Disclosure Statement & Psychotherapy Contract

Disclosure Statement and Psychotherapy Contract

Wilfried Busse, Ph.D.
Licensed Psychologist
Maryland State License #03181
4801 Hampden Lane 3104
Bethesda, MD 20814

Introduction to the Psychological Services Offered by Dr. Wilfried Busse, Ph.D.

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you have so that we can discuss them. When you sign this document, it will represent an agreement between us.

What is Psychotherapy?
Psychotherapy is not easily described. It is a process that varies depending on the personalities of the psychologist and the client, and the particular concerns you bring forward. Through psychotherapy you may gain insight into yourself, learn to make better decisions, and acquire a deeper awareness of your needs and those of others. Psychotherapy is a collaborative process in which I serve as your guide to help you on your journey of self-discovery. It is not like visiting a medical doctor, in that it requires a very active effort on your part during sessions and at times between sessions.

Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger and frustration, loneliness and helplessness. Psychotherapy often requires recalling unpleasant aspects of your past, especially if you have experienced severe trauma whose memories you may have attempted to suppress. At times people may even experience a heightened sense of distress before they feel better. However, psychotherapy has been shown to have benefits for people who undertake it. It often leads to a significant reduction of feelings of distress and better relationships and resolutions of specific problems.

My Credentials, Training, and Approach to Treatment
I received my Doctor of Philosophy (Ph.D.) and Master of Arts (M.A.) degrees in counseling psychology from the University of Maryland. I am a licensed psychologist in the state of Maryland. My clinical training has covered the full range of psychological services from hospital-based inpatient and outpatient mental health services, including psychological assessment, individual, group and couples therapy. I am a former director of the Baltimore VA Medical Center Trauma Recovery Programs and former Clinical Assistant Professor at the University of Maryland School of Medicine. I have extensive teaching, training, consulting and clinical supervision experience. I specialize in the treatment of trauma and anxiety disorders. I am certified in Eye Movement Desensitization and Reprocessing (EMDR), one of the most highly recommended treatment approaches for trauma and other psychological issues. As an Approved Consultant in EMDR, I consult with therapists and consultants-in-training whose aim is to become certified as EMDR practitioners and approved consultants. In addition to my degrees in psychology, I hold an M.A. in Philosophy of Religion and a B.A. in Modern Languages. One of my clinical interests includes working with clients' spiritual concerns as they relate to other social-emotional issues. Finally, I have been a long-time member of the following professional organizations: American Psychological Association (Division 17—Counseling Psychology and Division 36—Psychology of Religion); Maryland Psychological Association; Eye Movement Desensitization and Reprocessing International Association (EMDRIA).

While primarily a cognitive-behavioral in orientation, my approach to therapy is eclectic and draws from many traditions of psychotherapy. A cognitive-behavioral approach assumes that many emotional and social problems derive from the negative interpretations we habitually make of events that happen to us, thus leading to distorted thinking and attendant emotional dysfunction. As one adopts more realistic and positive perspectives in the place of negativistic thinking, one achieves more control over our thoughts, feelings, and behaviors. Developing insight about the nature of our problems within the context of an empathic, collaborative therapeutic relationship can lead to increased intellectual and emotional flexibility, healthier relationships, and richer, more satisfying lives.

I draw on other approaches in my work when appropriate. Sometimes providing symptom relief is more important, in the short term, that achieving understanding or insight about a particular problem. And some presenting concerns respond well to more structured, behavioral approaches. I may also refer you to other health care providers, such as naturopathic or general practice physicians, nurse practitioners, or psychiatrists, as indicated.

In addition to having my own ideas about how to approach your presenting concerns, I will be very interested in yours, and particularly in what you have found helpful in the past. I want to hear from you about how you are experiencing therapy. If you are finding that our work is not helpful, please tell me so that we can think together about how else we might approach your treatment. Please feel free to ask me at any time questions you have about my educational background, clinical training, and approach to psychotherapy.

What you share with me, and the fact that you are receiving treatment, is confidential. Ordinarily, I may not disclose your health care information to any other person without your written permission. There are several exceptions to this rule of which you should be aware: (1) If I have good reason to believe you intend to harm someone else, I am required by law to attempt to notify that person and law enforcement. (2) If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I am required by law to notify Child Protective Services within 48 hours and Adult Protective Services immediately. (3) If in my judgment you are in imminent danger of harming yourself, I may call the police or the county crisis team. I would attempt to explore other options with you before taking this step. (4) While I may legally speak to another health care provider or a member of your family without your prior consent, I will not do so except in an emergency. (5) If you are utilizing an insurance company to furnish payment, you will likely be required to consent to the release of information such as your clinical diagnosis, and your records may be reviewed.

I will inform you if at any time I am required to share information about you without your informed consent. You may direct me in writing to share information with whomever you choose, and you can revoke that permission at any time. I regularly consult with colleagues about my work. If I discuss your treatment, I will make every effort to do so in a way that will protect your privacy: I will not use your name or other identifying details.

Fees and Payment
My fee is currently $175 per 60 min. session, to be paid at the time service is rendered by cash or check. If my schedule allows, I will often go over the hour without extra charge. If you are late for a session or choose to leave early, you will be expected to pay for a full session. I may increase my fee over time, and I will give you reasonable notice of my intention to do this. In addition to regular appointments, I charge the individual session fee on a prorated basis for other professional services you may require, such as preparation of records or treatment summaries, consultations with other professionals that you have authorized and requested, or the time required to perform other services that may arise in the context of your treatment.

I am not a forensic psychologist and do not ordinarily engage in legal proceedings. However, if you become involved in litigation that requires my participation, you will be responsible for paying for the professional time required as well as any associated travel costs, even if I am compelled to testify by another party. Because of the complexity and difficulty of legal involvement, I will charge $250 per hour for the preparation for and attendance at any legal proceeding.

If you are insured and believe you are eligible for reimbursement from your insurance carrier, I will provide you with a monthly invoice for you to submit to your insurance carrier. Since I do not participate with any insurance panels, I may be considered an "out-of-network" provider. (Please note that some insurance companies will require that you see a provider in their network.) Please be aware that your agreement to treatment assumes that you are taking responsibility for payment whether or not you are reimbursed by a third party.

Cancellation Policy
If you need to cancel an appointment, please notify me at least 24 hours in advance. If I do not receive such notice, you will be charged a full fee for that session. Please note that insurance cannot be billed for missed sessions. If business travel or other obligations result in frequent cancellations, we may need to work out other arrangements.

Telephone Accessibility and Emergencies
If you need to contact me between sessions, please leave a message on my voicemail at 301-656-0701. I check my messages daily and, normally, I return calls only during business hours (9:00 a.m. to 6:00 p.m. weekdays). In your message, please inform me of the severity of your need and how best I can reach you; however, be aware that I do not provide formal emergency services. In a life-threatening situation you should call 911 or go directly to a hospital emergency room for evaluation by the mental health professional on call.

Both the law and the standards of my profession require that I keep treatment records for a period of seven years from the date of my last appointment with you. I maintain your records in a secure location that cannot be accessed by anyone else. I will not disclose your record to others unless you request in writing that I do so or unless the law or a court authorizes or compels me to do so.

This office is compliant with federal HIPAA rules for the privacy of personal health information. This means I will disclose the minimum necessary information to required entities for payment, bookkeeping, or other administrative services.

Ethics & Professional Standards
I abide by the ethical, professional, and legal standards established by the American Psychological Association and the State of Maryland. If you are unhappy with what's happening in our work, I hope you will talk about it with me so that I can respond. I will receive your feedback with seriousness and respect. If you believe that I have behaved unethically, you can complain about my behavior to the Board of Examiners of Psychology, Department of Health and Mental Hygiene; 4201 Patterson Ave.; Baltimore, MD 2115, or you may call them at 410-764-4787. You are also free to discuss our work in therapy with anyone you wish, since you have the right to determine what you would like kept confidential.

Termination of Treatment
Our psychotherapy relationship is entirely voluntary. You may decide to end it and/or consider alternate modes of treatment at any time. However, I strongly suggest that we discuss termination at least three weeks before the final session so that we may be clear on what basis the decision to terminate is made. Often termination decisions are quite appropriate and based on resolution of therapeutic issues. At other times, there may be unstated reasons for termination that may be useful for you to discuss with me.

Consent to Psychotherapy
I have read this statement, considered it carefully, and understand it. If a clinical diagnosis is required in order to bill for potential reimbursement from my insurance company, I consent to the use of diagnosis in billing, and to the release of that and any other information necessary to complete the billing and bookkeeping process. I agree to pay the hourly fee of $175 at the time of service. I agree to undertake psychotherapy with Wilfried Busse, Ph.D. I understand that I can end therapy at any time and that I can refuse any requests or suggestions made by Dr. Busse.


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Client Signature                                                                                      Date

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Therapist Signature                                                                                Date
Wilfried Busse, Ph.D.





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