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151 Kalmus Drive, Building B, Suite 150, Costa Mesa, CA 92626
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Please select your therapist
*
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
Demographics:
Child/Youth Name:
*
First
Last
Gender:
Race:
Home Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
SS#:
Date of Birth:
MM slash DD slash YYYY
Referred By:
Phone #:
Email:
Primary Care Physician:
Psychiatrist/Other:
Parent 1 Name
First
Last
Parent 1 Phone #:
Parent 1 Email:
Parent 1 Home Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Parent 1 Employer:
Parent 2 Name:
First
Last
Parent 2 Phone #:
Parent 2 Email:
Parent 2 Home Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Parent 2 Employer:
Insurance:
Insurance Carrier:
Policy #:
Group #:
Carrier Phone #:
Insured's Name
First
Last
Insured's Date of Birth:
MM slash DD slash YYYY
Presenting Problem:
Reason for seeking evaluation at this time:
Behavioral/Emotional Problems:
None
Drug Use
Alcohol Abuse
Chronic Lying
Stealing
Violent Temper
Fire-Setting
Hyperactive
Animal Cruelty
Assaults Others
Disobedient/Oppositional
Repeats Others' Words
Not Trustworthy
Hostile/Angry Mood
Indecisive
Immature
Bizzare Behavior
Self-Injurious Threats
Frequently Tearful
Lack of Attachment
Extreme Worrier
Impulsive
Poor Concentration
Breaks Things in Anger
Distrustful
Self-Injurious Acts
Easily Distracted
Often Sad
Frequent Daydreams
Social Interaction:
Normal Social Interaction
Isolates Self
Very Shy
Associates w/Acting-Out Peers
Inappropriate Sex Play
Dominates Others
Alienates Self
Intellectual/Academic Functioning:
Normal Intelligence
High Intelligence
Learning Problems
Authority Conflicts
Attention Problems
Underachieving
Mild Intellectual Deficit
Moderate Intellectual Deficit
Severe Intellectual Deficit
What other behaviors does the Child currently do too often, too much, or at the wrong times that gets him/her in trouble?:
What behavior does the Child fail to do as often, as much as, or when you would like?:
What behavior does the Child do that you or others like?:
What other concerns do you or others have about the Child?:
From the preceding list of the Child’s behavior concerns, what problem behaviors do you want to see changed first?:
Family History:
Present in Childhood:
Parent 1
All
Part
None
Parent 2
All
Part
None
Stepmother
All
Part
None
Stepfather
All
Part
None
Brother(s)
All
Part
None
Sister(s)
All
Part
None
Other(s)
All
Part
None
Describe Parent 1:
Full Name:
First
Last
Occupation:
Education:
Health:
Describe Parent 2:
Full Name:
First
Last
Occupation:
Education:
Health:
Parents' current marital status:
Married to each other
Separated (note years below)
Divorced (note years below)
Mother remarried (note times below)
Father remarried (note times below)
Mother involved with someone
Father involved with someone
Mother deceased (note year and age below)
Father deceased (note year and age below)
Describe Childhood family experience:
Outstanding home environment
Normal home environment
Chaotic home environment
Any Special Circumstances in Childhood:
Witnessed Abuse:
Physical
Verbal
Sexual abuse
Experienced Abuse:
Physical
Verbal
Sexual abuse
Is Child Adopted?
Yes
No
At what age?:
Child's legal guardian(s):
Who does the Child currently live with?:
List all persons currently living in household:
First
Last
Age
Sex
Relationship
Person 2:
First
Last
Age
Sex
Relationship
Person 3:
First
Last
Age
Sex
Relationship
List Biological/Adopted siblings NOT living in household:
First
Last
Age
Sex
Relationship
Person 2:
First
Last
Age
Sex
Relationship
Person 3:
First
Last
Age
Sex
Relationship
Frequency of Visitation of Above
Describe any past or current significant conflicts within family relationships:
General Healtlh
Describe current physical health:
Good
Fair
Poor
Irregular Health Habits
Eating Concerns:
Exercise Patterns:
Sleep Patterns:
Sleep Patterns:
Hygiene Habits:
Daily Routine:
Wake-up time:
Breakfast time:
Lunch time:
Dinner time:
Bed time:
Activities between breakfast and lunch:
Activities between lunch and dinner:
Activities between dinner and bedtime:
Medical History
Problems During Mother's Pregnancy:
None
High Blood Pressure
Kidney Infection
German Measles
Emotional Stress
Bleeding
Alcohol Use
Drug Use
Cigarette Use
Other (please note below)
Birth
Normal Delivery
Difficult Delivery
Cesarean Delivery
Complications (note below)
Birth Weight:
Infancy Problems:
None
Feeding Problems
Sleep Problems
Toilet Training Problems
Childhood Health:
Chickenpox
German Measles
Red Measles
Whooping Cough
Autism
Asthma
Lead Poisoning
Mumps
Diptheria
Scarlet Fever
Mental Retardation
Tuberculosis
Poliomyelitis
Rheumatic Fever
Pneumonia
Ear Infections
Allergies
Head Trauma
Loss of Consciousness
Seizures
Dizziness
Headaches
Please note ages for any checked items above:
Developmental Delays (if any):
Sitting
Rolling Over
Standing
Walking
Controlling Bladder
Riding Bicycle
Dressing Self
Engaging Peers
Controlling Bowels
Riding Tricycle
Feeding Self
Tolerating Separating
Playing Cooperatively
Sleeping Alone
Speaking Words
Speaking Sentences
Please note ages for any checked items above:
Child as Infant (yes or no):
Affectionate
Appropriate eye contact
Appropriate gestures
Appropriate interest in objects or others
Pointing to items of interest
Smiling
Other nonverbal behaviors (explain below)
Any past or current concerns about the Child’s language, fine or gross motor development?
Describe Child as an Infant:
Other Details of Medical health Conditions:
List Any Non-Psychiatric Medications Currently Being Taken (Name, Dosage, Reason):
List Any Known Medication Allergies:
History of any of the following in the family:
Tuberculosis
Birth Defects
Emotional Problems
Drug Abuse
Diabetes
Behavior Problems
Thyroid Problems
Cancer
Mental Retardation
Stroke
Heart Disease
High Blood Pressure
Alcoholism
Alzheimer's Disease
Dementia
Other Chronic or Serious Health Problems in Family Members:
Indicate any serious hospitalizations or accidents:
Psychiatric History:
Family History:
Describe any history of family psychiatric hospitalization(s), psychiatric diagnoses, learning disorders, special education, or intellectual giftedness. (Please indicate relation to child.):
Individual History:
List any history of psychological COUNSELING received by Child (include provider name, contact phone, date of treatment, purpose, and outcome):
List any history of psychological TESTING administered to the Child (inlcude evaluator name, contact phone, date of testing, purpose, and results/diagnosis):
Substance Use:
CURRENT Family Alcohol/Drug Abuse:
No History of Abuse
Father
Mother
Siblings
Grandparent(s)
Step-Parent/Live-in
Uncles/Aunts
PRIOR Family Alcohol/Drug Abuse:
No History of Abuse
Father
Mother
Siblings
Grandparent(s)
Step-Parent/Live-in
Uncles/Aunts
Child - Substances Used:
Alcohol
Amphetamines/Speed
Barbituates/Downers
Caffeine
Cocaine
Crack Cocaine
Hallucinogens
Inhalants (e.g. glue, gas)
Marijuana or Hashish
Opioids
PCP
Prescription
Other
Please note first use age, last use age, current use (yes or no), frequency, and amount for any items checked above:
Academic History
Previous School Attended, Location, District, Grade, and GPA:
CURRENT School Attending, Location, District, Grade, and GPA:
Public or Private school:
Public
Private
Favorite Subject:
Least Favorite Subject:
Teacher's Name:
Phone:
Email:
What does the Teacher say about Child?
IEP History, if any:
Describe any repeated grade level, learning disability, speech therapy, or special education services:
Describe any placement history in giftedness or advanced placement classes:
Has the Child experienced any of the following problems at school?
Fighting
Suspension
Gang Influence
Lack of Friends
Incomplete Homework
Drug/Alcohol
Poor Attendance
Behavior Problems
Detention
Poor Grades
Socio-Economic History
Living Adequate:
Housing Adequate
Homeless
Housing Overcrowded
Housing Dangerous/Deteriorating
Living Companions Dysfunctional
Social Support System:
Supportive Network
Few Friends
Best Friend
Boyfriend/Girlfriend
Substance-use-based Friends
No Friends
Only Older Friends
Only Younger Friends
Social Networks Friends
Distant from Family
Legal History:
No Legal Problems
Now on Parole/Probation
Arrest(s) Not Substance-related
Court Ordered this Treatment
Jail/Prison (note total time below)
Describe last legal difficulty (below)
Sexual History
Heterosexual Orientation
Homosexual Orientation
Bisexual Orientation
Currently Sexually Active
Employment:
Employed and Satisfied
Employed but Dissatisfied
Not Employed
Describe any present/past involvements in Sports, Church, Social Groups, Dancing, etc.:
Describe any recent changes in these involvements:
How does the Child spend their solitary time (reading, hobbies, video games, etc.)?
Does Child have a driver's license?
Yes
No
Concerns about Child's social functioning?
PSY #29698 drhayley@thechildandfamilyconnection.com 949.236.6155 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
LMFT#103286 claire@thechildandfamilyconnection.com 949.393.1950 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
PSY#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
Email
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CFC Collateral Agreement
Please select your therapist
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
Introduction
I want to thank you for accepting the invitation to assist in psychotherapeutic treatment as it pertains to:
Patient Name:
First
Last
Who Is A Collateral Participant?
A collateral participant is usually a spouse, parent, family member, or friend who participates in therapy to assist the identified patient. The collateral participant is not considered to be a patient and is not the subject of therapeutic treatment. Psychologists have legal and ethical responsibilities to their patients and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. You also have less privacy protection.
Who Is A Collateral Participant?
A collateral participant is usually a spouse, parent, family member, or friend who participates in therapy to assist the identified patient. The collateral participant is not considered to be a patient and is not the subject of therapeutic treatment. Therapists have legal and ethical responsibilities to their patients and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. You also have less privacy protection.
The Role of Collaterals In Therapy
The role of a collateral participant can greatly vary. For example, a collateral participant might attend only one session, either alone or with the patient, to provide information to the therapist and never attend another session. In another case a collateral participant might attend all of the patient’s therapy sessions and his/her relationship with the patient may be a focus of the treatment. We will discuss your specific role in the treatment at our first meeting and at other appropriate times.
Benefits and Risks
Psychotherapy often engenders intense emotional experiences and your participation may engender strong anxiety or emotional distress. It may also expose or create tension in your relationship with the patient. While your participation can result in a better understanding of the patient or an improved relationship, or may even help in your own growth and development, there is no guarantee that this will be the case. Psychotherapy is a positive experience for many, but it may not be helpful for everyone.
Medical Records
No record or chart will be maintained on you in your role as a collateral. Notes about you may be entered into the identified patient’s chart. The patient has the right to access the chart and the material contained therein. It is sometimes possible to maintain the privacy of our communications. If that is your wish, we should discuss it before any information is communicated. As a collateral, you have no right to access that chart without the written consent of the identified patient. You will not carry a diagnosis, and there is no individualized treatment plan for you.
Fees
As a collateral you are not responsible for paying for my professional services unless you are financially responsible for the patient.
Confidentiality
The confidentiality of information in the patient’s chart, including the information that you provide, is protected by both federal and state laws. It can only be released if the identified patient specifically authorizes me to do so. There are some exceptions to this general rule:
If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency.
If I believe that you are a danger to yourself (suicidal) I will take actions to protect your life even if I must reveal your identity to do so.
If you threaten serious bodily harm to another I will take necessary actions to protect that person even if I must reveal your identity to do so.
If you, or the patient, is involved in a lawsuit, and a court requires that I submit information or testify, I must comply.
You are expected to maintain the confidentiality of the identified patient (your spouse, friend, or child) in your role as a collateral.
Do Collaterals Ever Become A Formal Patient?
Collaterals may discuss their own problems in therapy, especially problems that interact with issues of the identified patient. The therapist may recommend formal therapy for a collateral. These are some examples of when this might occur.
It becomes evident that a collateral is in need of mental health services. In this circumstance the collateral needs to have their own clinician, diagnosis, and medical chart.
Parents, who are seen as collaterals for their child in therapy, may need couples therapy to improve their relationship so they can function effectively as caregivers.
Most often, but not always, I will refer you to another clinician for treatment in these situations. There are two reasons the referral may be necessary:
Seeing two members of the same family, or close friends, may result in a dual role, and potentially cloud judgement. Making a referral helps prevent this from happening.
My primary obligation is to keep a focus on the original treatment plan for the identified patient. For example, if I started treating a child’s behavioral problem, then begin couples therapy with the child’s parents to address their relationship problems, the original focus of therapy with the child may be lost. A referral helps the clinician to stay focused.
One exception to these guidelines is when a family therapy approach can be effectively and ethically used to treat all members of the family.
Release of Information
The identified patient is not required to sign an authorization to release information (Authorization Form) to the collateral when a collateral participates in therapy. The presence of the collateral with the consent of the patient is adequate. This provides some assurance that full consent has been given to the clinician for the patient’s confidential information to be discussed with the collateral in therapy. The Authorization Form is also helpful to the clinician on those occasions when receiving a telephone call from a collateral or when the clinician calls a collateral for one reason or another. In most instances the clinician cannot take a call from a collateral without an Authorization Form.
Parents as Collaterals
Clinicians specializing in the treatment of children have long recognized the need to treat children in the context of their family. Participation of parents, siblings, and sometimes extended family members, is common and often recommended. Parents in particular have more rights and responsibilities in their role as a collateral than in other treatment situations where the identified patient is not a minor.
In treatment involving children and their parents, access to information is an important and sometimes contentious topic. Particularly for older children, trust and privacy are crucial to treatment success. Parents also need to be aware of certain information regarding their child's treatment. For this reason, we need to discuss and agree about what information will be shared and what information will remain private. I generally require a written contract signed by both you and your child/children concerning access to a child’s record and once that contract is made, I will treat it as legally binding, although it sometimes may be overridden by a judge. In general, I believe that parents should be informed about the goals of treatment and how the treatment is going and whether the child comes to his/her appointments. At the end of treatment, I prepare a summary for the parents. In addition, I will always inform you if I think that your child is in danger or if he/she is endangering others. One of our first tasks is to discuss and agree on our shared definition of dangerousness so we are all clear about what will be disclosed.
If you are participating in therapy with your child, you should expect the clinician to request that you examine your own attitudes and behaviors to determine if you can make positive changes that will be of benefit to your child.
Summary
If you have questions about therapy, my procedures, or your role in this process, please discuss them with me. Remember that the best way to assure quality and ethical treatment is to keep communication open and direct with your clinician. By signing below you indicate that you have read, understood and are in agreement with this document.
Signature
Date
MM slash DD slash YYYY
PSY #29698 drhayley@thechildandfamilyconnection.com 949.236.6155 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
LMFT#103286 claire@thechildandfamilyconnection.com 949.393.1950 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
PSY#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
Phone
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Electronic Communication Policy
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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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CFC Financial Responsibility
Please select your therapist
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
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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.
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Argentina
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Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
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Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Card Number:
Expiration Date (mm/yy)
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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
Email
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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
Email
This field is for validation purposes and should be left unchanged.
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Informed Consent to In-Home Psychotherapy Services
Please select your therapist
*
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
In-Home psychotherapy services allow The Child and Family Connection to diagnose, consult, treat and educate in an agreed upon location by the service provider and consumer. I hereby consent to participating in In-Home therapy psychotherapy with the clinician listed below:
Patient Name:
I understand I have the following rights under this agreement: I have a right to confidentiality with In-Home psychotherapy under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the In-Home interaction to any other entities shall not occur without my written consent. I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all patients will be effective. Thus, I understand that while I may benefit from In-Home psychotherapy results cannot be guaranteed or assured. I further understand that there are risks unique and specific to In-Home psychotherapy, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted if accessed by unauthorized persons. In addition, I understand that In-Home psychotherapy treatment is different from a traditional office setting and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services. I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction. I understand that I can withdraw my consent to In-Home communications by providing written notification to The Child and Family Connection. My signature below indicates that I have read this Agreement and agree to its terms and conditions.
Patient Signature
Date
MM slash DD slash YYYY
Authorized Signature for Patient
Date
MM slash DD slash YYYY
PSY #29698 drhayley@thechildandfamilyconnection.com 949.236.6155 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
LMFT#103286 claire@thechildandfamilyconnection.com 949.393.1950 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
LMFT #108189 ariel@thechildandfamilyconnection.com 949.221.4315 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
PSY#33647 drbrooke@thechildandfamilyconnection.com 949.356.6620 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
AMFT#126753 madeline@thechildandfamilyconnection.com 949.694.8139 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
×
Informed Consent to Telehealth
Please select your therapist
*
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
Telehealth allows The Child and Family Connection to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. I hereby consent to participating in psychotherapy via telephone or the internet (hereinafter referred to as Telehealth) with the clinician listed below:
Patient Name:
I understand I have the following rights under this agreement:I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or to others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent. I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all patients will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or accessed by unauthorized persons. In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services. I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction. I understand that I can withdraw my consent to Telehealth communications by providing written notification to The Child and Family Connection. My signature below indicates that I have read this Agreement and agree to its terms and conditions.
Patient Signature:
Date
MM slash DD slash YYYY
Authorized Signature for Patient:
Date
MM slash DD slash YYYY
PSY #29698 drhayley@thechildandfamilyconnection.com 949.236.6155 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
LMFT#103286 claire@thechildandfamilyconnection.com 949.393.1950 151 Kalmus Drive, Building B, Suite 150 Costa Mesa, CA 92626 www.thechildandfamilyconnection.com
PSY#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 to Treatment
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 #PSY29689 ARRIVAL AT COASTAL KIDS: When you arrive for your appointment, please wait in the waiting area. There is a receptionist for MEDICAL visits, not for my scheduled appointments. 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.
Initial(s):
PROFESSIONAL FEES: Initial consultations are 60-minutes in duration and are billed at the rate of $200.00 per hour. Psychotherapy is scheduled as a 45-minute clinical hour for face-to-face or phone sessions 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.
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.
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. Dr. Pedersen will use clinical discretion as to what is appropriate to disclose. Note to minors, if you are less than eighteen years of age please be aware that the law may provide your parents the right to examine your treatment records. If they agree to give up access to your records, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or another person. In this case, I will notify them of my concern. I may also offer a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. Parents are expected to bring their child to treatment personally (unless arranged in advance with The Child and Family Connection) and must stay in the waiting room or immediate area during the session. This enables parents to participate in treatment or help their child if necessary. Parents are also expected to be on hand to take a child to the restroom during sessions as needed. I understand that I am responsible for bringing my child to each session and remaining on site and available during the therapy hour. I agree to give up access to my child’s record and receive general information about treatment, unless there is an emergency, in which case I will be notified.
Initial(s):
Child/Adolescent Patient: By signing below, you show that you have read and understood the policies described above. If you have any questions as we progress with therapy, you can ask me at any time.
Minor's Signature:
Date:
MM slash DD slash YYYY
Parent/Guardian of Minor Patient: Please initial after each line and sign below, indicating your agreement to respect your child’s privacy: I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.
Initial(s):
Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.
Initial(s):
I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.
Initial(s):
Parent/Guardian Signature:
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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 1401 Avocado Avenue, Suite 709 Newport Beach, CA 92660 www.thechildandfamilyconnection.com
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CFC Authorization to Release Information
Please select your therapist
*
Dr. Hayley Pedersen
Claire Sfregola
Dr. Courtney Knapp
Dr. Brooke Herd
Bee-Yu (Ariel) Yung
Madeline Trujillo
I, the undersigned, give permission to The Child and Family Connection, to release and provide the following information (check all that apply):
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my attendance in therapy
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information relevant to coordinating care
when treatment is terminated and why
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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 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.
Initial(s):
PROFESSIONAL RECORDS: You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. When our work concludes, or it has been at least 30 days since our last contact, your file will be closed. You may request amendments to your record, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see my Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records. Except in specific circumstances, you are entitled to examine your or your child’s clinical record and/or receive a copy at a rate of ¢25 per page. If you wish to see you or your child’s records, you must request to do so in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In the event that you do review the full records I recommend that they are reviewed in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. You may request that any complaints you have about my privacy policies and procedures be recorded in your records. I understand my rights pertaining to my clinical records, and that my file will be closed at the conclusion of our work together or 30 days after our last contact.
Initial(s)
CONFIDENTIALITY AND LIMITS THEREOF: Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health-care professional must make reasonable attempts to protect the client and may or may not notify legal authorities and/or the family of the client.
Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your case. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you or your child may have at our next meeting. I will be happy to discuss these issues with you or your child if you need specific advice, but formal legal advice may be needed as the laws governing confidentiality are quite complex, and I am not an attorney. Please see my Notice of Privacy Practices for more detailed information regarding confidentiality. You or your child are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you or your child electronically (for example, faxing information), it will be done with special safeguards to insure confidentiality. I understand that my or my child’s mental health information will be kept confidential unless my psychologist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.
Abuse of Children and Vulnerable Adults (Dependent Adults and Elderly)
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your case. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you or your child may have at our next meeting. I will be happy to discuss these issues with you or your child if you need specific advice, but formal legal advice may be needed as the laws governing confidentiality are quite complex, and I am not an attorney. Please see my Notice of Privacy Practices for more detailed information regarding confidentiality. You or your child are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you or your child electronically (for example, faxing information), it will be done with special safeguards to insure confidentiality. I understand that my or my child’s mental health information will be kept confidential unless my therapist believes that I, or my child, may harm myself, or his/her self, or someone else, if I disclose that a child, elderly person, or disabled person is being mistreated, if a judge orders it, or If disclosure is otherwise specifically required by federal, state, or local laws.
Initial(s):
COUPLES: This is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. I will remind you of this policy before beginning such individual sessions.
MINORS: In regard to information disclosed by minors in session, it is important that they are able to trust the therapy process completely. Therefore, it is my policy to request an agreement from parents that they give up access to their child’s records. Thus, such information will be kept confidential in the same way that confidentiality is maintained for an adult (please see the “Confidentiality” section above for details). As the parent or guardian, you have the right and responsibility to question and understand the nature of treatment and progress with your child. Therapist will use clinical discretion as to what is appropriate to disclose. Note to minors, if you are less than eighteen years of age please be aware that the law may provide your parents the right to examine your treatment records. If they agree to give up access to your records, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or another person. In this case, I will notify them of my concern. I may also offer a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. Parents are expected to bring their child to treatment personally (unless arranged in advance with The Child and Family Connection) and must stay in the waiting room or immediate area during the session. This enables parents to participate in treatment or help their child if necessary. Parents are also expected to be on hand to take a child to the restroom during sessions as needed. I understand that I am responsible for bringing my child to each session and remaining on site and available during the therapy hour. I agree to give up access to my child’s record and receive general information about treatment, unless there is an emergency, in which case I will be notified.
Initial(s):
Child/Adolescent Patient: By signing below, you show that you have read and understood the policies described above. If you have any questions as we progress with therapy, you can ask me at any time.
Minor's Signature:
Date:
MM slash DD slash YYYY
Parent/Guardian of Minor Patient: Please initial after each line and sign below, indicating your agreement to respect your child’s privacy: I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed.
Initial(s):
Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.
Initial(s):
I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.
Initial(s):
Parent/Guardian Signature:
Date:
MM slash DD slash YYYY
Parent/Guardian Signature:
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MM slash DD slash YYYY
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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
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