Denika Y. Douglas, Ph.D. 
Licensed Psychologist (Lic.# 35076)
Licensed Specialist in School Psychology (Lic.# 34421)

4801 Woodway Dr., Suite 300E														    				 (713) 574-8502
Houston, Texas 77056												    			   drdouglas@douglassolutions.com

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INFORMATION FOR CLIENTS

About Me
First, I must tell you that I come from a family that is dedicated to service. I am a native Houstonian and was raised with a passion for serving, strengthening, and uplifting my community. This passion for serving my community, along with my love of learning led me to the fields of education and mental health.                       

In 1999, I earned an undergraduate degree in Psychology from Texas A&M University. I later earned a Ph.D. in Counseling Psychology from the University of Houston. Before starting my private practice, I was employed by Houston Independent School District, first in the Psychological Services Department, then in the Special Education Department. While with HISD I continued to develop my skills in working with children, teens, parents, teachers, school administrators, and members of the community.     

I am a Licensed Psychologist and a Licensed Specialist in School Psychology. 

My approach to therapy is client-centered and I typically use cognitive-behavioral and systems interventions, with the goal of helping my clients build strengths, foster resiliency, and develop coping skills.  I currently see children, teens, adults, and families. I offer individual, family, and group therapy as well as play therapy and educational and psychological assessment. Though I work with a number of issues, I specialize in the assessment and treatment of attention-deficit/hyperactivity disorder, depression, anxiety, grief, trauma, and autism-spectrum disorders. In addition, I provide training to parents, school personnel, and community agencies on a variety of topics related to mental health.  

To Contact Me
You may call the office at 713-574-8502 or email me at drdouglas@douglassolutions.com. If I am with a client when you call, please leave a voice mail and I will return your call within 24 hours.  If you have an emergency, you can also reach me at 713-574-8502, as the office phone is forwarded to my cell phone after hours and on weekends. If you have a behavioral or emotional crisis and cannot reach me immediately by telephone, you or your family members should call the MHMRA Helpline at 713-970-7000 or 1-866-970-4770.

Time Issues
Therapy sessions last one hour, though I only spend 45 minutes of that time with you. The remaining time is used for paperwork, scheduling, and billing. It is very important that you be on time for your appointments.  If you arrive more than 15 minutes late, your appointment will have to be rescheduled.  
 
Cancellation Policy
Please give me at least 24 hours notice if you must cancel a scheduled appointment. You will be charged a $25 cancellation fee if this policy is not followed.  If you fail to attend two consecutive sessions without notifying me, I will assume that you intend to terminate services. 

The Benefits and Risks of Therapy
As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.
  
While you consider these risks, you should also know that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress.
 
About Confidentiality
I will treat with great care all the information you share with me. In general, any information you provide to me will be released to others only with your written consent. However, there are certain circumstances in which a psychologist must disclose confidential information without a client’s consent.  Here are the most common cases in which confidentiality is not protected:

1.	If you are a danger to yourself or others. 
2.	If you are a minor, elderly, or disabled person and are being abused. 
3.	If you have perpetrated abuse against a minor, elderly, or disabled person. 
4.	If you had sexual contact with a previous psychotherapist or clergy member. 
5.	If you file suit against me for breech of duty. 
6.	If you use insurance for payment, and the insurance company requests information about your case. 
7.	If a court order or other legal proceedings or statute require disclosure. 

In order to be compliant with HIPAA rules, you will be given a separate and more complete statement regarding confidentiality of records.

Records
I am required by law to maintain records of my work with you. These generally take the form of notes that I make during and after appointments, intake information, written information that you give to me, billing information, and any correspondence concerning your case. These records will not be released without your written consent except in the situations described under About Confidentiality. You may request a copy of your records, but I will charge for their reproduction and mailing.  

If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access.
 
Fees, Payments, and Billing
Insurance- Please be aware that the limits of coverage for outpatient mental health services vary widely across companies and plans. Your insurance company may have a "preferred provider list" which offers you a discounted rate for choosing one of the mental health providers from their network. I am a member of some of those plans. The decision about whether or not to reimburse you for psychological services is made by your insurance company. When you provide me with information about your insurance, I will determine the exact benefits to which you are entitled.

Payment at the time of service - Payment is expected at the time services are rendered. If I am a member of your managed care network, you need only pay your co-payment. The balance of your bill will be paid by your insurance plan. If you have insurance and I am NOT a member of your managed care network, then you must pay the FULL fee and then seek reimbursement through your insurance company.  I will supply you with an invoice for my services with the standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for reimbursement. 

Billing and collections- Because I expect all payment at the time of our meetings, I usually do not send bills. However, if we have agreed that I will bill you, I ask that the bill be paid within 5 days of when you get it. If your portion of the payment for services is not received within 30 days, you may be informed in writing that future services will not be provided, and you may be referred to a community agency or program or other practitioner to continue any needed services. Seriously overdue accounts may be referred to a collection agency.

Fees- The standard fees for my services are provided below. Contractual arrangements with managed care companies or other entities may reduce these fees.

• 15-minute phone consultation- free 
• Initial Office Visit- $150/session 
• Individual Therapy- $120/session 
• Family Therapy- $120/session 
• Group Therapy- Varies by Group 
• Assessment- $120/hr. 
• Observation/Presentation/Consultation- $120/hr. plus travel at $60/hr.

Other Points
I request that you do not bring children with you (other than those receiving services) if they are young and need babysitting or supervision, which I cannot provide. 

You will be charged for any damage to, or theft of, property in this office by you or anyone for whom you are legally responsible.

I cannot be responsible for any personal property or valuables you bring into this office.

(Please read and sign the next page)

 

Consent for Treatment 

I have read, understand, and have been given a copy of the Information for Clients brochure. 

I have been given a copy of the Notice of Privacy Practices (HIPAArelated). 

I know that I may ask further questions as needed. 

I give my consent to treatment by Dr. Denika Douglas.
 
If I want to use insurance, I authorize Dr. Douglas to file for my insurance and to accept assignment of insurance benefits for her services unless otherwise specified.

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Signature of client (or person acting for client) 				Date

____________________________________________		 
Printed name 	
										
Relationship to client:	❑  Self 	❑ Parent  	❑ Legal guardian
❑ Health care custodial parent of a minor (less than 14 years of age)
❑  Other person authorized to act on behalf of the client – specify

If you are a parent or guardian giving consent for the treatment of your minor child, please indicate your child’s name here:

_______________________________________________________________________

I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time, and have informed him or her of the issues and points raised in this brochure. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here.

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Signature of therapist 										Date