Informed Consent for Couple or Family Therapy

In order to provide the most effective therapy, there are important details to share. Please read the following and ask all your questions about anything on this form. Dr. Vanderhorst will answer all your questions to your satisfaction before we begin.

Education

Dr. Vanderhorst received her Ph.D. in Developmental Psychology from Bowling Green University, Bowling Green Ohio and her post-doctoral training in Clinical Psychology at Sinai Hospital, Baltimore, Maryland. Gloria has also been trained in Emotion Focused Therapy (EFT) by participating in EFT Externships with the North Carolina Center for EFT and the Washington-Baltimore Center for EFT and through direct training with the developer of this approach, Sue Johnson, Ph.D.

Professional Affiliations

Gloria is a member in good standing of the American Psychological Association and the Maryland Psychological Association as well as other professional organizations. She is licensed in Maryland and in the District of Columbia.

Services Offered

In couple or family therapy, your relationship(s) is the client. Dr. Vanderhorst offers EFT ( for couples, families, and individuals based on a humanitarian (Carl Rogers), attachment theory (John Bowlby) approach. We will work together to help you create and build better relationships with yourself, with members of your family, and the world around you. Creating and building these secure relationships can address the dynamics present in your life which cause you distress and discomfort. Together, we will find ways of interrupting the distressing dynamics and create healthy patterns of interaction which may lead to better, more secure relationships.

While benefits are the desired and expected outcome, no specific outcomes can be guaranteed. Exactly what these changes will look like is unknown and things may feel worse before they feel better.

Appointments, Fees, & Cancellation Requirements

Standard sessions are 60 minutes. The fee is $225 per therapeutic hour, payable by cash, check or charge. Gloria will keep a copy of your credit card information on file as a guarantee of payment and for your convenience. If you need to cancel a session, please cancel with at least 48 hours’ notice, except in emergencies, by calling 301.578.8760. Therapy time is reserved for you and a 48 hour notice will allow Dr. Vanderhorst to offer that time to another client. If you don’t cancel with 48 hours’ notice or you miss a scheduled appointment, the full fee will be charged.

If for some reason, you accumulate a balance on your account that is not paid within 3 weeks, Dr. Vanderhorst will take legal steps to receive payment in full and you will be responsible for all filing fees, interest charges and any fees incurred to pursue payment.

Reduced fee arrangements may be made on a case by case basis in an effort to make treatment as affordable as possible; however, successful health care is an expensive process requiring expertise and continuing training. Dr. Vanderhorst reserves the right to refer clients with special financial circumstances to the Pro Bono Counseling Project, a community mental health center or other affordable service providers.

Insurance Company Reimbursements

Gloria is an out-of-network provider for all insurance with the exception of Medicare. After each session, a receipt will be emailed or mailed via regular post with all the necessary information in order for you to submit the receipt to your insurance company if you are seeking reimbursement. You are responsible for researching and knowing the particulars of your insurance benefits and procedures for filing.

The following questions may be helpful for you when speaking with your insurance provider:

1. What are my out of system benefits?

2. Do I have a deductible? What portion of that has been met for the year?

3. What is the carrier’s reimbursement for service code: 90847?

4. Do my mental health benefits require authorization?

Confidentiality

All communications will be kept confidential and information revealed during therapy will not be released without your prior written consent. However, there are certain instances where Dr. Vanderhorst may be mandated by law to break confidentiality. These limits to confidentiality are:

  1. If information is revealed that leads the service provider to believe you are a danger to yourself or others.
  2. If you disclose instances in which you have committed child abuse or elder abuse or the service provider has reason to believe that such instances have occurred or will occur.
  3. If the service provider is court-ordered, records are subpoenaed, or the service provider is otherwise required by law to release information.

Other instances where confidentiality is not guaranteed:

  • If you direct the service provider to release your records and the service provider obtains a signed release of information from all parties present in the therapy sessions for the purposes of comprehensive care (e.g. school guidance counselors, primary care physician).
  • If collection proceedings become necessary. In this case, only the most basic information regarding dates and number of sessions attended will be revealed.
  • Email communication is not considered privileged. The service provider will use email for logistical issues such as scheduling appointments and for non-logistical issues when communication is initiated or requested by the client and for session summaries when a part of services for court ordered interventions. If you send an email to the service provider as a client for couples or family therapy, please also send it (cc) to your spouse/partner/other relevant session participants.
  • The service provider will make a professional judgment regarding any disclosure of information that has not been revealed previously. The service provider is not obligated to hold confidences between partners or family members although the service provider will not reveal information without the source of the information knowing ahead of time. The service provider will encourage transparency and work to assist any participant in disclosure.

If a partner or family member is not willing to reveal confidences, couple therapy may be contra-indicated and the service provider may terminate couple therapy. Referrals may be provided upon request.

Court Related Fees

Dr. Vanderhorst will not appear in court unless subpoenaed and all required and necessary releases of information or waivers of confidentiality are signed by all parties. If Dr. Vanderhorst is subpoenaed to court related to your court involvement, the fees for the Dr. Vanderhorst’s preparation time is $250 per hour and the fee for onsite court related work is $350 per hour with a five hour minimum.

Records

Dr. Vanderhorst will keep records for a period of seven years from the date of your last appointment. Minor children’s records are kept for a period of seven years from the date of their eighteenth birthday. After that time, any and all records regarding our therapy sessions will be destroyed.

Emergency Procedures

Dr. Vanderhorst is not an emergency or crisis provider. If you are having a mental health crisis or emergency, please call 911 or go to your nearest emergency room. After you have been seen by the emergency room staff, please ask the staff to call Dr. Vanderhorst with a summary of the service by calling 301.578.8760.

For continuing education & professional development purposes as well as for training other professionals, your service provider may be unavailable for appointments and phone contact periodically while she is teaching, training, or presenting.

Consent
By your signature below, you are indicating that you have read and understand this document of informed consent and that any questions you had were answered to your satisfaction. This form must be signed by all participating parties. Parents or legal guardians must sign for minors.

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Client Signature Date

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Client Signature Date

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Service Provider Signature Date

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