, I will explain the reason for denying your request.

7 page 7 of 7 EMERGENCIES If there is an emergency during our work together or after termination in which I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving psychiatric care, I will do whatever I can within the limits of the law to prevent you from injuring yourself or another, and to ensure that you receive appropriate medical care. For this purpose I may contact the person whose name you have provided on your Client Questionaire. QUESTIONS AND COMPLAINTS I encourage you to ask any questions you have about your treatment at any time, including questions about my professional background, techniques I use, suggestions I make, what you can expect to happen in your session, and what you have read in any document associated with my psychotherapy practice. If you have concerns or questions about your treatment, I hope you will talk directly with me. I will take your questions, complaints, or criticisms seriously, and I will respond with care and respect. If you think that I ve been unwilling to listen and respond, or that I have behaved unethically, you have the right to discuss your complaints about me with anyone you wish, and you do not have any responsibility to maintain confidentiality about our work together since you are the person who has the right to decide what information you want kept confidential. You can also contact the California Board of Psychology, which receives questions and complaints regarding the practice of psychology in this state: California Board of Psychology 1625 North Market Street, Suite N-215, Sacramento, CA Telephone:

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