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Client Forms

Please complete and submit these five forms immediately.

Electronic Communication Policy

Electronic Communication Policy
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Courtney Knapp
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
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 949-549-1397 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 949-221-4315 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 949-694-8139 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#25271 drcourtney@thechildandfamilyconnection.com 949.549.1397 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
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 949.694.8139 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
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HIPPA

NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
Please select your therapist
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Courtney Knapp
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
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#25271 drcourtney@thechildandfamilyconnection.com 949.549.1397 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
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 949.694.8139 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
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Informed Consent

Informed Consent to Treatment
Please select your therapist*
- Dr. Hayley Pedersen
- Claire Sfregola
- Dr. Courtney Knapp
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
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 #PSY25271
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 $350.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $200.00 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 $350.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $200.00 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) 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) 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) 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) 694-8139 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.
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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.
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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.
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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.
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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.
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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.
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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#25271 drcourtney@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
PSY#33647 drbrooke@thechildandfamilyconnection.com 949.356.6620 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
AMFT#126753 madeline@thechildandfamilyconnection.com 949.694.8139 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. Courtney Knapp
- Dr. Brooke Herd
- Bee-Yu (Ariel) Yung
- Madeline Trujillo
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#25271 drcourtney@thechildandfamilyconnection.com 949.549.1397 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
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 949.694.8139 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
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NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

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Dr. Hayley Pedersen

Claire Sfregola

Dr. Courtney Knapp

Dr. Brooke Herd

Ariel Yung

Madeline Trujillo