Consent for Evaluation and Treatment

Please take your time to read and review the information included below. It is important that you completely understand all the points to avoid any misunderstandings about the practice policies. Please ask questions if you are not sure about any portion of this form, information on the website, or specifics about any of the services. You have the right to ask questions and understand all the information on this form and website before starting any service.

Any information that you disclose will be maintained in the strictest confidence, unless you specifically authorize its release, or unless its release is required by law or professional standards of practice. In particular, your right to confidentiality may not be maintained if you are in immediate danger to yourself or to someone else, which may warrant steps to assure your own and/or another’s safety. Any clinician hearing about domestic violence from a client or that a child or elder is being or has been physically or psychologically abused is required, by law, to report this information to a designated agency. If it is deemed necessary to disclose information, information that you have provided in the course of treatment, to anyone else, this will be discussed with you.

All outpatient visits must be paid for prior to the start of the appointment. At the end of the month, you will be provided with an insurance statement to submit to your insurance company. I cannot accept responsibility for negotiating claims with insurance companies or other persons. You are responsible for payment of your care regardless of the status of your claim. Any other financial arrangement must be made prior to service.

Appointments can be rescheduled or cancelled with advanced notice of a minimum of one business day (24 hours). Cancellations for Monday’s appointments need to be left on voice mail by the preceding Friday, before 1:00 pm. However, if you do not give a one business day notice, you agree to be charged $40.00. Please call 805-284-1783 to cancel with proper notice.

Telephone Crisis Intervention/Counseling: $25.00 for every 15 minutes; Will be billed to your credit card.

If payment is not received 60 days after an appointment, your account may be sent to a collection service. By signing this form, you further agree to cover all court costs and legal expenses associated with resolving any unpaid charges. Under circumstances where a party other than the client is responsible for payment, that party must sign a separate agreement guaranteeing payment of the bill as well as payment for any legal expenses associated with collecting for any unpaid charges.

If you are not able to pay and still require services, you will be offered assistance to help you connect with affordable community resources. For returned checks, you agree to be billed for the total amount due plus the total bank penalty.

I have read and understood the foregoing, information on the web site, and I consent to this evaluation or treatment.

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