Introduction: This agreement is intended to provide you with important information regarding the practices, policies and procedures of THE FAMILY GUIDANCE AND THERAPY CENTER OF SOUTHERN CALIFORNIA and to clarify the terms of the professional therapeutic relationship between your assignedc clinicians (s)and you/your family. If you are a parent of a minor client, then you will need to consent to their treatment prior to the commencement of services. Any questions or concerns regarding the contents of this Agreement should be discussed prior to signing it. Please read the entire document carefully and ask any questions before signing the document. In the event that you do not understand or do not consent to any aspect of this form, we can set a phone consultation to review this form. All sections must be consented to, as part of the ethical and legal requirements of professional therapy.

Please initial each section to indicate that you have read and understood that particular section.

Practice Information: ​The individual marital and family therapist who operates this practice is Jennifer Palmiotto. Her license number is #47375. This practice is a Licensed Marriage and Family Therapist Corporation: THE FAMILY THERAPY GUIDANCE AND THERAPY CENTER OF SOUTHERN CALIFORNIA. This professional corporation operates under the fictitious business name of THE FAMILY GUIDANCE CENTER OF SOUTHERN CALIFORNIA. The Family Guidance and Therapy Center of Southern California also practices using the DBA of "The Family Guidance and Therapy Center" and "FGTC."

Therapist Background and Qualifications: ​ At your request, your clinician(s) will discuss their professional background information with you and provide you information regarding their experience, training, special interests, and professional orientation. You are free to ask questions at any time about the background, experience and professional orientation.

Professional Services Rendered:​ The Family Guidance Center of Southern California offers several services including mental health counseling, behavioral health services, and professional consultation. 

Process of services:  Therapy will include an initial assessment, treatment planning, and face-to face sessions. Before treatment begins, we will determine who needs to attend sessions. Depending on your individualized treatment plan. All therapy will promote healthier and more satisfying relationships. 

Risks and Benefits of Therapuetic Services ​Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participating in services may result in a number of benefits towards ameloriating the concerns that you have. There is no guarantee that services will yield benefits. Participating in therapuetic services may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. 

Professional Consultation: Professional consultation is an important component of clinical work. We regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, no personally identifying information concerning clients will be used. 

Records and Record Keeping:​ Records will be kept in accordance with the ethical and legal standards of each clinician. Records may be requested at any time in writing. Records will be stored in a locked file cabinet or by an Electronic Health Record system which is software is fully secure, confidential, encrypted, HIPAA-compliant practice management software. Records will be kept for 7 years after you've terminated therapy.

Participation in Litigation: ​Clinicians do not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. FGTC has a policy of not communicating with client's attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in a legal matter unless agreed upon at beginning of the therapeutic relationship. FGTC will not provide records or testimony unless compelled to do so. Should the clinician be ordered by a court of law, to appear as a witness in an action involving a client, client agrees to all fees including travel and prep above at $275/hour for all clinicians. 

Patient Privilege:​ The information disclosed by a client, as well as any records created, is subject is privileged.  It is akin to the attorney-client privilege or the doctor-patient privilege. If a clinician receives a subpoena for records, deposition testimony, or testimony in a court of law, FGTC will assert to assert privilege on client's behalf until instructed, in writing, to do otherwise by client or client's representative. Client should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney.

Notice of Privacy Practices: This practice is HIPAA compliant. Please indicate that you have received and signed the document named "Notice of Privacy Practices." This document further explains how your medical information will be used by this practice.

Confidentiality:​ All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release.

Exceptions to confidentiality: ​There are exceptions to confidentiality. For example, clinicans are required to report instances of suspected child or elder abuse. Clinicians may be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the patient that the FBI sought or obtained the items under the Act.

Minors and Confidentiality: ​Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who consented for their child's treatment are often involved in their treatment. Within professional judgment, clinicans will discuss the treatment progress of a minor patient with the parent or caretaker. Patients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their therapist.

Fee and Fee Arrangements for Services: ​The usual and customary fees are based on the educational and experience of each clinician. Your fees have been set at the start of serviecs.  Sessions longer than your scheduled appointment are charged for the additional time pro rata. FGTC reserves the right to periodically adjust this fee. You will be notified of any fee adjustment in advance. When a clinician engages in email or phone contact with you for purposes other than scheduling sessions, fees will be assessed at the agreed upon rate. In addition, from time-to-time, we may engage in telephone contact with third parties at client's request and with client's advance written authorization.

Client is responsible for payment of the agreed upon fee (on a pro rata basis). Clients are expected to pay for services at the time services are rendered through stored credit card from authorized user. 

Cancellation Policy: You are responsible for payment of the agreed upon fee for any missed session(s). You are also responsible for payment of the agreed upon fee for any session(s) for which you failed to give at least 24 hours notice of cancellation. Cancellation notice should be emailed to cancel@familyguidanceandtherapy.com

Therapist Availability:​ My office is equipped with a confidential voice mail system that allows a client to leave a message at any time. You may contact the office at 619-600-0683. We will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. FGTC is unable to provide 24-hour crisis service. In the event that client is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room. In the event that your clinician is unable to attend our schedule appointment, I will contact you via your preferred method of communication to cancel and re-schedule the session. You will be notified in advance of vacations or planned extended absences. 

Use of Telemedicine​: This practice uses telemedicine as part of treatment. Telemedicine includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Telemedicine also involves the communication of your medical/mental information, both orally and visually, to health care practitioners located in California or outside of California. You have the following rights with respect to telemedicine: (1) you have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of your medical information also apply to telemedicine. As such, the information disclosed by you during the course of you therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where you make your mental or emotional state an issue in a legal proceeding. The dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your written consent. (3) There are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of your psychotherapist, that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your medical information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. In addition, please understand that telemedicine based services and care may not be as complete as face-to-face services. I will advise you if you would be better served by another form of psychotherapeutic services (e.g. face-to-face services). You will be referred to a psychotherapist who can provide such services in your area. Finally, there are potential risks and benefits associated with any form of psychotherapy, and that despite your and my efforts, your condition may not be improve, and in some cases may even get worse. (4) you may benefit from telemedicine, but that results cannot be guaranteed or assured. (5)you have a right to access your medical information and copies of medical records in accordance with California law. You may discuss the use of telemedicine with me at any time.

Termination Of Therapy: ​You may terminate services at any time. FGTC also, reserve the right to terminate therapy at our discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, client needs are outside of my scope of competence or practice, or client is not making adequate progress in therapy. You also have the right to terminate services at your discretion.

Questions or Complaints: Based on the laws and regulations placed by The Board of Behavioral Sciences, we are informing you that if you have any complaints regarding services provided within the scope of practice of: marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors, that are unable to be resolved by contacting The Family Guidance and Therapy Center of Southern California directly, you can contact The Board of Behavioral Sciences online at www.bbs.ca.gov, or by calling (916) 574-7830. 

Acknowledgement: By signing below, client or legal guardian of client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client has discussed such terms and conditions with Jennifer Palmiotto, LMFT and has had any questions with regard to its terms and conditions answered. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy or other services with Therapist. Moreover, client agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

have read this Informed Consent document, I understand it and agree to comply.