Gayle G. Anderson, M.A.

, PLPC
Supervisor: V. David Weiss, M.S., LPC

Welcome! I realize that starting counseling is a major decision and you may have many
questions. This document is intended to inform you of office policies, state and federal
laws, and your rights as a client. If you have other questions or concerns, please ask and I
will try to provide you with all the information that you need.

I have a Master of Arts Degree in counseling from Lindenwood University. My

background and experience working with preadolescent/adolescent kids includes 32 years
of teaching/counseling. Until my retirement from the St. Charles R6 School District in
June, 2010, I had served as a school counselor at Hardin Middle School since 1997.
Currently, I am a Provisionally Licensed Professional Counselor (PLPC: License #
2010008296) practicing under the supervision of V. David Weiss, M.S.; LPC (License #
2003030509). I operate from a secular worldview with values, attitudes, beliefs, and
behaviors representative of a white, middle class male. However, I do not expect you to
share those beliefs nor will I judge you negatively based on my belief system. You do
have the right to know my value assumptions and are free to discuss them with me at any
time, though.

Primarily, I will use Behavioral therapy and/or Cognitive Behavior Therapy (CBT) as a
basis for much of our therapeutic work. I may, however, employ techniques from a
variety of other counseling theories. We may examine both your current circumstances
and personal history in order to discover and revise faulty thinking patterns and beliefs.
We may also work to explore and express your feelings, both past and present. The
therapeutic process may result in strong or painful emotional reactions. You may actually
feel worse before you begin to feel better. I will strive to provide an environment in
which you will feel secure and safe enough to participate fully in the counseling process.
Your responsibility throughout the counseling process is to participate fully to the best of
your ability. You may terminate the counseling relationship at any time.

Confidentiality

Your verbal communication and client records are strictly confidential except for:
information shared with your insurance company to process your claims; information you
and/or your children report about physical or sexual abuse; information you provide that
convinces me you are in danger of harming yourself of others; information necessary for
case supervision or consultation; information for which you have signed a release to
disclose to a third party; information covered under a court order.

Electronic mail (e-mail) is not a confidential means of communication. If you choose to

use e-mail to communicate with me, I cannot guarantee that your electronic
correspondence will remain confidential or that I will receive your transmission.

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 Gayle G. Anderson, M.A., PLPC
Supervisor: V. David Weiss, M.S., LPC

Emergency Situations

I am not always immediately available. If I am not available and you find yourself in
distress or are suicidal and need to talk to someone immediately, please call Life Crisis
Services at (314)647-4357. If it is an emergency, call 911. Do not e-mail me if you need
an immediate response, as I do not always check e-mail on a daily basis.

Appointment Scheduling and Cancelation

Individual appointments are approximately 50 minutes in length. Group, relationship, and

family counseling may run a little longer depending on the circumstances of a particular
session. Please be on time for your appointment as sessions cannot be extended because
of the client’s late arrival

Please make every effort to give 24 hour notice if you need to cancel or reschedule an
appointment. In the event you need to cancel or reschedule the same day as your
appointment, please call as early in the day as possible. If you miss a scheduled
appointment without notifying the therapist you will be responsible for the entire session
fee.

Payment Policies and Insurance

Standard fee is $75 per session. A sliding scale fee is also available based on each client’s
financial situation. Your specific fee will be discussed with you before you make the
decision to engage in counseling. Payment is expected at the beginning of each
counseling session unless other arrangements have been made. Payments can be made by
personal check, cash, or credit card.

You may be able to receive reimbursement for counseling services depending on your
insurance coverage. We will be happy to assist you in determining coverage amounts and
filing the appropriate claim forms. Currently, I practice on a fee for service basis only
outside all insurance plans except for straight Medicaid (MoHealthnet) for Kids.

I acknowledge that I am voluntarily seeking therapy services from Andy Anderson, M.A.;
PLPC under the supervision of V. David Weiss, M.S.; LPC. I have read, understand and
agree to the terms of this document. Any questions have been answered fully.

Client Signature _________________________ Date ______________

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 Gayle G. Anderson, M.A., PLPC
Supervisor: V. David Weiss, M.S., LPC

DOCUMENT OF INFORMED CONSENT OF RESEARCH PARTICIPANTS

I want to take this opportunity to thank you for participating in a research study
conducted by Anderson Counseling Services. You were informed about office policies,
state and federal laws, and your rights as a client in the document of Informed Consent on
the previous two pages. However, research participants may have additional rights as
delineated by the American Counseling Association (ACA) Code of ethics. I hold an
active membership in ACA and am responsible to the organization to follow the Code of
ethics in its entirety.

You must give written consent to become a participant in any research study. In the case
of minors, a parent or guardian must sign the document of informed consent for research
participants. Additionally, participants have the right to inquire about any procedure that
concerns them.

The purpose of this research project is to study the effectiveness of various anxiety
management techniques among student musicians in the performance setting. The
effectiveness of the anxiety management techniques to be used in the study will be
research – based. However, previous research may have been conducted with different
populations and settings. Possible benefits of participation in this research include
acquiring improved anxiety management skills that will hypothetically improve musical
performance results. However, the following paragraph spells out some but not all
possible negative results of this or any form of therapy.

I will use cognitive - Behavioral therapy (CBT) as a basis for many of the techniques
used. I may, however, employ techniques from a variety of other counseling theories as
well. We may examine both your current circumstances and personal history in order to
discover and revise faulty thinking patterns and beliefs. We may also work to explore and
express your feelings, both past and present. The therapeutic process may result in strong
or painful emotional reactions. You may actually feel worse before you begin to feel
better. I will strive to provide an environment in which you will feel secure and safe
enough to participate fully in the counseling process. Your responsibility throughout the
counseling process is to participate fully to the best of your ability. If at any time you feel
that the methods and techniques used in this research are inappropriate to your needs, I
will help you find alternative treatments either through this office or will refer you to a
different therapist. You are free to withdraw your consent and discontinue participation in
the project at any time without penalty.

Your verbal communication and client records are strictly confidential except for:
information shared with your insurance company to process your claims; information you
and/or your children report about physical or sexual abuse; information you provide that
convinces me you are in danger of harming yourself of others; information necessary for

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 Gayle G. Anderson, M.A., PLPC
Supervisor: V. David Weiss, M.S., LPC
case supervision or consultation; information for which you have signed a release to
disclose to a third party; information covered under a court order.

Electronic mail (e-mail) is not a confidential means of communication. If you choose to

use e-mail to communicate with me, I cannot guarantee that your electronic
correspondence will remain confidential or that I will receive your transmission.

Assessments may be used to measure anxiety, depression, or other psychological

constructs pertinent to the research study or that is deemed beneficial to the participant.
Any assessment instrument will be explained and results interpreted for participants
and/or parents/guardians.

Research findings will be used to identify effective anxiety management techniques for
use in my private practice. Any significant findings may be shared with other counselors
and mental health practitioners. In the event that significant research results are found,
the findings may be submitted to a professional journal(s) for publication. Every
precaution will be made to insure confidentiality at all times.

I acknowledge that I am a voluntary participant in the research study described in the

Document of Informed Consent of Research Participants. Gayle Anderson, M.A.; CIT
will conduct the research under the supervision of V. David Weiss, M.S.; LPC. I have
read, understand and agree to the terms of this document. Any questions have been
answered fully.

Client Signature _________________________ Date ______________

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