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K. PHILIPPE GENDRAULT, Ph.D.Clinical Psychologist, PSY 19040

3702 Sacramento StreetSan Francisco, CA 94118

Tel.: 415-289-7033

Consent to Treatment

About psychotherapy: Psychotherapy is often helpful as a means of relieving distress,understand ones person motivations, and improving the quality of ones life. It requires a

joint effort, and a significant commitment from you in terms of effort, time, and money. It isa process that varies depending on the personality of the therapist and the patient, as wellas motivation, effort, life circumstances, and the nature and severity of the problems to beaddressed. While therapy is designed to be helpful, it may at times be difficult anduncomfortable.

Confidentiality: Everything you discuss with me is confidential and I can only releaseinformation about our work together with written consent. There are certain circumstances,however, that under law require or permit me to disclose information:

1) When there is reasonable suspicion of child abuse or neglect, or evidence ofelder abuse.

2) When a person presents an imminent and/or potentially serious danger to selfor others

3) In the even of certain court order to subpoena information or records

Payment for Services: We will determine a fee together during our initial consultation. Thisfee will be reevaluated yearly. Payment is due at the time of service. Please notify me ifany problem arises during the treatment regarding your ability to make timely payments.

Cancellations: One we decide on a regular time or times to meet during the week you areresponsible for paying for that time. If you need to reschedule an appointment I will do mybest to accommodate you. If we are able to reschedule within a reasonably short time (1 to2 weeks) you will not be charged for the cancelled sessions, otherwise you will be charged.

You also will not be charged when the therapist is away from the office.

Your participation in therapy is voluntary and you may discontinue at any time. In the bestof circumstances we would decide together when to end treatment. In the event that youwish to end treatment, I would strongly encourage you to discuss this desire with me. Sinceuncomfortable feelings that arise in therapy often contribute to a desire to quit, it isimportant to fully explore these feelings to determine the best course of action (i.e.,

continued therapy, discontinue, seek other treatments).

Emergencies: If you nee to contact me, you can call me at 415-289-7033 and leave amessage at any time. I check my messages daily and will call you back as soon aspossible. If you have an emergency and cannot reach me immediately, you may call 911 orSFGH Psychiatric Emergency Services at 415-206-8125.

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By signing this form you are acknowledging that you understand and consent to the abovematerial.

Print your name: ____________________________________________________________________

Sign: _________________________________________________ Date _______________________