Therapist Consent Form
Arlene Irion, MA, AMFT
Associate Marriage & Family Therapist #109587
Supervised by Vived Gonzalez, Psy.D, LMFT #89060
Email address *
AGREEMENT FOR SERVICE / INFORMED CONSENT
Introduction
This Agreement is intended to provide (herein “Client”) with important information regarding the practices, policies and procedures of Arlene Irion, MA, AMFT (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Therapist Background and Qualifications
Therapist has a Master’s degree in Marriage & Family Therapy. Therapist is a registered Associate with the Board of Behavioral Sciences (BBS), which allows her to practice under supervision. Therapist is working under the supervision of Dr. Vived Gonzalez, Psy.D a licensed Marriage and Family Therapist (MFT 89060). As an Associate, this means that the clinical work between Client and Therapist together will include Therapist’s education, experience and dedication, as well the regular consultation and guidance that Therapist receives from the supervision of Dr.Vived Gonzalez. If you have any questions about Therapist’s background or experience, please ask.
Risks and Benefits of Therapy
Psychotherapy is a process in which Therapist and Client discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so Client can experience his/her life more fully. It provides an opportunity to better, and more deeply understand oneself, as well as, any problems or difficulties Client may be experiencing. Psychotherapy is a joint effort between Client and Therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors.

Participating in therapy may result in a number of benefits to Client, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of Client, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above.

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which Therapist will challenge Client’s perceptions and assumptions and offer different perspectives. The issues presented by Client may result in unintended outcomes, including changes in personal relationships. Client should be aware that any decision on the status of his/her personal relationships is the responsibility of Client.

During the therapeutic process, many Clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times but may also be slow and frustrating. Client should address any concerns he/she has regarding his/her progress in therapy with Therapist.
Records and Record Keeping
Therapist may take notes during session and will also produce other notes and records regarding Client’s treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist. Therapist will not alter his/her normal record keeping process at the request of any Client. Should Client request a copy of Therapist’s records, such a request must be made in writing. Therapist reserves the right, under California law, to provide Client with a treatment summary in lieu of actual records.

Therapist also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. Therapist will maintain Client’s records for ten years following termination of therapy. However, after ten years, Client’s records will be destroyed in a manner that preserves Client’s confidentiality.
Confidentiality
The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client, except where required or permitted by law.

Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse (physical, sexual – including “sexting” with minors, emotional neglect), when a Client makes a serious threat of violence towards a reasonably identifiable victim, or when a Client is dangerous to him/herself or the person or property of another.
Client Litigation
Therapist will not voluntarily participate in any litigation, or custody dispute in which Client and another individual, or entity, are parties. Therapist has a policy of not communicating with Client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Client, Client agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made him/herself available for such an appearance at Therapist’s usual and customary hourly rate of $300/hour.
Psychotherapist-Client Privilege
The information disclosed by Client, as well as any records created, is subject to the psychotherapist-Client privilege. The psychotherapist-Client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-Client privilege. Typically, the Client is the holder of the psychotherapist-Client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-Client privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-Client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-Client privilege with his/her attorney.
Therapist Availability
Therapist will make every effort to return calls within 24 hours (or by the next business day) but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, Client should call 911, or go to the nearest emergency room.

Therapist cannot guarantee that text messaging, email, and/or electronic receipts are secure or confidential forms of communication. Therefore, Therapist requests that Client refrain from text messaging her, and use voice message and person to person phone calls for communication.
Dual Relationships & Social Media
Dual relationships can impair the therapeutic process, Therapist's objectivity, clinical judgment, or therapeutic effectiveness that could be exploitative in nature. Therapist will never acknowledge working therapeutically with anyone without his/her written permission. For this reason, Therapist will not accept any invitations via social networking sites such as Facebook, Twitter, Linkedin or Instagram with current or former Clients.
Termination of Therapy
Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs that are outside of Therapist’s scope of competence or practice, or Client is not making adequate progress in therapy. Client has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, Therapist will generally recommend that Client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Client.
Acknowledgement
By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client has discussed such terms and conditions with Therapist and has had any questions with regard to its terms and conditions answered to Client’s satisfaction. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Client agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.
I have read and agree *
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Parent's First and Last Name *
This will constitute as my electronic signature
Parent's Cell Phone *
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