Forms

Client Forms

Please complete and submit these five forms immediately.

Child Intake Form

Personal Data
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
Demographics:
Child/Youth Name:*
First Last
Gender:
Race:
Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SS#:
Date of Birth:
MM slash DD slash YYYY
Referred By:
Phone #:
Email:
Primary Care Physician:
Psychiatrist/Other:
Parent 1 Name
First Last
Parent 1 Phone #:
Parent 1 Email:
Parent 1 Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent 1 Employer:
Parent 2 Name:
First Last
Parent 2 Phone #:
Parent 2 Email:
Parent 2 Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent 2 Employer:
Insurance:
Insurance Carrier:
Policy #:
Group #:
Carrier Phone #:
Insured's Name
First Last
Insured's Date of Birth:
MM slash DD slash YYYY
Presenting Problem:
Reason for seeking evaluation at this time:
Behavioral/Emotional Problems:
- None
- Drug Use
- Alcohol Abuse
- Chronic Lying
- Stealing
- Violent Temper
- Fire-Setting
- Hyperactive
- Animal Cruelty
- Assaults Others
- Disobedient/Oppositional
- Repeats Others' Words
- Not Trustworthy
- Hostile/Angry Mood
- Indecisive
- Immature
- Bizzare Behavior
- Self-Injurious Threats
- Frequently Tearful
- Lack of Attachment
- Extreme Worrier
- Impulsive
- Poor Concentration
- Breaks Things in Anger
- Distrustful
- Self-Injurious Acts
- Easily Distracted
- Often Sad
- Frequent Daydreams
Social Interaction:
- Normal Social Interaction
- Isolates Self
- Very Shy
- Associates w/Acting-Out Peers
- Inappropriate Sex Play
- Dominates Others
- Alienates Self
Intellectual/Academic Functioning:
- Normal Intelligence
- High Intelligence
- Learning Problems
- Authority Conflicts
- Attention Problems
- Underachieving
- Mild Intellectual Deficit
- Moderate Intellectual Deficit
- Severe Intellectual Deficit
What other behaviors does the Child currently do too often, too much, or at the wrong times that gets him/her in trouble?:
What behavior does the Child fail to do as often, as much as, or when you would like?:
What behavior does the Child do that you or others like?:
What other concerns do you or others have about the Child?:
From the preceding list of the Child’s behavior concerns, what problem behaviors do you want to see changed first?:
Family History:
Present in Childhood:
Parent 1
Parent 2
Stepmother
Stepfather
Brother(s)
Sister(s)
Other(s)
Describe Parent 1:
Full Name:
First Last
Occupation:
Education:
Health:
Describe Parent 2:
Full Name:
First Last
Occupation:
Education:
Health:
Parents' current marital status:
- Married to each other
- Separated (note years below)
- Divorced (note years below)
- Mother remarried (note times below)
- Father remarried (note times below)
- Mother involved with someone
- Father involved with someone
- Mother deceased (note year and age below)
- Father deceased (note year and age below)
Describe Childhood family experience:
Any Special Circumstances in Childhood:
Witnessed Abuse:
- Physical
- Verbal
- Sexual abuse
Experienced Abuse:
- Physical
- Verbal
- Sexual abuse
Is Child Adopted?
- Yes
- No
At what age?:
Child's legal guardian(s):
Who does the Child currently live with?:
List all persons currently living in household:
First Last
Age
Sex
Relationship
Person 2:
First Last
Age
Sex
Relationship
Person 3:
First Last
Age
Sex
Relationship
List Biological/Adopted siblings NOT living in household:
First Last
Age
Sex
Relationship
Person 2:
First Last
Age
Sex
Relationship
Person 3:
First Last
Age
Sex
Relationship
Frequency of Visitation of Above
Describe any past or current significant conflicts within family relationships:
General Healtlh
Describe current physical health:
Irregular Health Habits
Eating Concerns:
Exercise Patterns:
Sleep Patterns:
Sleep Patterns:
Hygiene Habits:
Daily Routine:
Wake-up time:
Breakfast time:
Lunch time:
Dinner time:
Bed time:
Activities between breakfast and lunch:
Activities between lunch and dinner:
Activities between dinner and bedtime:
Medical History
Problems During Mother's Pregnancy:
- None
- High Blood Pressure
- Kidney Infection
- German Measles
- Emotional Stress
- Bleeding
- Alcohol Use
- Drug Use
- Cigarette Use
- Other (please note below)
Birth
- Normal Delivery
- Difficult Delivery
- Cesarean Delivery
- Complications (note below)
Birth Weight:
Infancy Problems:
- None
- Feeding Problems
- Sleep Problems
- Toilet Training Problems
Childhood Health:
- Chickenpox
- German Measles
- Red Measles
- Whooping Cough
- Autism
- Asthma
- Lead Poisoning
- Mumps
- Diptheria
- Scarlet Fever
- Mental Retardation
- Tuberculosis
- Poliomyelitis
- Rheumatic Fever
- Pneumonia
- Ear Infections
- Allergies
- Head Trauma
- Loss of Consciousness
- Seizures
- Dizziness
- Headaches
Please note ages for any checked items above:
Developmental Delays (if any):
- Sitting
- Rolling Over
- Standing
- Walking
- Controlling Bladder
- Riding Bicycle
- Dressing Self
- Engaging Peers
- Controlling Bowels
- Riding Tricycle
- Feeding Self
- Tolerating Separating
- Playing Cooperatively
- Sleeping Alone
- Speaking Words
- Speaking Sentences
Please note ages for any checked items above:
Child as Infant (yes or no):
- Affectionate
- Appropriate eye contact
- Appropriate gestures
- Appropriate interest in objects or others
- Pointing to items of interest
- Smiling
- Other nonverbal behaviors (explain below)
Any past or current concerns about the Child’s language, fine or gross motor development?
Describe Child as an Infant:
Other Details of Medical health Conditions:
List Any Non-Psychiatric Medications Currently Being Taken (Name, Dosage, Reason):
List Any Known Medication Allergies:
History of any of the following in the family:
- Tuberculosis
- Birth Defects
- Emotional Problems
- Drug Abuse
- Diabetes
- Behavior Problems
- Thyroid Problems
- Cancer
- Mental Retardation
- Stroke
- Heart Disease
- High Blood Pressure
- Alcoholism
- Alzheimer's Disease
- Dementia
Other Chronic or Serious Health Problems in Family Members:
Indicate any serious hospitalizations or accidents:
Psychiatric History:
Family History:
Describe any history of family psychiatric hospitalization(s), psychiatric diagnoses, learning disorders, special education, or intellectual giftedness. (Please indicate relation to child.):
Individual History:
List any history of psychological COUNSELING received by Child (include provider name, contact phone, date of treatment, purpose, and outcome):
List any history of psychological TESTING administered to the Child (inlcude evaluator name, contact phone, date of testing, purpose, and results/diagnosis):
Substance Use:
CURRENT Family Alcohol/Drug Abuse:
- No History of Abuse
- Father
- Mother
- Siblings
- Grandparent(s)
- Step-Parent/Live-in
- Uncles/Aunts
PRIOR Family Alcohol/Drug Abuse:
- No History of Abuse
- Father
- Mother
- Siblings
- Grandparent(s)
- Step-Parent/Live-in
- Uncles/Aunts
Child - Substances Used:
- Alcohol
- Amphetamines/Speed
- Barbituates/Downers
- Caffeine
- Cocaine
- Crack Cocaine
- Hallucinogens
- Inhalants (e.g. glue, gas)
- Marijuana or Hashish
- Opioids
- PCP
- Prescription
- Other
Please note first use age, last use age, current use (yes or no), frequency, and amount for any items checked above:
Academic History
Previous School Attended, Location, District, Grade, and GPA:
CURRENT School Attending, Location, District, Grade, and GPA:
Public or Private school:
Favorite Subject:
Least Favorite Subject:
Teacher's Name:
Phone:
Email:
What does the Teacher say about Child?
IEP History, if any:
Describe any repeated grade level, learning disability, speech therapy, or special education services:
Describe any placement history in giftedness or advanced placement classes:
Has the Child experienced any of the following problems at school?
- Fighting
- Suspension
- Gang Influence
- Lack of Friends
- Incomplete Homework
- Drug/Alcohol
- Poor Attendance
- Behavior Problems
- Detention
- Poor Grades
Socio-Economic History
Living Adequate:
- Housing Adequate
- Homeless
- Housing Overcrowded
- Housing Dangerous/Deteriorating
- Living Companions Dysfunctional
Social Support System:
- Supportive Network
- Few Friends
- Best Friend
- Boyfriend/Girlfriend
- Substance-use-based Friends
- No Friends
- Only Older Friends
- Only Younger Friends
- Social Networks Friends
- Distant from Family
Legal History:
- No Legal Problems
- Now on Parole/Probation
- Arrest(s) Not Substance-related
- Court Ordered this Treatment
- Jail/Prison (note total time below)
- Describe last legal difficulty (below)
Sexual History
- Heterosexual Orientation
- Homosexual Orientation
- Bisexual Orientation
- Currently Sexually Active
Employment:
Describe any present/past involvements in Sports, Church, Social Groups, Dancing, etc.:
Describe any recent changes in these involvements:
How does the Child spend their solitary time (reading, hobbies, video games, etc.)?
Does Child have a driver's license?
Concerns about Child's social functioning?
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Comments
This field is for validation purposes and should be left unchanged.

Electronic Communication Policy

Electronic Communication Policy
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-236-6155 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-393-1950 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-346-2041 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-221-4315 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949.356.6620 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-549-1397 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.
Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-828-3528 so we can discuss it on the phone or if it can wait, we can discuss it during your next appointment. Telephone or face-to-face is a more secure mode of communication.

Social Media

I do not communicate with, or contact any of my patients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring them up when we meet so we can discuss it.

Fanning/Following

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

Websites

I have a website that you are free to access. I use it to provide professionally based information as it relates to my psychotherapy practice to the public. You are welcome to access and review the information that I have on my website and if you have questions about it, please bring them up when we meet so we can talk about it.

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on your treatment.
Patient Signature
Date
MM slash DD slash YYYY
Authorized Signature for Patient
Date
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Comments
This field is for validation purposes and should be left unchanged.

HIPPA

NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
Please select your therapist
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
Required HIPAA Notice of Privacy Practices

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IT WILL GENERALLY PROTECT YOUR PRIVACY TO A MUCH GREATER DEGREE THAN REQUIRED BY THE LANGUAGE OF THE DOCUMENT.

II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)

I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you which I have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of the health care. I must provide you with this Notice about my privacy practices and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, give, or otherwise disclose to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. I am legally required to follow the privacy practices described in this Notice; however, I reserve the right to change the terms of the Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office.

III. HOW I MAY USE AND DISCLOSE YOUR PHI

I will use and disclose your PHI for many different reasons. I will need your prior written authorization for some of these uses or disclosures; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

A. Uses and Disclosures. Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:

For Treatment. I can use your PHI within my practice to provide you with mental health treatment including discussing or sharing your PHI with my trainees and interns. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist to coordinate your care.

To Obtain Payment for Treatment. I can use your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process health care claims.

For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who have provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.

For Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent is not required if you need emergency treatment as long as I try to get your consent after treatment is rendered; or, if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to governmental agencies and law enforcement personnel about victims of abuse or neglect.

2. When judicial or administrative proceedings require disclosure. For example, I may have to use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or claim for workers’ compensation benefits. I may also have to use or disclose your PHI in response to a subpoena.

3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant.

4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a governmental official an adverse reaction that you may have to a medication.

5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.

6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. Any such disclosures will only be made to someone able to prevent the threatening harm from occurring.

7. For specialized government functions. For example, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations, if you are in the military.

8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you about your appointments or to give you information about treatment alternatives, other health care services, or other health care benefits that I offer that may be of interest to you.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate that is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in an emergency situation.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any situation not described in sections III A, B, and C, above, I will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action in reliance on such authorization) of your PHI by me.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

You have the following rights with respect to your PHI:

A. The Right to Request Restrictions on My Uses and Disclosures. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members, friends, or others involved in your care or who are financially responsible for your care. Please submit such requests to me in writing. I will consider your requests but am not legally required to accept them. If I do accept your requests I will put them in writing and will abide by them except in emergency situations. Be advised that you may not limit the uses and disclosures that I am legally required to make.

B. The Right to Choose How I Send PHI to You. You have the right to request that I send confidential information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). I must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and when appropriate, provide me with information as to how payment for such alternate communications will be handled. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

C. The Right to Inspect and Receive a Copy of Your PHI. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. If I do not have your PHI but I know who does, I will tell you how to get it. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.

D. The Right to Receive a List of the Disclosures I Have Made. You have the right to receive an Accounting of Disclosure listing the instances in which I have disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use; disclosures permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; and, disclosures made before April 14, 2003. I will respond to your request for an Accounting of Disclosure within 60 days of receiving such request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year I may charge you a reasonable, cost-based fee for each additional request.

E. The Right to Amend Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide, in writing, the request and your reason for the request. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request to amend your PHI, I will make the changes, tell you that I have done it, and tell others that need to know about the change to your PHI.

F. The Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this notice even if you have agreed to receive it via e-mail.

V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you think that I may have violated your privacy rights, or you disagree with a decision I have made about access to your PHI, you may file a complaint with me. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S. W., Washington D. C. 20201. I will not take retaliatory action against you if you file a complaint about my privacy practices.

VI. EFFECTIVE DATE OF NOTICE.

This Notice will go into effect on March 1, 2018. I reserve the right to change the terms of this notice. I will provide you with a revised notice as required.
Required HIPAA Notice of Privacy Practices

I, Madeline Trujillo AMFT 126753, am currently under the supervision of Dr. Hayley Pedersen, PSY 29698. I may disclose your PHI and information to Dr. Pedersen on an as-needed basis and for training purposes only.

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IT WILL GENERALLY PROTECT YOUR PRIVACY TO A MUCH GREATER DEGREE THAN REQUIRED BY THE LANGUAGE OF THE DOCUMENT.

II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)

I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you which I have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of the health care. I must provide you with this Notice about my privacy practices and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, give, or otherwise disclose to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. I am legally required to follow the privacy practices described in this Notice; however, I reserve the right to change the terms of the Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office.

III. HOW I MAY USE AND DISCLOSE YOUR PHI

I will use and disclose your PHI for many different reasons. I will need your prior written authorization for some of these uses or disclosures; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

A. Uses and Disclosures. Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:

For Treatment. I can use your PHI within my practice to provide you with mental health treatment including discussing or sharing your PHI with my trainees and interns. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist to coordinate your care.

To Obtain Payment for Treatment. I can use your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process health care claims.

For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who have provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.

For Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent is not required if you need emergency treatment as long as I try to get your consent after treatment is rendered; or, if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to governmental agencies and law enforcement personnel about victims of abuse or neglect.

2. When judicial or administrative proceedings require disclosure. For example, I may have to use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or claim for workers’ compensation benefits. I may also have to use or disclose your PHI in response to a subpoena.

3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant.

4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a governmental official an adverse reaction that you may have to a medication.

5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.

6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. Any such disclosures will only be made to someone able to prevent the threatening harm from occurring.

7. For specialized government functions. For example, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations, if you are in the military.

8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you about your appointments or to give you information about treatment alternatives, other health care services, or other health care benefits that I offer that may be of interest to you.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate that is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in an emergency situation.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any situation not described in sections III A, B, and C, above, I will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action in reliance on such authorization) of your PHI by me.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

You have the following rights with respect to your PHI:

A. The Right to Request Restrictions on My Uses and Disclosures. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members, friends, or others involved in your care or who are financially responsible for your care. Please submit such requests to me in writing. I will consider your requests but am not legally required to accept them. If I do accept your requests I will put them in writing and will abide by them except in emergency situations. Be advised that you may not limit the uses and disclosures that I am legally required to make.

B. The Right to Choose How I Send PHI to You. You have the right to request that I send confidential information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). I must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and when appropriate, provide me with information as to how payment for such alternate communications will be handled. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

C. The Right to Inspect and Receive a Copy of Your PHI. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. If I do not have your PHI but I know who does, I will tell you how to get it. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.

D. The Right to Receive a List of the Disclosures I Have Made. You have the right to receive an Accounting of Disclosure listing the instances in which I have disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use; disclosures permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; and, disclosures made before April 14, 2003. I will respond to your request for an Accounting of Disclosure within 60 days of receiving such request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year I may charge you a reasonable, cost-based fee for each additional request.

E. The Right to Amend Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide, in writing, the request and your reason for the request. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request to amend your PHI, I will make the changes, tell you that I have done it, and tell others that need to know about the change to your PHI.

F. The Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this notice even if you have agreed to receive it via e-mail.

V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you think that I may have violated your privacy rights, or you disagree with a decision I have made about access to your PHI, you may file a complaint with me. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S. W., Washington D. C. 20201. I will not take retaliatory action against you if you file a complaint about my privacy practices.

VI. EFFECTIVE DATE OF NOTICE.

This Notice will go into effect on March 1, 2018. I reserve the right to change the terms of this notice. I will provide you with a revised notice as required.
Agreement*
I have read and understand this notice.
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Name
This field is for validation purposes and should be left unchanged.

Informed Consent

Informed Consent to Treatment
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY29698
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Marriage and Family Therapist, California Board of Behavioral Sciences #LMFT103286
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY31023
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY34343
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY33647
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Marriage and Family Therapist, California Board of Behavioral Sciences LMFT#108189
This document contains important information about my professional services and business policies. Please read it carefully and inform me of any questions you might have so that we can discuss them during our next meeting. When you sign this document, it will represent an agreement between us.

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Associate Marriage and Family Therapist, California Board of Behavioral Sciences #AMFT 126753
ARRIVAL AT THE CHILD AND FAMILY CONNECTION: When you arrive for your appointment, please wait in the waiting area. I will come to the waiting area and greet you at the beginning of the appointment. If you are late, simply stay in the waiting area and I will check to see if you have arrived in a few minutes. Your prompt arrival ensures that you get the benefit of a full session.
PSYCHOLOGICAL SERVICES: I am a licensed Psychologist in the state of California. I provide individual, couples and family therapy and consultative services. Areas of specialization include: early childhood, poor coping, depression, anxiety, trauma/PTSD, ADHD, disruptive behavior, parenting skills, and relationship issues. During the course of therapy, I will likely draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (child, adult, family), or psycho-educational.

Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on you or your child’s part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations in which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended.

Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member can be viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

Our first few sessions will involve an evaluation of you or your child’s needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you or your child feel comfortable working with me. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. You, or your child, have the right to terminate therapy at any time although I recommend doing so only after discussing your concerns with me directly.

A decision on my part for early or premature termination of our professional relationship would be for one of the following reasons: it is reasonably clear that you or your child no longer need, are not benefitting from, or are being harmed by treatment, or if you or someone in a relationship with you threatens or endangers me, if you are in need of services that I am not able to provide, financial noncooperation, or any other needs of mine. Should we prematurely end our professional relationship, you or your child will be provided with appropriate referrals and recommendations about how to proceed unless your actions make it impossible, such as refusing to attend therapy sessions.

MEETINGS AND CANCELLATION: In most cases, I conduct an intake evaluation at the outset. During this time, we can decide together if I am the best person to provide the services you or your child need in order to meet your treatment goals. If psychotherapy is begun, I will schedule one 45-minute session per week at a time we agree on, although some sessions may be longer or more frequent. Scheduling an appointment involves the reservation of time specifically for you or your child. Once an appointment hour is scheduled, you will be expected to pay the standard fee for it unless you provide 48 hours advance notice of cancellation.

I understand that I must cancel sessions 48 hours in advance or I may be billed for the scheduled hours.
PSYCHOLOGICAL SERVICES: I am a licensed Marriage and Family Therapist in the state of California. I provide individual, couples and family therapy and consultative services. Areas of specialization include: early childhood, poor coping, depression, anxiety, trauma/PTSD, ADHD, disruptive behavior, parenting skills, and relationship issues. During the course of therapy, I will likely draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (child, adult, family), or psycho-educational.

Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on you or your child’s part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations in which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended.

Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member can be viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

Our first few sessions will involve an evaluation of you or your child’s needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you or your child feel comfortable working with me. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. You, or your child, have the right to terminate therapy at any time although I recommend doing so only after discussing your concerns with me directly.

A decision on my part for early or premature termination of our professional relationship would be for one of the following reasons: it is reasonably clear that you or your child no longer need, are not benefitting from, or are being harmed by treatment, or if you or someone in a relationship with you threatens or endangers me, if you are in need of services that I am not able to provide, financial noncooperation, or any other needs of mine. Should we prematurely end our professional relationship, you or your child will be provided with appropriate referrals and recommendations about how to proceed unless your actions make it impossible, such as refusing to attend therapy sessions.

MEETINGS AND CANCELLATION: In most cases, I conduct an intake evaluation at the outset. During this time, we can decide together if I am the best person to provide the services you or your child need in order to meet your treatment goals. If psychotherapy is begun, I will schedule one 45-minute session per week at a time we agree on, although some sessions may be longer or more frequent. Scheduling an appointment involves the reservation of time specifically for you or your child. Once an appointment hour is scheduled, you will be expected to pay the standard fee for it unless you provide 48 hours advance notice of cancellation.

I understand that I must cancel sessions 48 hours in advance or I may be billed for the scheduled hours.
PSYCHOLOGICAL SERVICES: am an Associate Marriage and Family Therapist in the state of California. I am currently under supervision of Dr. Hayley Pedersen PSY 29698.
- Trainees receive intensive ongoing guidance, evaluation, and education in providing clinical services to you.
- The supervision process requires that supervisors of trainees periodically observe their work with you, either directly or through audio and video recordings. This will only happen with your consent.
- This supervision is protected by the same laws pertaining to client confidentiality as stated in the Health Information Practices and Privacy Policies, which has been provided to you.
- If you have any questions or concerns about this supervision process, please contact Dr. Hayley Pedersen at 949-236-6155 or drhayley@thechildandfamilyconnection.com
I provide individual, couples and family therapy and consultative services. Areas of specialization include: early childhood, poor coping, depression, anxiety, trauma/PTSD, ADHD, disruptive behavior, parenting skills, and relationship issues. During the course of therapy, I will likely draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (child, adult, family), or psycho-educational.

Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on you or your child’s part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations in which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended.

Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member can be viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

Our first few sessions will involve an evaluation of you or your child’s needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you or your child feel comfortable working with me. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. You, or your child, have the right to terminate therapy at any time although I recommend doing so only after discussing your concerns with me directly.

A decision on my part for early or premature termination of our professional relationship would be for one of the following reasons: it is reasonably clear that you or your child no longer need, are not benefitting from, or are being harmed by treatment, or if you or someone in a relationship with you threatens or endangers me, if you are in need of services that I am not able to provide, financial noncooperation, or any other needs of mine. Should we prematurely end our professional relationship, you or your child will be provided with appropriate referrals and recommendations about how to proceed unless your actions make it impossible, such as refusing to attend therapy sessions.
I, the person served or their legal, custodial parent, or legal guardian, acknowledge that I am voluntarily authorizing that I or my child receives services from Madeline Trujillo, AMFT, under supervision of Dr. Hayley Pedersen. I have been informed of the purpose of the services and any corresponding risks, consequences, and/or benefits. Initial(s):
MEETINGS AND CANCELLATION: In most cases, I conduct an intake evaluation at the outset. During this time, we can decide together if I am the best person to provide the services you or your child need in order to meet your treatment goals. If psychotherapy is begun, I will schedule one 45-minute session per week at a time we agree on, although some sessions may be longer or more frequent. Scheduling an appointment involves the reservation of time specifically for you or your child. Once an appointment hour is scheduled, you will be expected to pay the standard fee for it unless you provide 48 hours advance notice of cancellation.

I understand that I must cancel sessions 48 hours in advance or I may be billed for the scheduled hours.
Initial(s):
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $375.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $225.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $300.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $175.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $375.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $225.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $375.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $225.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $375.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $225.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $300.00 per session. $225 60 min intake, $175 all 45 min sessions after that. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $175.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $300.00 per session. $225 60 min intake, $175 all 45 min sessions after that. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $175.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

If you or your child becomes involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Due to the difficulty of legal involvement, I charge $320 per hour for preparation and attendance at any legal proceeding.

I understand the fee schedules set forth by The Child and Family Connection.
Initial(s):
BILLING AND PAYMENTS: You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. Fees are collected at each visit for the hours performed that day. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.

There will be a returned check fee of $25.00 should there be any problems clearing your check. If for any reason you do not pay your bill at the time of service, a $50.00 late fee will be assessed for each 30-days that you do not pay. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is the patient’s name, the nature of services provided, and the amount due.

I understand that I must pay at the time of each visit.
Initial(s):
INSURANCE: Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance company. Upon specific request, I can provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. Please be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If you have questions about the coverage, call your plan administrator.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 236-6155 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 393-1950 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 346-2041 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 356-6620 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 549-1397 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 221-4315 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 828-3528 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

Please do not e-mail content related to your therapy sessions, as e-mail is not completely secure or confidential. If you choose to communicate by e-mail, be aware that all e-mails are retained in the logs of both (client and therapist) internet service providers. You should also know any e-mails with therapeutic content received from you will become part of your legal record. If you are comfortable, text or e-mail may be used to arrange or modify appointments. Please no texting outside of appointment modification.

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.
Initial(s):
PROFESSIONAL RECORDS: You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. When our work concludes, or it has been at least 30 days since our last contact, your file will be closed. You may request amendments to your record, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see my Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records. Except in specific circumstances, you are entitled to examine your or your child’s clinical record and/or receive a copy at a rate of ¢25 per page. If you wish to see you or your child’s records, you must request to do so in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In the event that you do review the full records I recommend that they are reviewed in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. You may request that any complaints you have about my privacy policies and procedures be recorded in your records.

I understand my rights pertaining to my clinical records, and that my file will be closed at the conclusion of our work together or 30 days after our last contact.
Initial(s)
CONFIDENTIALITY AND LIMITS THEREOF: Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health-care professional must make reasonable attempts to protect the client and may or may not notify legal authorities and/or the family of the client.
Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your case. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you or your child may have at our next meeting. I will be happy to discuss these issues with you or your child if you need specific advice, but formal legal advice may be needed as the laws governing confidentiality are quite complex, and I am not an attorney. Please see my Notice of Privacy Practices for more detailed information regarding confidentiality.

You or your child are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you or your child electronically (for example, faxing information), it will be done with special safeguards to insure confidentiality.

I understand that my or my child’s mental health information will be kept confidential unless my psychologist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.
Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your case. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you or your child may have at our next meeting. I will be happy to discuss these issues with you or your child if you need specific advice, but formal legal advice may be needed as the laws governing confidentiality are quite complex, and I am not an attorney. Please see my Notice of Privacy Practices for more detailed information regarding confidentiality.

You or your child are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you or your child electronically (for example, faxing information), it will be done with special safeguards to insure confidentiality.

I understand that my or my child’s mental health information will be kept confidential unless my therapist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.
Initial(s):
COUPLES: This is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. I will remind you of this policy before beginning such individual sessions.
MINORS: In regard to information disclosed by minors in session, it is important that they are able to trust the therapy process completely. Therefore, it is my policy to request an agreement from parents that they give up access to their child’s records. Thus, such information will be kept confidential in the same way that confidentiality is maintained for an adult (please see the “Confidentiality” section above for details). As the parent or guardian, you have the right and responsibility to question and understand the nature of treatment and progress with your child. Therapist will use clinical discretion as to what is appropriate to disclose.

Note to minors, if you are less than eighteen years of age please be aware that the law may provide your parents the right to examine your treatment records. If they agree to give up access to your records, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or another person. In this case, I will notify them of my concern. I may also offer a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.

Parents are expected to bring their child to treatment personally (unless arranged in advance with The Child and Family Connection) and must stay in the waiting room or immediate area during the session. This enables parents to participate in treatment or help their child if necessary. Parents are also expected to be on hand to take a child to the restroom during sessions as needed.

I understand that I am responsible for bringing my child to each session and remaining on site and available during the therapy hour. I agree to give up access to my child’s record and receive general information about treatment, unless there is an emergency, in which case I will be notified.
Initial(s):
Child/Adolescent Patient:

By signing below, you show that you have read and understood the policies described above. If you have any questions as we progress with therapy, you can ask me at any time.
Minor's Signature:
Date:
MM slash DD slash YYYY
Parent/Guardian of Minor Patient:

Please initial after each line and sign below, indicating your agreement to respect your child’s privacy:

I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.
Initial(s):
Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.
Initial(s):
I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.
Initial(s):
Parent/Guardian Signature:
Date:
MM slash DD slash YYYY
Parent/Guardian Signature:
Date:
MM slash DD slash YYYY
Mailing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth:
MM slash DD slash YYYY
PLEASE NOTE: The Child and Family Connection is an independent practitioner and is not formally associated with Costal Kids or any other practitioner. Sharing office space, forms, or expenses with other clinicians does not imply any professional involvement with other practitioners, and they are not responsible in any way for actions The Child and Family Connection may take. Likewise, The Child and Family Connection is not responsible for any actions taken by colleagues sharing office space, forms or expenses.
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com

Financial Responsibility

CFC Financial Responsibility
Please select your therapist
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
Patient Name:
Parent/Guardian/Spouse (if applicable):
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Email:
Payment Authorization
Counseling Fee (per session):
Assessment Fee (total):
Initial Payment Amount:
Payment Due Date
MM slash DD slash YYYY
The patient and/or guardian are ultimately responsible for payment of all services. As a result, it is our policy to have a credit/debit card on file for each patient. Check or cash is otherwise accepted at time of visit.
Cardholder Name:
Billing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Card Number:
Expiration Date (mm/yy)
CVV Code
CANCELLATION POLICY

Cancellations of an appointment less than 48 hours in advance and “no show” constitute a missed appointment and will be subject to a full fee for the appointment time. In the event of a late cancellation, no-show, or missed appointment, I agree to be responsible for the per session fee and authorize The Child and Family Connection to charge my credit card for the amounts due. I certify that I am the authorized user of this credit card and that my signature below indicates that I have read this Agreement and agree to its terms and conditions.
Client Signature
Date
MM slash DD slash YYYY
Authorized Signature for Client
Date
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Email
This field is for validation purposes and should be left unchanged.

Please complete these forms on an as-needed basis.

Collateral Agreement

CFC Collateral Agreement
Please select your therapist
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
Introduction
I want to thank you for accepting the invitation to assist in psychotherapeutic treatment as it pertains to:
Patient Name:
First Last
Who Is A Collateral Participant?
A collateral participant is usually a spouse, parent, family member, or friend who participates in therapy to assist the identified patient. The collateral participant is not considered to be a patient and is not the subject of therapeutic treatment. Psychologists have legal and ethical responsibilities to their patients and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. You also have less privacy protection.
Who Is A Collateral Participant?
A collateral participant is usually a spouse, parent, family member, or friend who participates in therapy to assist the identified patient. The collateral participant is not considered to be a patient and is not the subject of therapeutic treatment. Therapists have legal and ethical responsibilities to their patients and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. You also have less privacy protection.
The Role of Collaterals In Therapy
The role of a collateral participant can greatly vary. For example, a collateral participant might attend only one session, either alone or with the patient, to provide information to the therapist and never attend another session. In another case a collateral participant might attend all of the patient’s therapy sessions and his/her relationship with the patient may be a focus of the treatment. We will discuss your specific role in the treatment at our first meeting and at other appropriate times.

Benefits and Risks
Psychotherapy often engenders intense emotional experiences and your participation may engender strong anxiety or emotional distress. It may also expose or create tension in your relationship with the patient. While your participation can result in a better understanding of the patient or an improved relationship, or may even help in your own growth and development, there is no guarantee that this will be the case. Psychotherapy is a positive experience for many, but it may not be helpful for everyone.

Medical Records
No record or chart will be maintained on you in your role as a collateral. Notes about you may be entered into the identified patient’s chart. The patient has the right to access the chart and the material contained therein. It is sometimes possible to maintain the privacy of our communications. If that is your wish, we should discuss it before any information is communicated. As a collateral, you have no right to access that chart without the written consent of the identified patient. You will not carry a diagnosis, and there is no individualized treatment plan for you.

Fees
As a collateral you are not responsible for paying for my professional services unless you are financially responsible for the patient.

Confidentiality

The confidentiality of information in the patient’s chart, including the information that you provide, is protected by both federal and state laws. It can only be released if the identified patient specifically authorizes me to do so. There are some exceptions to this general rule:
- If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency.
- If I believe that you are a danger to yourself (suicidal) I will take actions to protect your life even if I must reveal your identity to do so.
- If you threaten serious bodily harm to another I will take necessary actions to protect that person even if I must reveal your identity to do so.
- If you, or the patient, is involved in a lawsuit, and a court requires that I submit information or testify, I must comply.
You are expected to maintain the confidentiality of the identified patient (your spouse, friend, or child) in your role as a collateral.

Do Collaterals Ever Become A Formal Patient?
Collaterals may discuss their own problems in therapy, especially problems that interact with issues of the identified patient. The therapist may recommend formal therapy for a collateral. These are some examples of when this might occur.
- It becomes evident that a collateral is in need of mental health services. In this circumstance the collateral needs to have their own clinician, diagnosis, and medical chart.
- Parents, who are seen as collaterals for their child in therapy, may need couples therapy to improve their relationship so they can function effectively as caregivers.
Most often, but not always, I will refer you to another clinician for treatment in these situations. There are two reasons the referral may be necessary:
- Seeing two members of the same family, or close friends, may result in a dual role, and potentially cloud judgement. Making a referral helps prevent this from happening.
- My primary obligation is to keep a focus on the original treatment plan for the identified patient. For example, if I started treating a child’s behavioral problem, then begin couples therapy with the child’s parents to address their relationship problems, the original focus of therapy with the child may be lost. A referral helps the clinician to stay focused.
One exception to these guidelines is when a family therapy approach can be effectively and ethically used to treat all members of the family.

Release of Information
The identified patient is not required to sign an authorization to release information (Authorization Form) to the collateral when a collateral participates in therapy. The presence of the collateral with the consent of the patient is adequate. This provides some assurance that full consent has been given to the clinician for the patient’s confidential information to be discussed with the collateral in therapy. The Authorization Form is also helpful to the clinician on those occasions when receiving a telephone call from a collateral or when the clinician calls a collateral for one reason or another. In most instances the clinician cannot take a call from a collateral without an Authorization Form.

Parents as Collaterals
Clinicians specializing in the treatment of children have long recognized the need to treat children in the context of their family. Participation of parents, siblings, and sometimes extended family members, is common and often recommended. Parents in particular have more rights and responsibilities in their role as a collateral than in other treatment situations where the identified patient is not a minor.
- In treatment involving children and their parents, access to information is an important and sometimes contentious topic. Particularly for older children, trust and privacy are crucial to treatment success. Parents also need to be aware of certain information regarding their child's treatment. For this reason, we need to discuss and agree about what information will be shared and what information will remain private. I generally require a written contract signed by both you and your child/children concerning access to a child’s record and once that contract is made, I will treat it as legally binding, although it sometimes may be overridden by a judge. In general, I believe that parents should be informed about the goals of treatment and how the treatment is going and whether the child comes to his/her appointments. At the end of treatment, I prepare a summary for the parents. In addition, I will always inform you if I think that your child is in danger or if he/she is endangering others. One of our first tasks is to discuss and agree on our shared definition of dangerousness so we are all clear about what will be disclosed.
- If you are participating in therapy with your child, you should expect the clinician to request that you examine your own attitudes and behaviors to determine if you can make positive changes that will be of benefit to your child.
Summary
If you have questions about therapy, my procedures, or your role in this process, please discuss them with me. Remember that the best way to assure quality and ethical treatment is to keep communication open and direct with your clinician. By signing below you indicate that you have read, understood and are in agreement with this document.
Signature
Date
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Comments
This field is for validation purposes and should be left unchanged.

Authorization to Release Information

CFC Authorization to Release Information
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
I, the undersigned, give permission to The Child and Family Connection, to release and provide the following information (check all that apply):*
- Select All
- my attendance in therapy
- my diagnosis
- my treatment plan
- information relevant to coordinating care
- when treatment is terminated and why
- other (please explain in detail below)
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
I understand that this release is valid for a period of 365 days. I further understand that I may revoke this authorization at any time in writing. In consideration of this consent, I hereby release the above parties from any legal liability resulting from the release of this information.*

Patient Signature (please print your full name)
Date*
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
Comments
This field is for validation purposes and should be left unchanged.

Consent for Telehealth Services

Informed Consent to Telehealth
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
Telehealth allows The Child and Family Connection to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. I hereby consent to participating in psychotherapy via telephone or the internet (hereinafter referred to as Telehealth) with the clinician listed below:
Patient Name:
I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or to others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent. I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all patients will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or accessed by unauthorized persons. In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services. I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications by providing written notification to The Child and Family Connection. My signature below indicates that I have read this Agreement and agree to its terms and conditions.
Patient Signature:
Date
MM slash DD slash YYYY
Authorized Signature for Patient:
Date
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com

Consent In-Home Psychotherapy

Informed Consent to In-Home Psychotherapy Services
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Carlee Walsh
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
- Dr. Jenna Syverson
In-Home psychotherapy services allow The Child and Family Connection to diagnose, consult, treat and educate in an agreed upon location by the service provider and consumer. I hereby consent to participating in In-Home therapy psychotherapy with the clinician listed below:
Patient Name:
I understand I have the following rights under this agreement:

I have a right to confidentiality with In-Home psychotherapy under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the In-Home interaction to any other entities shall not occur without my written consent.

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all patients will be effective. Thus, I understand that while I may benefit from In-Home psychotherapy results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to In-Home psychotherapy, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted if accessed by unauthorized persons. In addition, I understand that In-Home psychotherapy treatment is different from a traditional office setting and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to In-Home communications by providing written notification to The Child and Family Connection. My signature below indicates that I have read this Agreement and agree to its terms and conditions.
Patient Signature
Date
MM slash DD slash YYYY
Authorized Signature for Patient
Date
MM slash DD slash YYYY
PSY #29698
drhayley@thechildandfamilyconnection.com
949.236.6155

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT#103286
claire@thechildandfamilyconnection.com
949.393.1950

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
LMFT #108189
ariel@thechildandfamilyconnection.com
949.221.4315

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#33647
drbrooke@thechildandfamilyconnection.com
949.356.6620

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
PSY#31023
drcarlee@thechildandfamilyconnection.com
949.346.2041
#PSY34343
drjenna@thechildandfamilyconnection.com
949.549.1397

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com
AMFT#126753
madeline@thechildandfamilyconnection.com
949.828.3528

151 Kalmus Drive, Building B, Suite 150
Costa Mesa, CA 92626
www.thechildandfamilyconnection.com

Adult Intake

Client Personal Data

Demographics:

Patient First Name(Required)

Last Name(Required)

Date

Month

Day

Year

Office ID#

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

SS#

Date of Birth(Required)

Month

Day

Year

Phone(Required)

Email(Required)

Referred by

Military Rank

Race

Gender

Marital Status

Spouse Name

Employer

Position

Work Phone

Primary Care Physician

Psychiatrist

Had Previous Therapy

Date of Last Therapy

Month

Day

Year

Insurance

Insurance Carrier

Policy #

Group #

Total Sessions Authorized

General Notes

Describe the current presenting concerns(Required)

Emotional / Psychiatric

Prior OUTPATIENT psychotherapy?

Yes

If Yes, on how many occasions?

Longest treatment by __________________ for _____ sessions from _________ to _________.

Please fill in the blanks below, separate by a comma

Prior Provider Name

Provider Address

Diagnosis

Intervention / Modality

Beneficial?

Has any family member had outpatient psychotherapy?

Yes

If yes, who/why

Prior INPATIENT treatment for a psychiatric, emotional, or substance use disorder?

Yes

If Yes, on how many occasions?

Longest treatment at __________________________________ (location) from __________ to __________.

Please fill in the blanks below, separate by a comma

Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder?

Yes

If yes, who/why

Prior or current psychotropic medication usage?

Yes

Medication

Dosage

Frequency

Start/End Dates

Physician

Side effects

Beneficial?

Has any family member used psychotropic medications?

Yes

If yes, who/why

Family History

Family of Origin

Mother present in childhood

All

Part

None

Father present in childhood

All

Part

None

Stepmother present in childhood

All

Part

None

Stepfather present in childhood

All

Part

None

Brother(s) present in childhood

All

Part

None

Other(s) present in childhood

All

Part

None

Sister(s) present in childhood

All

Part

None

Father's Full Name

Father's Occupation

Father's Education

Father's Health

Please describe

Mother's Full Name

Mother's Occupation

Mother's Health

Please describe

Mother's Education

Parents current marital status

Please fill out all that apply

Married to each other

Yes

Divorced for ________ years

Separated for _______ years

Mother remarried _______ times

Mother deceased for ______ years at age ______

Mother involved with someone

Yes

Father involved with someone

Yes

Mother deceased for ______ years at age ______

Father deceased for ______ years at age ______

Describe childhood family experience:

Outstanding home environment

Normal home environment

Chaotic home environment

Witnessed physical/verbal/sexual abuse

Experienced physical/verbal/sex abuse

Special circumstances in childhood

Age of Emancipation from Home

Circumstances

Immediate Family

Marital Status:

Cohabitating

Divorced

Married

Separated

Single

Widowed

Intimate Relationship:

Cohabitating

Never been in a serious relationship

Not currently in relationship

Relationship Satisfaction:

Very satisfied with relationship

Satisfied with relationship

Somewhat satisfied with relationship

Dissatisfied with relationship

Very dissatisfied with relationship

List all persons currently living in household. Include Name, Age, Sex, Relationship

List Biological/Adopted children NOT living in household. Include Name, Age, Sex, Relationship

Frequency of Visitation of Above

Describe any past or current significant issues in intimate relationships

Describe any past or current significant issues in other immediate family relationships

Medical

Describe current physical health:

Good

Fair

Poor

Details of Health Condition:

List Name of Primary Care Physician

Primary Care Physician Phone:

List Name of Psychiatrist (if any):

Psychiatrist Phone:

1. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____

2. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____

3. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____

List Any Known Allergies:

Is there a history of any of the following in the family:

Tuberculosis

Drug Abuse

Thyroid Problems

Stroke

Alcoholism

Birth Defects

Diabetes

Cancer

Heart Disease

Alzheimer’s Disease

Emotional Problems

Behavior Problems

Intellectual Disability

High Blood Press

Dementia

Other Chronic or Serious Health Problems in Family Members:

Describe any serious hospitalizations or accidents:

List any abnormal lab test results:

Substance Use

Family Alcohol/Drug Abuse History:

Father

Mother

Grandparent(s)

Siblings

Step-Parent/Live-in

Uncle(s)/Aunt(s)

Spouse/Significant Other

Children

Other:

Other Family Alcohol/Drug Abuse History

Substance Use Status:

No history of abuse

Active abuse

Early full remission

Early partial remission

Sustained full permission

Sustained partial remission

Patient Treatment History:

Outpatient at age

Inpatient at age

12 step program age

Stopped on own age

Other:

Please specify age to any items applicable in field below.

Specify Age(s) for patient treatment history and specify Other if selected.

Substances Used:

Alcohol

Amphetamines/Speed

Barbiturates/Owners

Cocaine

Crack Cocaine

Hallucinogens

Inhalants (e.g. glue, gas)

Marijuana or Hashish

Opioids

PCP

Prescription

Other

Specify Other Substances Used:

Please list Substance used____, First Use Age____, Last Use Age____, Current Use____, Frequency____, Amount____

Consequences of Substance Abuse:

Hangovers

Seizures

Blackouts

Accidental Overdose

Arrests

Binges

Withdrawal Symptoms

Medical Conditions

Increase in Tolerance

Loss of Control with Amount

Job Loss

Sleep Disturbance

Assaults

Suicide Attempts

Suicidal Impulses/Thoughts

Relationship Conflicts

Developmental History

Problems During Mother’s Pregnancy:

None

High Blood Pressure

Kidney Infection

German Measles

Emotional Stress

Bleeding

Alcohol Use

Drug Use

Cigarette Use

Other:

Specify Other Problems During Mother’s Pregnancy:

Birth:

Normal Delivery

Difficult Delivery

Cesarean Delivery

Complications:

Birth Weight:

Please list any complications and birth weight.

Infancy Problems:

None

Feeding Problems

Sleep Problems

Toilet Training Problems

Childhood Health:

Chickenpox at age _____

German Measles at age _____

Red Measles at age _____

Whooping Cough at age _____

Autism

Asthma

Lead Poisoning at age _____

Mumps at age _____

Diphtheria at age _____

Scarlet Fever at age _____

Mental Retardation age _____

Tuberculosis at age _____

Poliomyelitis at age _____

Rheumatic Fever at age _____

Pneumonia at age _____

Ear Infections

Allergies: ______

Significant Injuries: __________

Chronic Health Problems: _______

List age(s) and any other details such as allergies, significant injuries and health problems in the field below.

List age(s) and any other details such as allergies, significant injuries and health problems

Delayed Developmental Milestones (not occurring at expected age):

Sitting

Rolling Over

Standing

Walking

Controlling Bladder

Riding Bicycle

Dressing Self

Engaging Peers

Controlling Bowels

Riding Tricycle

Feeding Self

Tolerating Separating

Playing Cooperatively

Sleeping Alone

Speaking Words

Speaking Sentences

Other

List Other Delayed Developmental Milestones (not occurring at expected age):

Emotional/Behavior Problems:

None

Drug Use

Alcohol Abuse

Chronic Lying

Stealing

Violent Temper

Fire-Setting

Hyperactive

Animal Cruelty

Assaults Others

Disobedient

Repeat Other’s Words

Not Trustworthy

Hostile/Angry Mood

Indecisive

Immature

Bizarre Behavior

Self-injurious Threats

Frequently Tearful

Lack of Attachment

Extreme Worrier

Impulsive

Poor Concentration

Breaks Things in Anger

Distrustful

Self-injurious Acts

Easily Distracted

Often Sad

Frequent Daydreams

Other

List Other Emotional/Behavior Problems:

Social Interaction:

Normal Social Interaction

Isolates Self

Very Shy

Associates w/Acting-Out Peers

Inappropriate Sex Play

Dominates Others

Alienates Self

Other

List Other Social Interaction:

Intellectual/Academic Functioning:

Normal Intelligence

High Intelligence

Learning Problems

Authority Conflicts

Attention Problems

Underachieving

Mild Retardation

Moderate Retardation

Severe Retardation

Current or Highest Education Level

Describe any other development problems or issues:

Socio-Economic History

Living Adequate:

Housing Adequate

Homeless

Housing Overcrowded

Dependent on Others for Housing

Housing Dangerous/Deteriorating

Living Companions Dysfunctional

Military:

Never in Military

Served in Military – no incident

Service in Military – with incident

Military - Provide details:

Social Support System:

Supportive Network

Few Friends

Substance-use-based Friends

No Friends

Distant from Family of Origin

Employment:

Employed and Satisfied

Employed but Dissatisfied

Unemployed

Coworker Conflicts

Supervisor Conflicts

Unstable Work History

Disabled_______

Specify Disability:

Legal History:

No Legal Problems

Now on Parole/Probation

Arrest(s) Not Substance-related

Court Ordered this Treatment

Jail/Prison for ______ total time

List Jail / Prison Total Time:

Describe last legal difficulty:

Sexual History: Age First Sex Experience:

Age First Pregnancy/Fatherhood:

History of Promiscuity Age_____ - ____

History of Unsafe Sex Age _____ - ____

Additional Information: ____________

Cultural/Spiritual/Recreational History:

Cultural Identity (e.g. ethnicity, religion)

Describe any cultural issues that contribute to current problem and/or should be taken into account during treatment planning:

Cultural/Spiritual/Recreational Activity:

Currently Active in Community / Recreational Activities

Formerly Active in Community / Recreational Activities

Currently Engaged in Hobbies

Currently Participate in Spiritual Activities

Additional information Relating to Cultural/Spiritual/Recreational History:

Sources of Data

Sources fo Data

Patient self-report for all

A variety of sources (check appropriate sources below)

For Presenting Problems/Symptoms - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

For Family History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

For Developmental History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

For Emotional/Psychiatric History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

For Medical/Substance Use History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

For Socioeconomic History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other

Forms

Client Forms

Child Intake Form

Personal Data

Demographics:

Insurance:

Presenting Problem:

Family History:

Present in Childhood:

Describe Parent 1:

Describe Parent 2:

General Healtlh

Irregular Health Habits

Daily Routine:

Medical History

Psychiatric History:

Family History:

Individual History:

Substance Use:

Academic History

Socio-Economic History

Electronic Communication Policy

Electronic Communication Policy

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

Email Communications

Social Media

Fanning/Following

Websites

Web Searches

HIPPA

NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

Informed Consent

Informed Consent to Treatment

Financial Responsibility

CFC Financial Responsibility

Payment Authorization

CANCELLATION POLICY

Collateral Agreement

CFC Collateral Agreement

Authorization to Release Information

CFC Authorization to Release Information

Consent for Telehealth Services

Informed Consent to Telehealth

Consent In-Home Psychotherapy

Informed Consent to In-Home Psychotherapy Services

Adult Intake

Client Personal Data

Demographics:

Insurance

General Notes

Emotional / Psychiatric