E. THOMAS DOWD, PhD., ABPP

Welcome to my office at Rainier Associates. The following information is provided to familiarize you with my practice and background.

CREDENTIALS: I am aBoard-Certified Psychologist who provides psychotherapy for adults and older adults. I also provide couples counseling and therapy for relationship enhancement and repair. I received my Ph.D. from the University of Minnesota and am a Fellow of the American Psychological Association, a Fellow of the Association for Behavior and Cognitive Therapies, President of the American Board of Behavioral and Cognitive Psychology, and President-Elect of the Division of Psychological Hypnosis of the American Psychological Association. I hold board certification in Behavioral and Cognitive Psychology through the American Board of Professional Psychology, Inc.

APPOINTMENTS: Your appointment time is held exclusively for you. It is important that you arrive on time for your appointment, as it cannot be extended. If you are unable to keep your appointment for any reason, please contact the office at least 24 hours in advance to cancel or reschedule; otherwise, you will be charged $50 for the missed session. Insurance will not pay for missed sessions; you will be responsible for the charge. If a pattern of no shows/ late cancellations occurs, our working relationship will terminate, and you will need to obtain care elsewhere. You will receive a reminder call for your appointment. But it is your responsibility to remember and keep track of your appointments.

PROCESS OF THERAPY: I have extensive experience in both academic and practice settings with a focus on a broad spectrum of cognitive-behavioral treatment for emotional and behavioral problems. I primarily utilize the cognitive-behavioral-developmental model, in which existing problems are placed within the context of the client’s developmental and familial history. But I am eclectic in many ways. I treat depression and anxiety disorders, fears and phobias, religious and spiritual issues, relationship problems, adjustment difficulties, stress management, career and occupational counseling, self-esteem issues, smoking cessation, grief and bereavement, as well as utilizing hypnosis and hypnotherapy for a variety of concerns. I attempt to teach and provide compassion and insight to help clients overcome destructive life patterns. I promote positive psychology. I constantly search for new challenges and opportunities and encourage my clients to do the same, because this is the way we grow.

There are no guarantees that the results of any evaluation or therapy will conform to your every expectation. Effective therapy can sometimes be confusing and emotionally painful. Effective treatment and accurate assessment depend to a significant degree on your openness, your commitment to change, and your collaboration.According to Washington Law, if you appear to pose a danger to yourself or others, to engage in child or elder abuse, I may need to report this. If the initial evaluation indicates problems outside of my professional practice I may need to refer you to another provider.

Please be advised that I do not perform evaluations or Assessments for Social Security Disability, Long Term Disability, Short Term Disability, Legal (Forensic) Purposes or Psychological Reports. I do not treat anger, aggression and related disorders.

EMERGENCY CALLS: An answering machine takes all emergency calls outside of regular business hours. If it is a true emergency (self- harm or harm to others) I would suggest calling 911 or the pierce county crisis line at (253) 798-4333.

BILLING AND PAYMENT: Patients are responsible for their accounts and are expected to pay their bill when due, whether medical insurance pays for a portion or not, including charges for evaluation, printed materials, reports, letters, consultations and telephone calls. A finance charge of 1% per month may be added to any balance not paid within 60 days after the charge was incurred. When 90 days have passed without a payment, accounts may be sent to collections and the patient may be responsible for any additional legal and/or collection agency charges. Results of evaluations or reports may not be released until accounts are paid in full. I understand that this is an expensive treatment and I am prepared to arrange an extended payment plan. This entails a written agreement to pay a fixed amount regularly each month until the balance is paid. If regular payments stop, the balance will be considered delinquent, and finance charges and collection procedures may be instituted.

Bills are sent out monthly and detail the dates of visits, the type of service provided, whether your insurance company had been billed for that visit, and all payments made into your account. If you have any questions about your bill, please contact our billing department.

You are expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage. If you have insurance coverage you are expected to pay your co-pay at the time of each appointment. If you are uncertain about your co-pay I encourage you to contact your insurer. If you have any other questions on this matter I would suggest asking our office staff.

INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be sure to check with your insurer and my intake office to learn whether I am a provider for your plan. You should also learn whether you need a referral or preauthorization to be eligible for your mental health benefit, whether you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of visits or a maximum yearly dollar amount. My billing department will submit claims to insurance companies that I am contracted with. For this to occur you must complete the insurance portion of the “Patient Information” form that was given to you with this office policy. You also need to provide a copy of your insurance card.

CHANGES TO THIS OFFICE POLICY: From time to time I may change the business policies described in this document. I will attempt to notify you of relevant changes.

INFORMED CONSENT: your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

INFORMED CONSENT FOR ADULTS: I hereby authorize E Thomas Dowd Ph.D., ABPP. a licensed psychologist, to render psychological services to ______. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and notice of privacy practices and have received a copy of this office policy for myself.

Date______Signature______

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