Private entrepreneur, psychologist Hanna Usatenko, psychotherapy agreement
WHAT TO EXPECT FROM FAMILY THERAPY AND ARTS-BASED PSYCHOTHERAPY:
My practice is governed by professional counseling standards as well as professional and ethical standards of the Ukrainian Union of Psychotherapists. My work is distinguished by the integration of a variety of arts modalities in concert with traditional family therapy. The arts as an additional way of psychotherapy are powerful instruments of change; they can help us to discover, express, contain and reflect upon aspects of ourselves not easily explored by simple talk, ever-alert to clients’ well-being.
I am committed to protecting client confidentiality. Confidentiality assists in the building of trust, an essential component to getting the most out of therapy. I will not share a client’s information without written consent. Be aware that there are a few exceptions to confidentiality, which I disclose upfront so that you are not taken off-guard should I be forced to break confidentiality. I am mandated to report any threat of serious harm to you or others, child or elderly abuse or neglect, or a medical emergency. I may also be forced to disclose confidential information by way of a court order. Legal guardians can be notified if a minor children report suicidal intent. Though I may discuss some aspects of our work together within confidential consulting sessions for purposes of my own professional supervision, I will never share private or identifying information in this context.
Each session lasts 55 minutes unless otherwise arranged. If you are unable to keep your appointment, 24 hours’ notice is appreciated. Except in the case of an emergency, you will be charged for any session missed without a 24-hour advance notice by phone or email. I respond to phone or email messages within 24 hours in most cases. In the event of a mental health crisis, you may call to a state medical emergency service (103 from desktop and cell phones in Ukraine).
My fee is $ 40.00/session (EUR 35 or UAH 1100), $60 (EUR 55, UAH 1650) for a 1 hour 20 min session, with payment required at the conclusion of each session. Client (or responsible party signing below if client is a minor) is responsible for payment. Only payment by cash or check is accepted. In the event that payment is not received at the end of a session, or if any fees are owed for missed appointments, the balance owed must be paid before another session can be scheduled.
CONSENT TO TREATMENT:
Your signature below indicates that you understand and agree to the above. If at any time you have concerns or questions regarding your treatment or this agreement, feel free to discuss them with me. You have the right to refuse psychotherapy counseling at any time and to request a referral to another therapist.
Client’s Signature Date
Responsible Part’s Signature (if client is a minor) Date