RUNE MOELBAK, PH.D.
PSYCHOLOGIST (TX#36117)
3400 BISSONNET ST #270
HOUSTON TX 77005
Phone: 832-542-6244
Informed consent for individual therapy
Welcome: Before starting your therapy, it is important to know what to
expect, and to understand your rights as well as commitments. This con-
sent form is an attempt to be as transparent with you as I can about the
therapy process, so you are fully informed prior to starting your journey.
My credentials: I am a clinical psychologist who is licensed in the state
of Texas by the Texas State Board of Examiners of Psychologists. As a
licensed psychologist my work is regulated by Texas mental health laws,
and the rules and regulations of my license.
What to expect from therapy: Psychotherapy is a process of opening
up about your life experiences and your genuine thoughts and feelings
in order to increase your self-awareness of psychological and emotion-
al conicts that keep you stuck in unwanted patterns. My approach to
therapy is psychodynamic and emotion-focused. This means that I focus
on helping you uncover the root causes and stuck emotions that contrib-
ute to current life distress. The therapy may involve temporary periods of
discomfort as you begin to work through past trauma or confront psycho-
logical conicts you have previously been avoiding.
Fees: Individual therapy is billed at the rate of $250 for a 50 min session.
I, the client, agree to pay the stated fee by cash, check, or credit card at the
beginning of each session. If I, the client, am prevented from attending my
scheduled session and do not cancel my appointment at least 24 hours in
advance, I agree to pay the full session fee. This practice of being charged
for no-shows or late cancellations is standard practice in the eld, and
takes into account that you are not just paying for services rendered, but
reserving a time slot which I cannot oer to someone else on short notice.
Insurance: I do not accept payment directly through health insurance
plans. However, some insurance companies may reimburse part of your
therapy expenses if you have out-of-network coverage for behavioral or
mental health. Upon request, I am happy to provide you with a receipt
that you can include when ling an insurance claim with your insurance
company. Out-of-network reimbursement is often contingent on receiv-
ing a medical or mental health diagnosis and certain diagnoses may not
qualify. I do not accept responsibility for collecting payment from your
insurance company and cannot guarantee that you will be reimbursed
or that you will qualify for a reimbursable diagnosis. Please contact your
insurance provider to nd out if you have out-of-network coverage and
bring any necessary forms to your rst appointment.
Condentiality: The information you share with me during therapy ses-
sions is considered condential information and is protected by state law.
As a psychologist I cannot reveal to third parties whether or not you are
a past or current client of mine and cannot disclose any of the informa-
tion you discuss during our sessions without rst obtaining your written
consent to do so.
In the following instances, however, I may be mandated or allowed to
share information without your written consent:
• If during your therapy, you are deemed to pose a threat of harm to
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someone else or to yourself, I am allowed to collaborate with the
police or a hospital to take necessary measures to prevent harm from
happening.
• If you talk about events that lead me to believe that a child under
the age of 18 or an elderly or disabled person is at risk for emotional,
physical or sexual abuse, neglect, or exploitation, I am required by
state law to make a report to Texas Family and Protective Services
with or without your consent.
• If you are not yet 18 years of age, your parents or legal guardians may
have access to your records and may authorize release of information
to other parties on your behalf.
• If you disclose sexual misconduct by a previous therapist I am re-
quired to make a report to the licensing board governing the license
of the therapist.
• If a judge in a court of law orders me to release information or if I
need to respond to a lawfully issued subpoena.
• If I need to cooperate with legal actions against a mental health pro-
fessional by a licensing board.
• If you submit an out-of-network health insurance claim and the
insurance provider needs information to authorize the therapy or the
billing.
E-mail notications: When appointments are scheduled, automatic
email reminders of your appointment will be sent to the e-mail you used
when scheduling your rst appointment. By signing this consent form, I
agree to receive these notications, and understand that email is not a con-
dential medium for transmitting health information.
The scope of my services: I am qualied to work with a wide variety of
clients and problems, but sometimes I may not have the training needed
to address a particular concern. If this is the case I will discuss it with you
and make sure that you receive a referral to another professional who
is better qualied to serve you. If you are looking for a very specialized
treatment for an eating disorder, obsessive compulsive disorder, attention
decit/ hyperactivity disorder, panic disorder, or substance use disor-
der, or a very specic treatment method such as exposure and response
prevention, and if you do not want to explore how personality dynam-
ics, personal history, and internal conicts may contribute to the above
problems, I may not be the best therapist for you. Also, if you are having
current hallucinations/ delusions, severe thoughts of suicide or self-harm,
or extreme Bipolar mood swings you may need more support than I can
oer you through weekly psychotherapy, and I reserve the right to refer
you to a dierent or more intensive treatment if I believe you exceed the
level of care I can oer.
I, the client, consent to the above terms and agree to initiate treatment with
Rune Moelbak, Ph.D. (Psychologist, License TX #36117)
___________________________ _____________________
(Print Name) (Date of Birth)
___________________________ ______________________
(Signature) (Date)
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