Informed Consent for Therapy Services

Welcome to my practice. This document contains important information about my professional services and business policies, including a summary of HIPAA protections and your rights regarding your Protected Health Information (PHI). Please read it carefully — we can discuss any questions when you sign or at any time in the future.

Psychological services

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand, along with legal limitations you should be aware of. I, as your therapist, have corresponding responsibilities to you.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, since the process often requires discussing unpleasant aspects of your life. Psychotherapy has also been shown to have real benefits, including reduced distress, increased satisfaction in relationships, greater personal insight, and improved coping skills — though there are no guarantees about outcomes. Psychotherapy requires active effort on your part, including work on what we discuss outside of sessions.

The first 2–4 sessions involve a comprehensive evaluation of your needs. By the end of the evaluation, I will offer initial impressions of what our work might include, and we will discuss treatment goals and create an initial treatment plan. You should evaluate this information and decide whether you feel comfortable working with me; if doubts persist, I am happy to help you set up a second opinion with another mental health professional.

Appointments

Appointments are ordinarily 45–50 minutes, once per week at an agreed time, though frequency may vary as needed. Your scheduled time is reserved for you alone. I ask for 24 hours notice to cancel or reschedule. If you miss a session without canceling, or cancel with less than 24 hours notice, my policy is to collect $100 unless we agree you were unable to attend due to circumstances beyond your control. Insurance does not reimburse cancelled sessions, so this fee is your responsibility and cannot be billed to your plan. This fee does not apply to clients covered by Medi-Cal. You are also responsible for arriving on time; a late arrival does not extend your session.

Professional fees

My standard fee is $140.00 to $160.00 per session, including the initial intake. Your specific rate will be agreed upon before we begin. If you are covered by an insurance plan I accept, including Santa Clara County Medi-Cal, this fee does not apply and you are responsible only for any copay or cost-share your plan requires. Payment is due at the time of session unless prior arrangements are made, by check, cash, Venmo, Zelle, or PayPal (HSA cards can be used through PayPal). Returned checks are subject to an additional fee of up to $25.00 to cover bank fees. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

Other professional services — such as report writing, phone conversations longer than 15 minutes, requested meetings or consultations, or other requested services — are billed on the same prorated hourly basis. If you anticipate involvement in a court case, I recommend discussing this fully before waiving confidentiality; you will be responsible for professional time required even if compelled to testify by another party.

Insurance

If you have health insurance, it may provide some coverage for mental health treatment. With your permission, my billing service and I will assist you in filing claims and understanding your coverage, but you are responsible for knowing your benefits and notifying me of any changes. Managed care plans (HMOs, PPOs) often require advance authorization and may limit coverage to short-term treatment; approval for continued therapy may be required after a set number of sessions. If your plan will not allow me to continue seeing you once benefits end, I will help you find another provider.

Most insurers require authorization to provide them with a clinical diagnosis, and sometimes additional clinical information such as treatment plans, summaries, or records. This information becomes part of the insurer's files and is outside of my control once submitted; I will provide you a copy of any report I submit upon request. By signing this agreement, you authorize me to provide requested information to your carrier if you plan to use insurance, and you acknowledge that co-insurance, co-payments, and deductibles may apply and are your responsibility. You always have the right to pay for services yourself to avoid these considerations, unless prohibited by my provider contract. If I am not a participating provider for your plan, I will supply a receipt you can submit for out-of-network reimbursement, where available.

Professional records

I keep appropriate records of the psychological services I provide in a secure location, including session dates, reasons for seeking therapy, treatment goals and progress, diagnosis, topics discussed, relevant history, records from other providers, records I send to others, and billing records. Except in unusual circumstances involving danger to yourself, you have the right to a copy of your file; because these are professional records, I recommend initially reviewing them with me or another mental health professional. If I deny a request for access, you have the right to have that decision reviewed. You also have the right to request that your file be shared with another health care provider at your written request.

Confidentiality

My confidentiality policies and other privacy rights are fully described in a separate document, the Notice of Privacy Practices, which you have been provided and which we have discussed. You may reopen that conversation at any time during our work together.

Parents and minors

Parental involvement can be essential even though privacy is crucial to progress. It is my policy not to treat a child under 13 unless they agree I can share necessary information with a parent. For clients 14 and older, I request an agreement between the client and parents allowing me to share general progress and attendance information, plus a treatment summary at completion. All other communication requires the child's agreement, unless I believe there is a safety concern, in which case I will make every effort to notify the child of my intent to disclose and address any objections raised.

Contacting me

I am often unavailable by phone, especially while with clients. Please leave a message on my confidential voicemail; non-urgent calls may take a day or two to return. If you cannot wait for a return call or feel unable to keep yourself safe: contact the Mobile Crisis Response Team at 1-800-704-0900, the Santa Clara County Suicide and Crisis Hotline at 1-855-278-4204, go to your local hospital emergency room, or call 911 and ask for the mental health worker on call. The National Suicide Prevention Hotline is 1-800-273-8255. I will make every attempt to inform you in advance of planned absences and provide the name and number of the colleague covering my practice.

Other rights

If you are unhappy with any aspect of therapy, I hope you will talk with me so I can respond to your concerns; such feedback is taken seriously and handled with care and respect. You may request a referral to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about my training and experience, and to expect that I will not have social or sexual relationships with clients or former clients.

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Consent to psychotherapy

My signature below indicates that I have read this Agreement and the Notice of Privacy Practices and agree to their terms.