Bernie D. Kastner, Ph.D.

Individual and Family Counseling


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Initial Intake/Informed Consent Form

 


BERNIE D. KASTNER, Ph.D.

Karnibad 3

Jerusalem 97248

Phone: 02-587-0021

Cellular: 052-263-4385


Date: m/d/y

Name of client(s):

Address:

Phone #:

Home:

Cell:

Work:

E-mail:

Place of Birth:

Education/Degrees:

Occupation:

Marital Status:

Children:


Referred by:

Primary Care Physician:

Please describe the reason for coming to today’s session.

What results do you expect/hope to achieve?

This will confirm that I/we have retained the professional services of Bernie D. Kastner, PhD. for the following:

Psychotherapy/Counseling   

Graphological Consultation   

I/We hereby acknowledge that the fee policy and procedures have been explained to me/us and I/we am/are aware and in agreement that:

  1. The fee is 400 N.I.S. Plus VAT ($130 U.S.) per session hour (50 minutes) for psychotherapy/counseling.  A graphological report is 900 NIS plus VAT
    ($350 U.S.).
  2. There will be no billing for fees.  Payment is due in cash or check at the end of each session.
  3. I/We acknowledge that unless otherwise agreed upon in writing, we are jointly and severally responsible for counseling fees up to and until such time that notice is given to the contrary.
  4. If I/we do not keep an appointment and fail to give 24 hours notice of cancellation, that I/we will be charged for the appointment in full.
  5. I/We agree not to subpoena Bernie D. Kastner, Ph.D. or his notes for any legal proceedings*.
  6. I/We give permission to Bernie D. Kastner, Ph.D. to correspond with my (or my/our child's) physician.


*Litigation Limitation:  Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and  custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records  be requested. 

I/we have read and understood this agreement.   


 

Helping you take

charge of your life


Israel:    02-587-0021

U.S.: 1-718-710-4776

e-mail or Skype

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