Forms

Please print and complete these forms, and bring them along to your first appointment.

Client Information Form (.pdf)

Office Policies and General Information (.pdf)

Consent for Treatment of an Adult (.pdf)

Consent for Treatment of a Minor (.pdf)

Office Policies

The information below is partial. You will be required to read and sign the full Office Policies and General Information Form (.pdf) above upon your first appointment.

Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy involves your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Dr. Curtin will ask for your feedback and views on your therapy, its progress and other aspects of therapy and will expect you to answer openly and honestly.

  • Dr. Curtin provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within the scope of her practice.
  • Payment is to be made at the end of each session unless other arrangements have been made in advance. Cash or checks are accepted for payment. An accounting statement will be given to you each month if requested.
  • There is a 24-hour cancellation policy. Cancellations or rescheduling can be made by leaving a message via voicemail. Late cancellations and missed appointments with no notice given will be billed at 100% of the full session fee. Please note that late cancellations and missed appointments are not covered by insurance companies. In the case of a late cancellation or missed appointment, you are responsible for the full session fee, not solely the copayment.
  • Clients who carry insurance should remember that professional services are rendered and charged to the client, not to the insurance company.
  • A processing fee of $20 will be charged for all returned checks.
  • E-mail correspondence is not considered to be a confidential medium of communication. Dr. Curtin does not use e-mail unless previous arrangements have been made.
  • Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law.
    • When Disclosure is Required by Law: Some of the circumstances where disclosure is required by law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled or when client’s family members communicate to client's therapist that the client presents a danger to others.
    • When Disclosure May be Required: Disclosure may be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain psychotherapy records and/or testimony by your therapist. 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 attorneys, nor anyone acting on your behalf will call on Dr. Curtin to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
    • In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members. In child therapy, Dr. Curtin will use her clinical judgment when revealing to parents specific issues which may arise. Dr. Curtin will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment. In cases of divorce or separation, both parents must give consent for treatment of their child and must authorize any release of information.