Informed Consent to Treatment

Please select your therapist*

Dr. Hayley Pedersen
Claire Sfregola
Dr. Carlee Walsh
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Dr. Jenna Syverson
Anne Xiao

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY29698

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Marriage and Family Therapist, California Board of Behavioral Sciences #LMFT103286

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY31023

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY34343

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Clinical Psychologist, California Board of Psychology #PSY33647

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Licensed Marriage and Family Therapist, California Board of Behavioral Sciences LMFT#108189

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

SERVICE PROVIDER: The Child and Family Connection

REGISTRATION: Associate Marriage and Family Therapist, California Board of Behavioral Sciences #AMFT 142662

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.

Initial(s):

PROFESSIONAL FEES: Initial consultations are 90-minutes in duration and are billed at the rate of $390.00 per session. Psychotherapy is scheduled as a 45-minute session for face-to-face or telehealth at the rate of $235.00 per session. In addition to weekly appointments, I charge a fee for other professional services you or your child may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Sessions lasting over 45-minutes in length for couples, family sessions, or other reasons, may be subject to additional service fees.

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

I understand the fee schedules set forth by The Child and Family Connection.

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

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

I understand the fee schedules set forth by The Child and Family Connection.

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

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

I understand the fee schedules set forth by The Child and Family Connection.

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

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

I understand the fee schedules set forth by The Child and Family Connection.

Initial(s):

BILLING AND PAYMENTS: You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. Fees are collected at each visit for the hours performed that day. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.

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

I understand that I must pay at the time of each visit.

Initial(s):

INSURANCE: Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance company. Upon specific request, I can provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. Please be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If you have questions about the coverage, call your plan administrator.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 236-6155 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 393-1950 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 346-2041 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 356-6620 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 549-1397 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 221-4315 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

CONTACT & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my confidential voice mailbox (949) 385-3389 and your call will be returned as soon as possible. I check my messages a few times a day Monday through Friday, unless away from the office. If an emergency situation arises, please indicate it clearly in your message. However, if you need to talk to someone right away, dial 911 or go to your nearest hospital emergency room.

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

I understand that The Child and Family Connection does not provide emergency services. In an emergency situation, I know to call 911 or go to the nearest hospital emergency room.

Initial(s):

PROFESSIONAL RECORDS: You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. When our work concludes, or it has been at least 30 days since our last contact, your file will be closed. You may request amendments to your record, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see my Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records. Except in specific circumstances, you are entitled to examine your or your child’s clinical record and/or receive a copy at a rate of ¢25 per page. If you wish to see you or your child’s records, you must request to do so in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In the event that you do review the full records I recommend that they are reviewed in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. You may request that any complaints you have about my privacy policies and procedures be recorded in your records.

I understand my rights pertaining to my clinical records, and that my file will be closed at the conclusion of our work together or 30 days after our last contact.

Initial(s)

CONFIDENTIALITY AND LIMITS THEREOF: Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health-care professional must make reasonable attempts to protect the client and may or may not notify legal authorities and/or the family of the client.

Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.

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

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

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

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

I understand that my or my child’s mental health information will be kept confidential unless my psychologist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.

Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.

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

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

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

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

I understand that my or my child’s mental health information will be kept confidential unless my therapist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.

Initial(s):

COUPLES: This is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. I will remind you of this policy before beginning such individual sessions.

MINORS: In regard to information disclosed by minors in session, it is important that they are able to trust the therapy process completely. Therefore, it is my policy to request an agreement from parents that they give up access to their child’s records. Thus, such information will be kept confidential in the same way that confidentiality is maintained for an adult (please see the “Confidentiality” section above for details). As the parent or guardian, you have the right and responsibility to question and understand the nature of treatment and progress with your child. Therapist will use clinical discretion as to what is appropriate to disclose.

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

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

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

Initial(s):

Child/Adolescent Patient:

By signing below, you show that you have read and understood the policies described above. If you have any questions as we progress with therapy, you can ask me at any time.

Minor's Signature:

Date:

Parent/Guardian of Minor Patient:

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

I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.

Initial(s):

Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.

Initial(s):

I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.

Initial(s):

Parent/Guardian Signature:

Date:

Parent/Guardian Signature:

Date:

Mailing Address:

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

Date of Birth:

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.

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drhayley@thechildandfamilyconnection.com
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Costa Mesa, CA 92626
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Costa Mesa, CA 92626
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949.549.1397

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