ROBERT M. GORDON, Ph.D., ABPP
DIPLOMATE IN CLINICAL PSYCHOLOGY AND
DIPLOMATE IN PSYCHOANALYSIS
1259 S. CEDAR CREST BLVD., SUITE 325ALLENTOWN, PA. 18103-6261
PHONE: 610-821-8015, FAX:  610 821-1072,  WWW.MMPI-INFO.COM

INFORMED CONSENT TO TREATMENT

Before you begin treatment, I would like you to understand a few things. I lease set appointment times from my practice.  You are responsible for any missed sessions regardless of the reason.  Cancellations of appointments with less than 3 full business days notice will be charged full fee.  Take care of all scheduling and payment issues at the beginning of each session. You are responsible for payment.

All contacts are limited to the scheduled therapy time, except for brief phone calls between sessions. Leave any message for me at 610-821-8015.  In the case of a serious emergency, you may contact Crisis Intervention.

Although research has found that psychotherapy is highly effective for most people, its effectiveness is dependent upon the patient’s willingness to be honest with his or her faults, and to freely discuss thoughts and feelings. Therapeutic interventions are mainly limited to clarification of distortions and interpretation of unconscious self-defeating patterns. Confidentiality will be maintained at all times, except in life-threatening situations, or when required by law, statute or by the court.

Some patients may require medication to help them with their anxiety and/or depression.  I will work along with the patient’s physician to offer suggestions concerning medication.  However, the responsibility for medication or any organic condition lies solely with the physician.

Therapy may end at any time the patient wishes.  However, it is important that you discuss this with me.  This is an important phase of treatment since issues of ending and closure are important. I will answer any questions about my credentials and your treatment.

I have read and agreed to the above conditions.

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FOR GROUP THERAPY:

In addition to the above informed consent for individual therapy, for group therapy, scheduling and payment issues are handled at the beginning of each session.  Group members are responsible for payment whenever the group is in session regardless of the reason for missing.  Group therapy members maintain strict confidentiality of all the members.  Avoid any outside contact or dual relationships. You have a three-week trial period when starting group that does not require a time period to terminate group. After that, you must give at lest 3 weeks notice to terminate group sessions.

I have read and agreed to the above conditions.

Signature                                                                          Date