Herald Square Psychology GK
Informed Consent

This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.


Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.


We normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if Herald Square Psychology is the best place to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, we will usually schedule at least one 45-50-minute session (one appointment hour of 45-50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or 72 hours for a weekend or Monday appointment. For this you will be charged 10,000 JPY secured by credit card. You may choose to pay by other methods. Your card will not be charged without notification. Preferably, this will not be necessary; if it is possible, we will try to find another time to reschedule the appointment.


The hourly fee is $200 to $300 a session, unless a lower rate is arranged. In addition to weekly appointments, we charge this amount for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require our participation, you will be expected to pay for my professional time even if we are called to testify by another party. Because of the difficulty of legal involvement, we charge 30,000 JPY per hour for preparation and attendance at any legal proceeding.


You will be expected to pay for services at the end of every month by credit card, bank transfer or cash. If you have insurance coverage which requires another arrangement, this can be discussed. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.


The Japanese health insurance will not cover the cost for our services. If you have other insurance, we may be able to arrange coverage.


We are often not immediately available by telephone. If you are unable to reach us and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. In emergencies, or if anyone is in immediate danger, you must call 119 and not your provider or anyone else at Herald Square Psychology.


The standards of my profession require that we keep treatment records. We can prepare a summary for you if you request it within a reasonable time frame. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.


In general, the privacy of all communications between a patient and a psychologist will be protected to the extent guaranteed by Japanese law. Apart from government force, we only release information about our work to others with your written permission. Please note: All client cases at Herald Square Psychology are supervised by Tyson Furr, Ph.D., owner and director of Herald Square Psychology. Any other communication about your case is strictly confidential except in the following exceptions.

In most legal proceedings, you need to consult with a legal professional to protect your confidential information if the Japanese government demands.

There are some situations in which we are ethically obligated to take action to protect others from harm, even if we have to reveal some information about a patient’s treatment. For example, if we believe that a child is being abused, we would file a report with the appropriate state agency.

If we believe that a patient is threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

These situations have rarely occurred in our practice. If a similar situation occurs, we will make every effort to fully discuss it with you before taking any action.

We may occasionally find it helpful to consult other professionals about a case. During a consultation, we make every effort to avoid revealing the identity of the client. The consultant is also ethically bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality may be complex, and we are not attorneys.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.