Terms and Process
This page contains the same basic information as my 3-page “informed consent for treatment” form that all of clients sign before
counseling begins. The contents of the form below will provide you with a thorough description of the terms, conditions, and process
of our counseling work together.
Informed Consent for Treatment
Welcome to the counseling services of Randy Gilchrist, Psy.D. The following information will help you understand the nature and
terms of our work together.
My role as your counselor/therapist is to help you accomplish your goals for better psychological, relational, and emotional health
through my training, and experience. Your job is to work towards your goals and be committed to the process. The changes you can
expect will be largely determined by the work we’ll do in the sessions combined with the efforts you make outside of the office. Most
likely, you will change as much or as little as you allow yourself to through your commitment to the counseling process.
Most clients have weekly 45-50 minute sessions, although some come bi-weekly, monthly, or “as needed”. A typical counseling
process lasts between 6-20 sessions, but this could be more or less, depending on your circumstances. During the first session, I
gather the main goals you wish to work on plus some relevant background information. The following sessions will all focus on
helping you attain your goals.
Successful sessions will include mutual listening, the utilization of therapy techniques, and creation of a homework assignment. After
a number of sessions, you will come to realize when you are ready to end our sessions together after feeling ready to continue
without additional support. Of course, follow-up or relapse sessions will always be made available.
The discussions and records from counseling sessions will remain private and confidential. However, there are some exceptions. By
signing this agreement, you state that you have received and agree to all of the terms in the “Notice of Privacy Practices” form
regarding limits of your confidentiality (available at www.dr-rg.com). This form is in accordance with federal law guidelines for health
records from the Health Insurance Portability and Accountability Act (HIPPA).
These exceptions to confidentiality include, but are not limited to:
1) individuals or entities you have given us written permission to mutually share your counseling-related information with (using the
“Authorization for Release of Information” form)
2) your mutual communication with my staff regarding administrative issues (such as
appointment changes and reminders, payment of fees, etc.)
3) when you reveal information that I, as a mandated reporter, am legally and/or ethically obligated to report
Mandated reporting issues include (but are not limited to): child abuse, elderly/dependant abuse, or being in danger of harming
yourself or others.
Fees and Payment
My self-pay fees are about the average "going rate" for a Doctoral-level, dual-licensed psychotherapist in the Roseville/Granite Bay
Area. Unless otherwise arranged, my standard counseling fees are as follows:
45-50 minute session: $130 (Typical Session)
75-minute session: $190
90-100 minute session: $260
A lower fee may be made available on a case by case basis based on demonstrated need and/or special circumstances. This will
need to be mutually agreed upon in writing.
Failing to show up to a scheduled appointment (“no-shows”) and late cancellations (less than 24 hours notice) will be charged the full
standard fee for that appointment. If you need to cancel an appointment, you may always leave me a voice mail.
Phone consultations will be charged at a rate of $2.60 per minute. (Note: brief initial consultations and calls to schedule or change
appointments are free).
I generally do not charge for email. The main purpose for the email I receive at my website (www.dr-rg.com) is for potential clients to
ask me questions about myself and my services. Other emails from existing clients will generally be addressed face to face at the
next scheduled session. Please do not use email to cancel your sessions, as I may not check my email in time to get the message.
Clients are responsible to pay all fees up front before the session. The accepted methods of payment include check, cash (exact
amount), major credit card (Visa, Mastercard, American Express, or Discover), or ATM/debit card (with a major credit card symbol).
Bounced checks will be assessed an additional $30 fee to the balance due. All outstanding balances will be assessed a $10 monthly
processing fee and 21.0% interest, accruing each 30 days past due. After 60 days, clients with an outstanding balance are subject to:
1) referral for services with another counselor/therapist, 2) their balance being turned over to a collections agency, and 3) their non-
payment being reported and reflected on their credit report. (So please, pay your bills completely and on time!)
All of the above fee terms apply unless alternate arrangements have been mutually agreed upon and signed in writing.
If you find I (Randy Gilchrist, Psy.D.) have a valid and current agreement to be a provider with your insurance company, you must call
your insurance and attain an “authorization for counseling services number” before beginning our work together, then record this
number on your client information form. Most insurances refuse retroactive payment without prior authorization. If you are late
attaining an authorization number, you will be responsible for paying the total balance at the standard fee rate (see page 2).
If I, Randy Gilchrist, Psy.D., am not an official counseling provider with your insurance’s network/panel, you may still attempt to receive
reimbursement from them with myself as an “out of network provider” (which may or may not be successful). Upon your request, I
will give you a billing statement with the necessary information from our sessions for you to seek reimbursement from your
insurance. You may then take and send this information directly to your insurance company. If your insurance company decides to not
cover your services for any reason—whether or not I have a contract with them—you are still responsible for the remaining payment
at the standard fee rate.
Except for insurance companies that I (Randy Gilchrist, Psy.D.) have signed agreements with, the terms of your insurance
reimbursement are between you and your company. This consent form represents a separate contact between you and I regarding
the terms of your service.
**If hypnosis will be a part of our sessions, I agree that I have received and agree to the terms on the “hypnosis” form (available upon
request or at www.dr-rg.com).
**Based on my discussion with Randy Gilchrist, Psy.D., my payment arrangements for our counseling sessions are as follows:
**By signing below, I accept the terms to all 3 pages of this agreement. If there is anything on this or any other form I have received
from Dr. Randy Gilchrist that I do not understand, it is my responsibility to seek clarification. If I am under 18 years of age, my parent
or legal guardian/representative will sign below on my behalf:
Signature (Adult Client or Parent/Guardian/Representative) Date
Signature (2nd Adult Client) Date
Signature of Dr. Gilchrist Date
Randy Gilchrist, Psy.D.
1899 East Roseville Parkway Suite 100
Roseville, CA 95661
(916) 899-4990 firstname.lastname@example.org
Counseling and Psychotherapy Services
Licensed Clinical Psychologist #PSY19726
Licensed Marriage and Family Therapist #MFC39159