Informed Consent for Psychotherapy
Welcome to Holistic Psychotherapy Center!
Please read important information regarding my practice policies:
APPOINTMENTS: Each session is 45 minutes long. Extended sessions can be scheduled at your request.
In-person and telehealth sessions are available for your convenience.
FEES: My fee is $250 per session payable at the end of each session. There is an additional fee in cases where you request a report and/or any additional services.
Payment may be made by cash, check, CC (except American express), Venmo or Zelle.
CANCELLATION & RESCHEDULING POLICY: Your appointments are reserved especially for you. I understand that sometimes schedule adjustments are necessary. I request at least 36 hours’ notice for cancellation or rescheduling appointments. In cases when you cancel or miss a session with less than 36 hours’ notice, you will be responsible to pay the full amount of the session missed. Please understand that when you change your appointment without enough notice, I miss the opportunity to fill this appointment time to someone else who would like to come in.
CONFIDENTIALITY AND EXCEPTIONS TO CONFIDENTIALITY: All information disclosed within your sessions is confidential and may not be revealed to anyone without your written consent except where disclosure is required by law.
Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect, where a client presents a danger to self, to others, to property, or is gravely disabled, or when a client's family members communicates to me as your psychotherapist that the client presents a danger to others or self.
In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon.
AUTHORIZATION TO RELEASE INFORMATION: There are times when you may want me to communicate with a third party such as a doctor or a family member for overall treatment progress. In this case you must complete and sign an Authorization to Release Information form. If you are in family or couples therapy, it must be signed by all adult parties who are part of the treatment.
MEDICAL RECORDS: You have the right to request relevant medical information (not including my personal notes regarding your psychotherapy) to be made available to you or any other health care provider, insurance company or anyone else. Your medical record can be released only with your written consent.
California law requires that counseling records be maintained for 7 years from the end of therapy and after that time they can be destroyed.
INSURANCE BILLING: I don’t provide insurance billing. I can gladly provide you with a super-bill at the end of each month that you will submit to your insurance company for reimbursement. You can check with your medical insurance plan your out network coverage for Mental Health services.
TREATMENT FOR A MINOR: I require the consent of both parents/legal guardians prior to providing any services for a minor child under the age of 18.
WAYS TO REACH ME: I don’t take direct calls by you but you can always leave me a message in the following ways:
By phone at 818-501-8029
By text at 818-665-2120
By Email firstname.lastname@example.org
I respond as soon as possible within 24 hours.
In case of an emergency please go to your local emergency room or call 911.
CLIENT’S SIGNED STATEMENT:
By signing below I acknowledge that I have read, understood and agreed to the terms described in this document