Psychotherapy Practice Information and Informed Consent For Valerie Chu, MA, ATR-BC, LCAT at ArtSpring Creative Arts

Therapy, PLLC Thank you for choosing me as a partner in your emotional health pursuits. The following information is provided to you in written form as a reference to help clarify the guidelines of my practice. Should you have further questions, I would be happy to answer them. Therapist I am a licensed professional art therapist engaged in independent practice providing mental health care services to clients directly. My certifications include: ATR-BC #09-250 (Nationally Registered and Board-Certified Art Therapist). LCAT #001304 (New York State Licensed Creative Arts Therapist). I am also trained by EMDR HAP (Eye Movement Desensitization and Reprocessing Humanitarian Assistance Program) to perform EMDR. Mental Health Services While it may not be easy to seek help from a mental health professional, I hope that our work together will help you move towards resolving your difficulties. Using my therapeutic skills as well as knowledge of human development and behavior, I will assist you in exploring your issues and feelings, and provide suggestions for new ways to approach them. Psychotherapy is a partnership between us which involves your active involvement. It will be important for you to examine your own feelings and thoughts and to try new approaches in order for change to occur. Appointments & Cancellations Appointments are scheduled through contacting me via phone or email. Please call or email to cancel or reschedule your appointment at least 24 hours in advance, or you will be charged for the missed appointment. However, I do recognize that emergencies and health issues may arise, so one (1) late cancellation will be excused per year. Please note that, by law, your insurance company is not liable for payment of a late cancellation or a missed appointment. In these cases, you will be held financially responsible for the full session fee. Number of Visits The number of sessions needed depends on many factors. Typically, we meet once a week, but sometimes frequency can be increased to twice weekly or decreased to bi-weekly depending on your treatment goals. We can discuss this following the completion of your initial evaluation. Please note that there are times during the year when I will need to be away to attend professional conferences or work on special projects. I will notify you well in advance of any lengthy anticipated absences and will make arrangements for another therapist to cover my practice if needed. You have the right to end therapy at any time without moral or legal obligation. I would request that we meet at least one more session to review our work together. If I feel, at any point, that my skills and expertise are not appropriate to address the issues that you have, I will provide a referral to another therapist who might be able to help you.

Length of Psychotherapy Sessions Psychotherapy sessions are typically 50 minutes in length. Focused EMDR sessions can be as long as 75 minutes. If you arrive late, we will have less time in which to work and progress may be delayed. I will keep track of the session time and remind you when the session is about to end. Therapeutic Relationship Your relationship with me is professional and therapeutic. In order to preserve this relationship, it is imperative that I do not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship and are also unethical and illegal. Payment for Services Standard rate for 50-minute session: Standard rate for 75-minute session: Package of 4 sessions: Package of 8 sessions: $115 $170 $400 $720

Sliding scale for per-session rates is also available if you are encountering significant financial difficulties. These rates will be determined on a case-by-case basis. All clients are self-pay. If your insurance plan covers out-of-network providers, I can assist you in completing the professionals portion of the paperwork to submit for reimbursement. Although it is my goal to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. Confidentiality Without written consent, all discussions between psychotherapist and client, including minors, are strictly confidential. Possible exceptions to confidentiality include, but are not limited to, the following situations: suspected child abuse (including neglect and emotional abuse); suspected abuse of the elderly or disabled; suspected sexual exploitation/abuse; when the client communicates threat of serious harm to another or is suicidal; when a third-party communicates to the therapist that a client is threatening harm to another; when information is required by law or ordered by the court; filing of a complaint with a licensing board. There are times when I need to consult with colleagues or specialists about our ongoing work, which ensures that I am providing you with high quality services. This will not involve your name or any specifics through which you could be identified. These other professionals are also required by professional ethics to keep your information confidential. Likewise, when I am out of town or unavailable, I may arrange for another therapist to help my clients in emergencies. I must give him or her some information about my clients, like you. I am required to keep records of your treatment, such as the notes I take when we meet. You have a right to review these records with me. I maintain your records in a secure location. If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are shortterm or long-term problems. If I do use a diagnosis, I will discuss it with you. If you have any

questions regarding confidentiality, you should bring them to my attention so that we can discuss the matter further. Risks of Therapy Therapy often involves change. You may learn things about yourself that you did not expect or like. Often growth cannot occur until you experience and confront issues that induce you to feel sadness, sorrow, anxiety, frustration or pain. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. However, most people who take the risks to make changes find that therapy is helpful. Telephone Messages and Callback Requests Telephone messages and callback requests are conducted solely via my voice mail system. I will try my best to return your calls within the same or next business day. Please understand that I do not answer my phone during sessions with clients. If telephone consultations extend beyond 10 minutes, you have two options: 1) continue the call and have the rest of the consultation pro-rated at the hourly fee, or 2) schedule an additional session. Consent to Treatment I, voluntarily, agree for myself/my child, to receive mental health assessment, care, treatment, or services, and authorize Valerie Chu, MA, ATR-BC, LCAT, to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment, or services that I receive through Valerie Chu at any time. I agree to pay in full at the time of service, the fee of____________________, through cash, check or credit card, for my therapy sessions, unless an agreement has been made on an alternate payment schedule. By signing this Psychotherapy Practice Information and Informed Consent form, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. __________________________________________________________________ Signature of client Date ___________________________________________________________________ Signature of Legal Guardian (If applicable) Date As witnessed by: ____________________________________________________________________ Valerie Chu, MA, ATR-BC, LCAT Date NYS LCAT #001304