Welcome to my office. I am very pleased that you have selected me to assist you in meeting your goals to improve your life. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment.

Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.

I am a Licensed Clinical Psychologist with over 30 years’ experience helping clients create the life they want to have. I have worked in private practice in the Atlanta area since 1985 and have been at my current office location in downtown Marietta since 2001.

I graduated with a Ph.D. in clinical psychology from the University of Southern Mississippi and completed a Clinical Internship at Louisiana State University Medical Center. Additionally, I have years of extensive post-graduate training in therapy issues and couples counseling.

Psychotherapy is not easy to describe. It varies depending on the particular problems that the clients bring, the training of the therapist, and the personalities of the clients and the therapist. Unlike a visit to a medical doctor, psychotherapy requires hard work on your part. In order to be successful, you will have to put a lot of effort into your sessions and the time between sessions. This also means avoiding any mind-altering substances including but not limited to alcohol and non-prescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return.

Psychotherapy has both benefits and risks. Research has shown that two-thirds to three-quarters of clients find therapy quite helpful. Psychotherapy often leads to a significant reduction of distress, better relationships, and resolution of specific problems. Unfortunately, since psychotherapy is not an exact science, there can be no guarantee about what your experience will be.

The risks of psychotherapy include feelings of frustration, fear, anger, and sadness. You may have to talk about things that are difficult to discuss. Psychotherapy will also probably involve making some changes in your habitual ways of doing things – and this may feel difficult at first. Your therapy may involve recalling unpleasant aspects of your life and life history. Also, you may have new insights into yourself and others that may initially feel uncomfortable.

If you have questions or problems with any part of your therapy, please bring these to my attention in session as soon as possible. It is essential that we talk about your concerns, explore them and resolve them. Sometimes, I may be able to modify my procedures so that they work better for you. Sometimes, greater explanation will help you understand why I do certain things and why they may be helpful. Research has shown that the most important predictor of therapy success is a good working relationship between clients and therapist. Since therapy involves a large commitment of time, money and energy, we need to work together to establish good teamwork. However, if your doubts, concerns, or problems about therapy persist, I will refer you to another therapist. Your personal development is my number one priority. I encourage you to let me know if you feel that transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit.

Confidentiality & Records

All contacts are held confidential under the laws of the state of Georgia. The standards of my profession require that I keep appropriate treatment records which include information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, your treatment goals, your billing records, and any reports; which is known as Protected Health Information (PHI). Your PHI will be filed electronically on a secure computer system which is password protected. You may request access to your PHI and may request this information be sent to another health care provider. However, written authorization is required before any information about you can be provided to others. This includes any communications with health care providers or your family members.

Exceptions to the right of confidentiality are required by law, such as threat of harm to yourself or to others; suspected abuse of a child, elderly person or disabled person; and court ordered disclosure. In the latter case, my license does provide me with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a therapist. The state of Georgia has a very good track record in respecting this legal right. If for some reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say to me confidential.

If you are seeking couples or family therapy, understand records of any contacts with me can be released only if written authorization is given by all adults who participated in the sessions.

If you are under eighteen years of age, please be aware that the law provides your parents with the right to information about your therapy. Because privacy in psychotherapy is critical to successful progress, I request an agreement from parents that they consent to waive this right. I provide parents with only general information on how treatment is progressing. Any other communication requires the client’s authorization. However, if I feel a minor client is in danger or is a danger to someone else, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the minor client, if possible.

In some cases I find it helpful to consult with other professionals. In these consultations the identity of the client is not identified. The consultant is also obligated to keep all information about a case confidential.

Fees & Cancellation Policy

The fee for the initial one-hour Diagnostic Evaluation is $250.00. Subsequent psychotherapy sessions are charged $200.00 for a standard 45-minute outpatient session and $400.00 for the extended 90-minute session. Fees include the additional time used for charting, progress summaries, and correspondence. Payment in full is required at the time of appointment. If you are unable to afford my fee, please discuss this with me. I may be able to make a referral that will allow you to get the help you need at a price you can afford.

The fee for each session will be due at the conclusion of the session. Cash, personal checks, VISA and MasterCard, are acceptable for payment, and we will provide you with a receipt of payment. The receipt of payment may also be used as a statement for insurance if applicable to you. Please note that there is a $30.00 fee for any returned checks.

When we schedule an appointment, we have both reserved that time for the session. If either one of us needs to change an appointment, we each agree to give the other as much notice as possible. If you have to change or cancel an appointment with less than 24 hours’ notice, you will be required to pay my full fee for that time. If I change an appointment with less than 24 hours’ notice, I pay you my full fee for that time. The “24 hour notice” policy applies regardless of reason for the cancellation. The only exceptions are situations that require immediate medical attention, funerals, and deaths in the family. There is no charge in these circumstances. However, there are some circumstances that do result in a charge, even though you may have no control over them. These include last-minute business meetings, car breakdowns, minor illnesses, babysitters who don’t show up, and similar difficulties. I empathize with these problems, and I sometimes have them myself. Nonetheless, if they cause me to cancel an appointment with less than 24 hours’ notice, I will pay you my full fee. And if they cause you to have to cancel an appointment with less than 24 hours’ notice, you will have to pay my full fee for that time. If you arrive late for your appointment, the session will stop at the end of your scheduled time.

Insurance Reimbursement

If you have health insurance, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled. It is very important that you find out exactly what mental health services your insurance policy covers. Most policies have limits on frequency of visits, and limit what services are covered. Please be sure you know your policy limitations, deductibles, and co-pays as it not possible for me to know and monitor each client’s specific insurance benefits. As a courtesy you can arrange with me to bill insurance and have the payments made to me directly. However, you (not your insurance company) are responsible for full payment of my fees. I accept no responsibility for services denied by insurance. If your account is more than 60 days delinquent and we have not agreed on a payment plan, I have the option of utilizing a collection agency to obtain payment.

You should be aware that if you are using insurance benefits, your contract with your health insurance company requires that I provide it with information. Health insurance benefits can only be used for the “treatment of illness”. This means I must assign you a psychiatric diagnosis before benefits will be available. Additionally, some insurance carriers utilize case management where I am required to provide additional clinical information such as treatment plans or summaries before authorization of treatment is given. I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands.

Contacting Me

Because I do not come to the telephone when I am with a client, I am typically not immediately available. However, you may leave messages for me on confidential voice mail at any time. I check for messages throughout each business day and daily on weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for a return call.

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper nor am I available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. If you have a mental health emergency, I encourage you not to wait for a call back, but to do one or more of the following:

Call Ridgeview Institute at 770.434.4566 or Peachford Hospital at 770.454.5589

The Georgia Crisis and Access Line at 800.715.4225

Call 911.

Go to your nearest emergency room and ask for the psychiatrist on call.

If I will be unavailable for an extended time (vacations or multi-day workshops or meetings), I will provide you with the name of a trusted colleague who provides “on call” coverage while I am away.

Relationship

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other ways (e.g., social, business, etc.), we would then have a "dual relationship." Dual relationships may compromise our treatment and, therefore, are discouraged in the mental health profession. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.

You should also know that therapists are required to keep the identity of their clients’ secret. As much as I would like to, for your confidentiality I will not address you in public unless you speak to me first. I also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way; they are strictly for your long-term protection.

Technology Statement

In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to me to maintain your confidentiality, respect your boundaries, and ascertain that our relationship remains therapeutic and professional. Therefore, I’ve developed the following policies:

Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. If you would like for me not to use a cell phone when contacting you, please let me know.

Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please discuss this with me. However, please know that it is my policy to utilize these means of communication strictly for brief topics such as appointment confirmations. Please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy of all emails and texts as part of your clinical record.

Facebook, LinkedIn: It is my policy not to accept requests from any current or former client on social networking sites such as Facebook or LinkedIn because it may compromise your confidentiality. Additionally, my ethics code prevents me from soliciting endorsements from clients, and the concept of “Fanning” is considered to be bordering on such solicitation. However, it is still your prerogative to view or share any content on my professional pages. Please note that you should be able to subscribe to my professional Facebook page via Really Simple Syndication (RSS) without becoming a Fan and without creating a visible, public link to my Page, which I strongly encourage for your privacy.

Google: I do not search for clients on Google. I respect your privacy and make it a policy to allow you to share information about yourself to me as you feel appropriate. If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material out and bring it to your session.

In summary, technology is constantly changing, and there are implications to all of the above that I may not realize at this time. Please feel free to ask questions, and know that I’m open to any feelings or thoughts you have about these and other modalities of communication.

Statement Regarding Ethics, Client Welfare & Safety

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the Georgia professional licensing board that governs my profession.

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I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask.

Agreement

My signature indicates that I have read this agreement and accept its terms; and also serves as an acknowledgement that I have received the Health Insurance Portability and Accountability Act (HIPAA) Notice form which details your privacy protections under federal law.

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Client Name (s) (Please Print)

_____________________________________

Signature (s)

_____________________________________

Date _______________

If Applicable:

__________________________________________________ _______________

Parent’s or Legal Guardian’s Name (Please Print)	Date

__________________________________________________

Parent’s or Legal Guardian’s Signature

My signature below indicates that I have discussed this form with you and have answered any questions you have regarding this information.

__________________________________________________ ______________

Therapist’s Signature Date

Revised May, 2022

GC

Georgia Psychological Consultants, P.C.

Today’s Date: _____/_____/_______

Name: ___________________________________________________ Date of birth: _______/________/________

Address:___________________________________________________________________________________________

__________________________________________________________________________________________________

City	State	Zip

If client is a minor please provide names and contact information for both parents. Use back if necessary.

Prefer to be called at #: ______________________________ Other #: _____________________________________

Is this home, cell, or work?	Is this home, cell, or work?

Can messages be left on voice mail at these numbers? ____yes ____no

Can I contact you by e-mail? ______yes ______no E-mail address: _________________________________________

Social Security #: ___________________________________________________

(While I respect and will protect the sensitivity of this information, this is necessary if you are not paying in full at time of service.)

Emergency Contact____________________________________________________________________________________

Name	Relationship	Contact #

*If you are planning to use insurance, please provide this information:

(If you have secondary coverage please provide additional information on back.)

Name of Policy Holder: __________________________________________________ Date of birth: _____/_____/______

Relationship to client: ______________ Insurance Company: _________________________________________________

Phone #: ___________________________	Employer: _______________________________________________________

Member ID#: ________________________________________ Group#: ________________________________________

Address: _____________________________________________________________________________________________

City	State	Zip

* Unless other arrangements have been made, payment in full is expected at the time of service. As a courtesy, I will fill out forms and provide you with whatever assistance I can in helping you receive your insurance benefits; however, you (not your insurance company) are responsible for full payment of my fees. I accept no responsibility for services denied by insurance. It is very important that you find out exactly what mental health services your policy covers. Most policies have limits on frequency of visits, and limit what services are covered. Please be sure you know your policy limitations, deductibles, and co-pays as it is not possible for me to know and monitor each client’s specific insurance benefits.

Assignment of Benefits

Clients offering health insurance as complete or partial payment of their fees may do so by assigning anticipated insurance payments to Dr. Leisa Bailey. Signature indicates agreement to release information necessary to submit insurance claims to your carrier and assignment of benefits to Dr. Bailey.

Client (or guardian’s) Signature: _________________________________________

**Please complete as much as you are comfortable disclosing**

Name: __________________________ Age: ______ Date of birth: _____________

Who referred you to Dr. Bailey? ______________________________________________

May I have your permission to thank this person for the referral? ___ Yes ___No

What is the main problem that led you to coming here? ______________________________

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_____________________________________________________________________

_____________________________________________________________________

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How long have you had this problem? ___________________________________________

Describe any previous treatment including psychotherapy and use of medications. ____________

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Who raised you? ________________ Where were you raised? ______________________

Number of brothers and sisters? ________ Birth order? _______________

What work did your father do? _______________________________________________

What work did your mother do? ______________________________________________

Did you have any significant or severe childhood illnesses or injuries? _____________________

_____________________________________________________________________

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Who in your family has been treated for psychological problems or problems with alcohol or drugs?

_____________________________________________________________________

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Education: Please circle the number that most closely represents your level of education (years):

High School College Graduate School

Other _____ 7 8 9 10 11 12 13 14 15 16 17 18 19 20 other ____

What is your current occupation? ___________________________________________

If retired, what was your occupation? _________________________________________

What is your spouse’s occupation? ___________________________________________

Please circle your religious affiliation: Catholic Protestant Jewish None Other

All things considered, how important is your faith/religion in your life?

1	2	3	4	5	6	7

Not at all important	Somewhat important	Very important

What is your current marital status? ____	How many times have you been married? ____

How long have you been married to your current spouse? ___________

How many children do you have with your current spouse? __________

Do you have any other children (step-children)? Yes/No	If yes, how many? ______

How many children live with you? _____ Please list the ages and gender of your children:

__________________________________________________________________________

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MEDICAL HISTORY:

Who is your primary care physician? _______________ Psychiatrist? __________________

Do I have your consent to communicate with your other health care providers about your treatment with me? ______ Please provide phone numbers and addresses.

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Please explain any significant medical problems, symptoms, or illnesses:

_____________________________________________________________________

_____________________________________________________________________

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Current Medications:

Name of Medication	Dosage	Purpose	Prescribing Doctor

Sexual Identity: Heterosexual__ Lesbian__ Gay__ Bisexual__ Transgender__ In Question__

What allergies do you have? _________________________________________________

How many cigarettes a day do you smoke? ______ How long have you smoked? ____________

Do you drink alcohol? ______ How many days per week do you typically drink? ______

When you drink, how many drinks do you usually have? ________________________

Which of the following have you experienced? ____lost job because of drinking

____ missed work because of drinking _____ were in fights because of drinking

____ DUI _____Lost license

Which drugs do you, or did you abuse? ____ Does not apply ____ Narcotics ____Recreational

_____ Prescription

Has there been a change in your weight? _____No _____ Weight gain (how much) ______

_____Weight loss (how much) _____ Yes, due to dieting (how much) _____

What problems do you have with your sleep? _____________________________________

____________________________________________________________________

Have you had a significant loss or trauma in the past 2 years? Please describe. _______________
_____________________________________________________________________
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Briefly describe anything else you feel would be important for me to know about you.

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_____________________________________________________________________
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Directions to the office of Dr. Leisa Bailey

600 Kennesaw Avenue

Suite 300

Marietta, GA 30060

(770) 428-6698

From I-75:

Take Exit 267 – B off of I-75. This will place you on Highway 5 South

If you are coming down I-75 South, when you take Exit 267-B you will need to stay in the left most lane to get onto Highway 5 South.

If you are coming up I-75 North, this exit will automatically place you on Highway 5 South.

The first traffic light is Tower Road. Turn right onto Tower (which runs along the right side of Kennestone Hospital).

Continue down Tower Road until you reach a stop light at Kennesaw Avenue.

Turn left onto Kennesaw Avenue and travel approx. 1 mile to 600 Kennesaw Avenue. The Marietta Garden Center will be on your right and my office condominium complex will be on your left. Turn into the parking lot. My office is in the building to the left – about midway – Suite 300. The sign outside of my office reads “Psychological Consultants”.

From the Marietta Square:

Drive away from the square on Cherokee Street, heading North.

You will come to the intersection of Cherokee Street and the 120 Loop. Turn left onto the HWY 120 Loop, get into the left lane, and continue one block until you come to Church Street.

Turn left onto Church Street. This is a two-lane one-way street which goes into the Marietta Square. Get into the right lane.

Turn at the first street on the right (this is a very quick right) which is Kennesaw Avenue.

Proceed on Kennesaw Avenue (across railroad tracks) for approximately one mile. At 600 Kennesaw Avenue there is a small office condominium complex on your right.

Turn into the parking lot. My office is in the building to the left – about midway – Suite 300. The sign outside of my office reads “Psychological Consultants”.