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Scheduling your first appointment is fast and easy

STEP 1

Complete and submit the "ABOUT ME & INFORMED CONSENT" electronic form below.  I will email you back to confirm your appointment after you have paid for your session. 

STEP 2

Go to our SHiFT.sessions page to purchase services using your debit/credit card. 

 If you would like to have a FREE over the phone consultation to ensure I'm a good match for you, please email me at shiftccc@hushmail.com to setup a date and time.


Informed Consent & Intake Form

Name *
Name
Not required but recommended.
Home Address *
Home Address
Date of proposed appointment *
Date of proposed appointment
Time of proposed appointment *
Time of proposed appointment
Choose a password that will be used for encrypted emails.
Please give a brief introduction as to what you are seeking help for and what you would like to accomplish.
Distance services: It is my expectation that you will benefit from our services, but just as in any other service, there is no guarantee. Our services are conducted using interactive and encrypted video, email and text messaging. It is important to realize that our services are intended to provide quality information, practical answers to psychological issues, and to work on present problems. Online based services may not be appropriate for you if you are experiencing any of the following: Schizophrenia, Bipolar I/II Disorders, Severe Major Depression, Severe forms of Anxiety or a pervasive personality disorder, if you are in an abusive or violent relationship, or if you have serious substance abuse dependence. If it is found that you are experiencing any symptoms of the above, I would refer you to an outpatient face- to-face therapist who would be a more appropriate fit or if you are currently experiencing any homicidal, suicidal, or psychotic symptoms: please call 911 or 1-800-SUICIDE (the National Suicide Hotline) or Tel: 00 33 1 46 21 46 46 (SOS Help, confidential English help line in France). Confidentiality: The information disclosed during the course of your sessions is confidential, however there are legal exceptions including: child, elder, and dependent adult abuse; threats of harm to self or others, or if I am court ordered. Your consultant will take all precautions to ensure your services are confidential, however, be informed that transmission could possibly be disturbed or distorted by the unlikelihood of technical failures, or interrupted or accessed by unauthorized persons. We use the communication of double encrypted email accounts, an encrypted video-conferencing system (ReGroup), and an encypted text messaging service. Encryption provides a HIPPA approved high standard of security. Appointments and Charges for Services: Payment will be made via SHiFTccc.com prior to appointment. There is a 24 hour cancellation requirement and if you cancel/no show within that time frame, there will not be a refund. 1 hour Video/phone sessions are $65, 1 hour coaching sessions are $50, 1 hour text messaging feedback is $35 and email journaling is $20 per professional feedback email. Insurances are not accepted at this time, but an invoice can be provided for you upon request. Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties can occur from time to time. Should a disruption occur, the client agrees to immediately email the provider and the lost time will be rescheduled when the internet services improve. By signing this form, I agree to the following: I agree to the terms/conditions above, I have read the HIPPA Notice of Privacy that is available for me to read on SHiFTccc.com and am currently 18 or older or a minor with the consent of a parent.
Signature *
Signature
Please type your name to give consent to terms of treatment
Date of Signature *
Date of Signature
Please type today's date of online signature
By checking this box, I understand that my electronic signature constitutes a legal signature *