Informed Consent

The therapeutic relationship is unique in that it is a highly personal relationship and, at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read, then indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and increasing awareness of feelings attached to those events can bring on strong emotions. There are no miracle cures. I cannot promise that your behavior or circumstances will change. I can promise to do my best to understand you and help you move toward the life you want.

Confidentiality

Your treatment, including session content and relevant materials, will be held confidential unless you provide written permission to release specific information to specific individuals.

There are exceptions to confidentiality mandated by law. I am required to report any instance of neglect or physical, emotional, or sexual abuse of a child, elder, or dependent adult. I also must break confidentiality if clients present an imminent, substantial risk of incurring serious bodily harm to themselves or causing serious bodily harm to another person. I also have to break confidentiality if a court of law issues a legitimate subpoena for information. Finally, there are additional, rare instances where disclosures are allowed or required by law.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Limited information about you may be shared in this context.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. However, if you acknowledge me first, I will be more than happy to speak briefly with you.

Fees for Services

I accept cards for payment of treatment. Although I do not bill insurance directly, I am able to provide receipts of service if your insurance reimburses for out-of-network providers. It is your responsibility to understand your insurance benefits and submit claims to insurance. These invoices will include information about you, including a diagnosis, if applicable. If you submit claims to insurance, there is a chance that they will ask me for additional information, such as treatment plans.

If you are behind in payment, I will work with you to come up with a plan for repayment. If you continue to fall behind in payments, I reserve the right to terminate treatment and refer you to other providers, including affordable options.

If you do not provide 48 hours notice to cancel an appointment, you will be responsible for the full session fee.

Session Time

Standard sessions are 50 minutes. If you are late to the session, you will lose time as I will still need to end on time. I reserve the right to not begin a session more than 25 minutes past the session start time as starting that late can be disruptive to therapy. I encourage you to use the reminders function on Simple Practice as needed and am willing to help you set those up.

Threats and Intimidation

Because threats and acts of intimidation are so damaging to the therapeutic relationship, if they occur, I reserve the right to immediately terminate therapy. I also reserve the right to break confidentiality for the purpose of informing authorities, if I deem this reasonable or necessary.

Availability Between Sessions

I am available through email, phone, or text, with limits. Please allow 48 hours for a response. Text and email should only be used for administrative tasks, such as scheduling. Email is not a secure medium of communication and can be intercepted or stored on servers. Text and email should not be used for urgent matters or emergencies. All communication is part of your medical record.

If you are in need of emergency assistance, please call 911 or visit your local hospital.

Telehealth Policy

Telehealth sessions may be offered over HIPPA-compliant video, or in limited cases, phone. Benefits of telehealth includes increased access of care and flexibility in location. Risks of telehealth include interruptions, unauthorized access, technical difficulties, potential lack of privacy on your end, and the loss of in person dynamics, such as nonverbal cues. Additionally, I may not have accurate technical information for the platform. If you engage in telehealth with me, you are accepting these risks.

A telehealth visit may be discontinued if you are not in a private area or if we agree that the technology is not adequate. If we are unable to connect, I will attempt to call you to continue the session or discuss alternatives.

Social Media Policy

I do not accept requests on personal social media sites such as Facebook, Instagram, or LinkedIn. This is to protect your confidentiality as well as to not confuse my role as a therapist. You can follow my professional pages if you wish, though there is no obligation to do so. Please know that some sites have a feature that recommends others to you based on contacts, location, and other data. I have no control if you are recommended to other clients. You can change your privacy settings with each site to reduce this occurrence.

Recording Devices

If you are interested in recording sessions for your personal use, please inform me before so we can discuss this. Also, many modern cellphones are always “listening” if voice control or virtual assistant is activated. Snippets of our sessions could be automatically sent to the companies providing these services.

Animals in the Office

I am a lover of animals and appreciate the value they can bring, particularly in an emotional time, such as a therapy session. However, because I share an office space with others, I am not able to accommodate animals in the office.

Emotional Support Animals (ESAs)

I do not complete assessments for ESAs, nor do I provide letters of support for an ESA.

Termination

You may withdraw from treatment at any time. I recommend that we discuss your desire to end treatment before taking action so that I can make recommendations and we can close our therapeutic relationship. If I assess that our sessions are not effective in helping you reach your goals, we will discuss this and, if appropriate, terminate treatment. In that case, I will work with you to identify alternative options.

If you do not keep your scheduled appointments and do not respond to communications from me, I will assume you have decided to terminate your treatment and I will close your file. If this occurs and you wish to resume your treatment, you can contact me to re-initiate therapy, though I cannot guarantee availability.

Complaint Filing Process

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of clinical social workers. You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

Personal Values

Many of my own values influence the work I do, which is why I want to include them here. I value equity and will attend to power differentials, both in our relationship as well as your other relationships. I also try to be mindful of cultural influences, including systems of oppression and privilege, including my own privilege. I deeply care about this work and will strive to help you thrive in your own life. I also value courage and adventure, so will become creative in therapy and attend to patterns of avoidance. Finally, I deeply value connection, which means I will work to make our relationship transparent, safe, and a place of care, understanding, and change.

No Surprises Act

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost:

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises