Mike Boswith, Psy.D.
Pastoral Counselor
Huntington Beach Community Church
8101 Slater Ave.
Huntington Beach, California 92647
714-847-3050
THERAPY INFORMATION
Description of Services:
As a pastoral counselor, I am not licensed by the state of California. I have been specially trained to understand and treat mental, emotional, and relational problems. Your (or your child's) therapy may include various forms of spiritual interventions, psychotherapy (counseling) and/or referral for pharmacotherapy (medication) depending on your needs and motivation. I may work with you individually or as a member of a couple, family, or group. Further I embrace a Christian worldview and my technique and interventions involve practices consistent with a spiritual perspective.
During your first session we will clarify your central areas of concern and current struggles in your life. We will begin to set goals and discuss how I can be of help to you in your efforts to lead a more effective and satisfying life. We will agree on your length, frequency, and expected number of sessions.
If you are a parishioner (i.e. attending) of Huntington Beach Community Church we may conduct up to 6 sessions in any 6 month period concerning the same issues before I will refer you to another therapist. This is necessary to maintain the pastoral relationship in the counseling setting. Some issues involve work at such an intimate level that the dual relationship as both your pastor and therapist becomes difficult to manage and often leads to the dissolution of both relationships. If your concerns are such that I determine that you require long term care I may make an immediate referral.
It is of central importance for you to understand that therapy is hard work, requiring honesty, courage, and dedication. Through spiritual interventions, psychotherapy and/or pharmacotherapy, I strive to help you to help yourself in this challenging and exciting process of healing and growth. You have the right to ask questions at any time, to refuse a specific intervention or treatment strategy, or to terminate therapy at any given time.
Please understand that during the process of the therapy, psychological pain and distress can arise as difficult issues are addressed and worked through.
Sometimes you will not obtain the desired results or goals from counseling in the time period expected. This can result in frustration and dissatisfaction. If adequate progress is not being made in therapy or if it becomes apparent that I do not have the skills necessary to address your issues, I may either refer you for more specialized care or discontinue therapy and assist you with a referral.
Confidentiality:
What you say and do in sessions with me will be kept in strict confidence. Your records are for my use only. You may authorize release of specific information to someone else such as another therapist, physician, your insurance company, or school.
The following exceptions to this confidentiality are important for you to understand:
First, if you have been referred to me by the Court ("Court ordered"), you can assume the Court wishes to receive some type of report or evaluation. In such instances, you have a right to tell me only what you want me to know. I reserve the right, however, to refuse treatment if I feel you cannot be completely honest with me in an area I believe is important to your therapy. In such a case, I would refer you back to the Court.
Second, if you are involved in litigation of any kind and inform the Court of the services that you are receiving from me (making your mental health an issue before the Court), you may be waiving your right to keep your records confidential. Consult your attorney regarding such matters before you disclose to the Court that you are receiving treatment.
Third, if you threaten to harm either yourself or someone else and I believe your threat to be serious, or if you are gravely disabled and unable to care for yourself, I am obligated under the law to take whatever actions seem necessary to protect you, and any others involved, from harm. This may include divulging confidential information to others and would only be done under circumstances where someone's life appeared to be in danger.
Fourth, if I have suspicion that you are abusing or neglecting your own or any other child/children or elders, I am obligated by law to report this to the appropriate state agency. This law is designed to protect children/elders from harm.
In summary, I will make every reasonable effort to safeguard the personal information you share with me. There are, however, certain instances when I may be obligated to release such information to others. If you have any questions about confidentiality, please feel free to discuss them with me.
Fees and Payment:
I charge for my time. My fee is $100 per 45 minute session. Your session also includes the time necessary to make payment and schedule your next appointment. For shorter sessions, telephone conversations, emergencies, reviewing records, preparing letters or reports, and any other appropriate services you request or require from me, I prorate my charges according to time spent.
Payment in full is requested at the time services are rendered and may be made by check. Checks should be made payable to Huntington Beach Community Church. Parishioners at HBCC are not normally charged. I do not accept insurance.
I will give you a statement that can be sent along with your completed medical claim form to your insurance company. Please instruct your insurance company to send reimbursements directly to you; do not assign insurance benefits to me. The best way to find out whether your insurance includes mental health benefits is to call your insurance company and ask what benefits you have for outpatient psychotherapy and/or psychiatric treatment. Find out yearly dollar or session limitations, deductible amounts, need for physician referral, and which provider license(s) the company will accept.
The patient (or parent/guardian) is considered responsible for payment of professional fees. Accounts retaining a balance for longer than 90 days may be sent, at my discretion, to a collection agency.
Canceled or Missed Appointments:
If you are unable to keep an appointment, please notify me as soon as possible. Leave a message stating your reason for canceling and whether you would like to reschedule prior to your next regular session. There is no charge for cancellations made at least 24 hours in advance or for time spent rescheduling appointments unless other issues are discussed. However, if a pattern of absences develops or you make frequent changes, this may suggest to me that you are not dedicated to your therapy and may not be ready to benefit from my services. You will be charged full fee for any session that is canceled or missed without 24 hours prior notice; these charges must be paid by the beginning of your next scheduled session.
Emergencies:
An emergency is when you are in danger or out of control. This includes intent to hurt yourself or someone else, being abused or threatened, experiencing overwhelming panic, sudden disorientation or loss of sense of reality, or any severe or sudden side effects of medication.
In the event of an emergency you may call me immediately, including nights and weekends. Monday through Thursday 9AM-4PM please call (714) 847-3050. If there is no answer or it is after regular business hours leave a message; my voice mail is number 6.
I am not always available to promptly return your calls. If I am unavailable or you are in severe distress or danger, go immediately to an Emergency Room or call 911.
Questions and Informed Consent:
You are always encouraged to discuss openly and freely any questions or concerns you have regarding this therapy information or any other aspects of your work with me. Signing this form indicates your consent to begin therapy in agreement with the above policies and procedures. This form and the one for my records on the following page must be signed and returned to me by the end of your second session.
"I ACKNOWLEDGE THAT I HAVE READ,
UNDERSTAND, AGREE TO ABIDE BY, AND HAVE BEEN GIVEN A PERSONAL COPY OF “THERAPY
INFORMATION” ON SERVICES, CONFIDENTIALITY, FEES AND PAYMENT, CANCELED OR MISSED
APPOINTMENTS, AND EMERGENCIES."
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Patient Name (please print)
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Patient Signature Date
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Parent/Guardian Signature Date
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age gender martial status
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address
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city state zip
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home phone other phone or pager
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e-mail address
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name of significant other living with you phone
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name of emergency contact person (other than above) phone
Medications you are currently taking: _______________________________________________
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Reason for today’s visit: _________________________________________________________
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