JULIE G. ZELIG, PSY.D.
OFFICE POLICIES & INFORMED CONSENT 1
Julie G. Zelig, Psy.D.
1217 S East Avenue
Suite 209
Sarasota FL 34236
(941) 548- 6071
Office Polices & Informed Consent
Agreement for Services
Welcome to my private practice! Please read this form carefully and feel free to ask me any questions that you
have. This form will hopefully help as you decide whether it makes sense for us to begin working together. Once
signed, this will represent an agreement between us.
About me: My qualifications and philosophy
I am a licensed psychologist in Florida State and New York with a Doctorate of Psychology (Psy.D.) My
therapeutic style is clinically flexible and integrative, meaning that I draw from various theoretical schools of
thought and I adjust therapy to meet the needs of each unique individual. I often incorporate cognitive behavioral,
interpersonal process, mindfulness, and solution-focused techniques into my sessions. I offer my clients a
confidential, non-judgmental and safe atmosphere for self-exploration.
As a psychologist, I bring certain expertise to our work together, but I will also rely on your self-knowledge,
reflection and personal goals. I believe that therapy is most beneficial when I am working collaboratively with a
client. I will continue to ask for your direct feedback, to make sure we are making the kind of progress you are
looking for. In addition, it can be extremely helpful to include the people who are most important to you in your
therapy. At your discretion only, and with careful consideration, we may decide to include involving significant
people in your life that you would like to have join you in some of your sessions.
Benefits and risks of psychotherapy
There are no guarantees of exactly what you will experience as a result of being in psychotherapy. However,
research indicates that 80-85% of people who participate in weekly psychotherapy experience numerous benefits,
including, but not limited to, reduced stress and anxiety, improved interpersonal relationships, increased selfconfidence,
increased comfort and satisfaction in various arenas of your life, and the resolution of the problems
that brought you to therapy in the first place. Working towards these benefits requires effort on your part, and
psychotherapy will be most effective with your active involvement, honesty, and openness. Although
psychotherapy can be rewarding, it sometimes involves challenges such as talking about unpleasant aspects of
your life. It is important and useful to vocalize all of your feelings, including uncomfortable or negative emotions
such as anxiety, anger, sadness and disappointment, as well as positive ones such as comfort, joy and relief.
Evaluation
As we get to know each other during our first few sessions, we will decide whether or not I am the right person to
provide the services that you need in order to meet your goals. If you or I feel that I am unable to offer you the
services that you need, I will provide you with referrals to someone who could be a better match. As we work
together, we will discuss how our work together may be helpful to you and what our goals for your treatment will
be.
Confidentiality
Generally, the law protects the privacy of all communications between client and psychotherapist. I can release
information to others about our work together only with your permission in writing. In most legal proceedings,
you have the right to decide whether or not you want me to provide information about your treatment to someone
who may be requesting it. However, you should be aware that in some situations, a judge may order me to turn
over my records or testify if he or she determines that the issues warrant such an action.
_____ (Initial here)
JULIE G. ZELIG, PSY.D.
OFFICE POLICIES & INFORMED CONSENT 2
There are also a few situations in which I am legally obligated to take action to prevent others from harm, which
may involve disclosing information about a client’s treatment. For example, if a client threatens to harm himself
or herself, I am obligated to seek hospitalization for this person, or contact friends or family who can provide
protection. If a client is threatening serious harm to someone else, I am required to take actions to protect that
person. Additionally, if I have reasonable suspicion of elder abuse, or child abuse or neglect, I am legally obligated
to send a written report to the appropriate state agency and call this agency. These situations have rarely occurred
in my practice, and if a similar situation occurs in our work together, I will make every effort to discuss it with you
before taking any action. ________ (Initial here)
Confidentiality of email, cell phone and fax communication
It is very important to be aware that email and cell phone communication can be relatively easily accessed by
unauthorized people, therefore, the confidentiality of such communication can be compromised. Please notify me
at the beginning of treatment if you want to avoid or limit in any way the use of any or all of the above mentioned
communication devices. I do not use email to communicate in any way other than for scheduling
purposes.______ (Initial here)
Client-Therapist privilege
Client-therapist privilege results from the special relationship of the client and therapist from a legal perspective.
If I receive a subpoena, I will assert this privilege until otherwise instructed by you, in writing. Please be aware
that you may be giving up this privilege if you make your mental or emotional condition an issue in a legal
proceeding. ____(Initial here)
Litigation
To maintain the integrity of psychotherapy, I do not voluntarily communicate with an attorney regarding your
treatment in any litigation or custody dispute in which you become involved. It is agreed that should there be
legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you
nor your attorney, nor anyone else acting on your behalf, will call on me to testify in court or any other proceeding,
nor will a disclosure of the psychotherapy records be requested. ____(Initial here)
Dual Relationships
Psychotherapy never involves sexual, business, friendship or any other dual relationships that could impair my
objectivity, clinical judgment or therapeutic effectiveness, or could be exploitative in nature. Please feel free to
bring up any questions that you may have about this.
Working with minors (people under the age of 18 years)
If you are under 18 years of age, I will need your parents’ or legal guardian’s written permission to treat you, along
with proof of guardianship.
Consultation
I regularly consult with other professionals in the field when I believe that doing so will help the psychotherapy.
During such consultations, I make every effort to avoid revealing the identity of my clients. The consultant with
whom I work is also bound to keep this information confidential.
Contacting me
Due to my work schedule, I am rarely immediately available by telephone, as I do not answer phone calls when I
am working with clients. Please leave me a message on my confidential voicemail that I monitor regularly, and I
will make every attempt to return your call within 24 hours, with the exception of weekends and holidays. If you
are also difficult to reach, please let me know the best times that I may be able to reach you directly.
In the case of an emergency
If you are experiencing an emergency and you cannot reach me, you can call the NAMI Crisis Intervention Line:
(800) 273-8255; (800) LIFENET; the Police (911); or you can proceed to the nearest hospital emergency room.
JULIE G. ZELIG PSY.D.
OFFICE POLICIES & INFORMED CONSENT 3
Other Rights
If you are at all unhappy with what is happening in individual or group therapy, I hope that you will talk with me,
so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect.
You have the right to ask questions about anything that happens in individual or group therapy. Please feel free to
give me feedback about your experience in therapy, or to ask me to try something that you think will be more
helpful.
Summary
Thank you for giving this notice careful attention. It is important that we discuss any questions or concerns that
you may have, and for you to understand and feel comfortable agreeing to the terms of this contract. Please bring
up any questions that you have.
I look forward to our work together!
Consent to Psychotherapy
Your signature(s) below indicate that you have read the information in this document and agree to abide by its
terms during our professional relationship.
I understand and agree to the information in this informed consent form, including the office policies.
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Client (or parent/guardian) Printed Name signature date
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Therapist Printed Name signature date