Informed Consent Agreement
Gaia C. Thiele, MA
799 # 4558,
4th Street, Arcata, CA 95518.
Welcome to my practice. This document contains important information about my professional services and business policies and how they may affect you. Please read it carefully and make note of any questions you want to discuss with me.
For telehealth clients, once you acknowledge that you have read this document, it will become a binding agreement between us and also provide your consent for us to begin therapy. For in person clients, once you have signed this document, it will become a binding agreement between us and also provide your consent for us to begin therapy. For in person clients, I will bring a copy to our first session for you to sign.
Therapy is a unique and highly individual experience with the outcome determined by the effort and motivation you bring to work towards a change in yourself and how you see the world around you. It can result in a number of benefits to you and can potentially help in your ability to detect, challenge, and change beliefs and attitudes that create, maintain, and worsen feelings of depression, anxiety, panic, anger, frustration, etc. Therapy also has the potential to help you gain new or deeper understanding about your issues and learn new ways of coping with and solving them.
However, there is no guarantee that therapy will yield positive or intended results. Because feelings will be explored, you may feel a range of emotions that can be intense and uncomfortable at times.
During the course of therapy, some of your assumptions, perceptions, or behaviors may be challenged, which can cause you to feel very upset, angry, depressed, uncomfortable, confused, or disappointed. I encourage you to explore those feelings during our sessions, as they are part of the therapeutic process. In the attempt to resolve issues that originally brought you to therapy, unintended changes in your personal and interpersonal relationships may result.
Our therapeutic relationship is strictly voluntary. At any time during our work together, you have the right to decide to end treatment. If you are thinking about ending therapy, I encourage you to discuss it with me, and if you wish, I will be glad to provide you with the names of other mental health providers. During the course of therapy, if I assess that I am either unable or not effective in helping you reach your therapeutic goals, I will discuss this with you, and if appropriate, terminate treatment. I will provide you with appropriate referrals and assist you in the transition to a new therapist if you so desire.
I have a masters in Counseling Psychology. I also have supervised hours behind me. However, I am not a licensed MFT yet. In addition, I have five years and counting as a grief group facilitator for Hospice and one year as a group facilitator for teens experiencing trauma with the Center for Attitudinal Healing. Furthermore, I have undergone extensive inner growth.
Each session lasts 50 minutes and will begin at the time agreed with you. Typically, therapy sessions take place on a weekly basis, at a mutually agreed time.
Cancellations and Rescheduling
If you need to cancel or reschedule a meeting, please notify me by telephoning my office at least 24 hours in advance of our scheduled meeting or you will be responsible for full payment for the session.
Keep in mind that insurance companies do not reimburse you for a missed session or a late cancellation.
Fees and Payment
Your telehealth session fee is $60.00. Payment of this fee needs to be made prior to the beginning of each session in full unless other arrangements have been made. Payment can be made on my the-listener website. For in person, sessions, please bring your check ready (made payable to Gaia Thiele) so that we can maximize your therapy time. Your session fee may be increased annually. In the event of any fee changes, you will be notified at least 30 days prior to such changes. I do not accept insurance at this time.
Extended sessions and telephone conversations that exceed ten minutes will be charged a fee based on your regular session fee. Written reports, evaluations authorized or requested by you, or copying of your file follow this same policy.
You may contact me at 707-620-4578 Monday through Friday until 9pm. I will try my best to reach you within 24 hours of your phone call. On weekends or holidays, I will only return calls in the cases of emergency, otherwise I will return calls on Monday or the day after the holiday. Phone calls are generally limited to 10 minutes, beyond this time you will be charged at a prorated amount of my usual fee.
Email and Texting Usage
By nature, therapy is confidential. You can have the confidence that your insights, vulnerable experiences, and feelings will not be repeated outside the therapeutic relationship established. By nature, email and texting correspondence is NOT confidential. My policy regarding email usage is as follows:
• Email and texting correspondence with me is NOT secure.
• Email and texting correspondence is NOT a substitute for person-to-person therapeutic treatment, unless discussed with me in advance and in person.
• I will not respond to your emails in general. Anything stated in an email from you will be discussed in session, and in session only.
• Email correspondence is NOT to be used in the case of an emergency to contact me.
• If you need to contact me with something that demands immediate attention, you will do so voicemail at the following number: 707-620-4578, call 911, or go to the emergency room.
• If it becomes necessary, I will terminate treatment if email usage is or becomes inappropriate.
If you are experiencing a life-threatening emergency and need to talk to someone immediately, you can call 911, the Suicide Prevention Hotline at (800) 273-TALK (8255), the police, or your local hospital emergency room and ask for the psychologist or psychiatrist on call.
Everything you say and share in session is strictly confidential. However, there are some exceptions to the rule of confidentiality. I am required by law to report:
– threats of harm to self or another - suspected child, dependent or elder abuse (past or present) – by court order
Other exceptions include:
- per your signed release
– I may discuss your case with supervisors or peer counselors, in order to provide excellence in the service I give and in accordance with accepted professional behavior. In doing so, I will keep your identity or any details allowing your identification confidential.
When working with minors, confidentiality will be kept unless there is a concern that the child is in danger to themselves, someone else, or has been harmed. In these cases the parent(s) will be notified of the concern and if possibly, I will have discussed the matter with the minor and have done my best to handle any objections he/she may have. During treatment, I will provide parents with only general information about the progress of treatment and the attendance of scheduled sessions.
I have read this information fully and completely, I have discussed any questions I had about the information, and I understand the information. I acknowledge that it is my choice to participate in psychotherapy (or have my child participate). I realize that the outcome of therapy depends upon my personal investment in the therapy process. I have familiarized myself with the fees and charges for services provided by Gaia C. Thiele, MA and I understand and agree that the therapeutic services rendered will be charged to me and not to any third-party payer. I acknowledge responsibility for payment of these services.
Ask a question or book an appointment below.
For emergencies call 911 or visit your nearest hospital