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PSYCHOTHERAPY ~ Individuals, Couples & Family

6625 South Rural Road, Suite 111

Tempe, AZ  85283


Fees ~ The policy of this office is that fees are to be paid at the time of the appointment unless other arrangements are made.  We should have an agreement regarding use of insurance or out-of-pocket fees that we discussed by phone before the first session.  If there is not an agreement or if you have further questions, please bring this up before we start the therapy process.


Cancellations ~ Please give 24 hours notice if you cannot keep your appointment.  If you fail to do so, the agreed upon insurance rate per session will be charged   Time reserved especially for you can rarely be filled by someone else on short notice.  (Circumstances beyond your control will be considered).   Please initial & Date (______) ______, (_______) ______


Informed consent ~ Psychotherapy is a team process between you (including a couple or family) and I, to resolve issues we identify.  Entering therapy does not guarantee a specific outcome, and at times is very hard work.  With good effort together the odds are that we will find solutions that are helpful. Treatment planning and review is a team process at every session.  If you are not feeling comfortable or sure about the process, it is your right to stop at anytime.  If you do want to stop, it is best for you and I to talk about it, to see what we can learn and see if other options would be helpful.  You may ask me for information about your treatment record at any time and a copy as soon as possible.


Confidentialities ~ Your records are strictly confidential with the following exceptions:  1) Duty to warn if there is a threat to harm self or others, 2) The requirement to report abuse of children or the elderly, 3) If you are involved in a lawsuit, your records may be subpoenaed by the court, although, it is usually possible to protect information that is not directly relevant to the suit, 4) Your insurer requires basic information to reimburse services provided to you, this does not include detailed psychotherapy notes.


In family information sharing ~ It is my policy that if I see an individual member outside family, group, or couples sessions, that this information can be shared with other family members as needed unless the individual requests that specific information not be shared.


I have read and understand the above and agree to voluntary treatment with Alan Asher, M.C.

Signature of Client ___________________________________________________              Date ________________________

Signature of Client (spouse) ____________________________________________               Date ________________________

Signature of Guardian _________________________________________________              Date ________________________



Please fill out, Print and Sign form

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