CONSENT FOR TREATMENT
Sign in to Google
to save your progress.
Welcome to therapy. Building a therapist-client relationship is dependent upon trust, openness, responsibility and respect. This document contains important information about my professional services. Please feel free to ask me questions about these services at any time.
Confidentiality: It is my goal to provide a safe and supportive environment for my clients as they participate in therapeutic services. I respect your privacy by keeping sessions confidential. Information about you is generally held in confidence by law and my policy is to never release information outside of sessions without your consent. Please be aware that state law and various court rulings require me to make a report to the proper authorities in one or more of the following circumstances:
• Suspected abuse, past or present, of a child under the age of 18 years.
• Suspected abuse of elders or dependent adults.
• Intention of serious and dangerous harm to self or others.
• When you waive your confidentiality. (For example, you waive your confidentiality when using your insurance company because your insurance company requires your information for payment or reimbursement of a claim.)
• When you voluntarily use your mental or emotional state in legal proceedings.
• Following a court order.
Additionally, if you have recently been under psychiatric and/or medical care, it may be necessary for me to consult with the treating physician for the purposes of diagnosis, treatment and continuity of care. This informed consent agreement includes your consent for me to consult with other health care professionals as needed.
Couples Therapy and Confidentiality: If you are here for couples counseling, my policy is to not hold secrets between the both of you. If one tells a secret between sessions or in an individual session, then I will assume that you are telling it in order to get help disclosing it to your partner.
Adolescents and Children: Adolescents and children in individual therapy will be afforded confidential treatment. Because trust is an important therapeutic issue, parents will be provided with general progress information only. No other information will be given unless it is determined by the therapist to be in the child’s best interest to do so. It is also imperative that treatment of children not be terminated abruptly. By signing the consent for treatment of a minor, you are agreeing to provide me with a minimum of thirty days notification of your intent to terminate your child’s treatment, and also allow for at least two pre-termination sessions in order to adequately process the termination with the child.
Fees: Full payment for service is due at the time service is rendered. Special arrangements are made, occasionally, on an individual basis due to a specific hardship or circumstance. Therapy sessions are 45 minutes in duration. The best results occur when appointments are regularly scheduled and consistently attended. My standard fee is $125 per 45 minute session. The standard fee will be charged on a prorated basis for report writing, attending meetings, telephone conversations longer than 10 minutes, or time required to perform requested services.
Returned Check Policy: There is an additional $35 fee for any check returned for non-sufficient funds.
Cancellations: If you wish to change your scheduled appointment, please provide 24 hour notice by calling (619) 624-0735. If you have scheduled an appointment on a Monday, a cancellation notice must be provided before 5:00 p.m. the previous Friday. Because time has been reserved for you, you will be charged the full session fee of $125 for missed or cancelled appointments unless 24-hour notice is provided. (Please note that insurance companies do not pay for cancellation or no show fees.)
Insurance: It is recommended that you contact your insurance carrier to find out how much they pay for out-of-network psychotherapy treatment. The amount of payment will depend on your policy. Many medical health insurance policies cover at least part of the cost of outpatient psychotherapy. Keep in mind that if you are utilizing insurance funds, third parties may review your medical record to obtain information about diagnosis, treatment process and prognosis for the purpose of treatment authorization, quality care management and payment for services. Please see the Service Fees page for a list of questions to ask your insurance carrier about reimbursement. You will receive a "superbill" at the end of each session that will provide all the relevant information your insurance carrier will want to process your claim.
Substance Use: Sobriety during sessions is mandatory. Should any individual attend therapy in an intoxicated state, the session will be immediately cancelled and payment will be required. This will also constitute a late cancelled appointment and insurance will not be billed.
Contacting Therapist: My voicemail is confidential. Please leave a message with your number, even if you think I already have it. I am able to return most calls daily or within 24 hours, but I usually cannot provide emergency treatment. If you cannot reach me and you need to speak with someone immediately, please call the San Diego 24-hour Crisis Hotline at 1-800-479-3339 or 911.
Email and Text Messages: Please do not use email or text messages to cancel or reschedule an appointment. I do not check my email or text messages on a consistent basis. If you have a question or have information you would like me to know, please call (619) 624-0735 and leave a confidential voice message. I check my phone messages throughout the day.
There may be times I may want to contact you or leave a message. To ensure your confidentiality, please initial the mode of communication and contact numbers that you prefer:
*Consent to treatment of a minor
Relationship to minor
Type your name here for your consent to use this information.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service