This document outlines my practice policies that are applicable to all clients, regardless of the type of therapy (service) you will be receiving. Please review this entire document before you electronically sign. If you have questions, please ask them prior to signing below.
General Information: The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. If you are unclear about anything contained in this document, please ask questions before you sign.
Description of Coparenting Counseling: Coparenting counseling is a therapeutic intervention where both parents work with a therapist to make decisions for their child(ren), learn how to protect their child from the conflict, and work towards a more productive way to move through conflict. For co-parenting counseling to be effective, it is important that both parents are willing to listen to the other parent’s concerns, can communicate their concerns/needs in a non-aggressive manner, are willing to compromise and negotiate, and stick to the agreements made in therapy. It is my expectation that any/all agreements made in co-parenting counseling will be written and signed by both parents. Sessions are highly structured to include agenda setting, problem-solving, and moving to written agreements. The course of coparenting counseling (frequency and duration) varies from family to family but can be discussed at your appointment.
Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are privileged and confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. due to the nature of the sessions, both parties will need to release the records.
When Disclosure Is Required by Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled.
When Disclosure May be Required: Disclosure may be required pursuant to a legal proceeding. Your therapist will use their clinical judgment when revealing such information. The therapist will not release records to any outside party unless authorized to do so by all apprpriate members who were part of the treatment.
Definition of Client: In coparenting counseling, the “client” is the coparenting unit. Meaning, both parents are the client.
Risks & Benefits: Participating in coparenting counseling can have tremendous benefits, including moving away from litigation/court involvement thereby saving costs, maintaining control and decision-making power regarding how to raise your children, and avoiding psychological damage and stress. Learning how to productively move through conflict can help your children better cope with your separation and can promote better mental health outcomes for all of those involved. There can be risks associated with coparenting counseling, including that you may be exposed to triggers that could cause flooding or other trauma symptoms. If therapy is court ordered, one or both parents may develop resentments due to the time and cost associated with participating in therapy, and this could have a negative impact on the process. Additionally, the therapist may assess that your behavior is interfering with the coparenting process, you may not be able to come to resolutions you are hoping for, it may be psychologically triggering to be in the same room (or virtual call) with your ex-partner, and in rare cases, conflict could get worse or changes could be made to custody/visitation based on observations/reports by the therapist or therapeutic process.
Not a Decision-Maker: The role of the therapist is to support the parents in coming to their own agreements and identifying dynamics that get in the way of this. The therapist may introduce IDEAS to help with negotiation or getting out of entrenched conflict. However, the therapist will NEVER make a recommendation about custody, visitation, or contact changes between a child and anyone in their life. The therapist also does not cast a “tie breaking vote” on coparenting issues.
No-Secrets Policy: After your intake, there are to be no secrets or information shared with the therapist without involving your co-parent. The only exceptions are: 1) if the therapist decides that both parents need additional 1-on-1 session with the therapist, and 2) if on co-parent requests a phone call or session to discuss how to best communicate their needs/requests/concerns to the other parent.
Collaboration & Releasing Information: Collaboration and releasing information requires a signed release by both participants of coparenting counseling. Best practices suggest that the outcomes of coparenting counseling improve when there is collaboration between the coparenting therapist and other professionals. The benefits of collaboration include that there can be an improvement of overall family system functioning, agreements can be provided to attorneys and in many cases, Court can be avoided, there can be input about realistic expectations to support the formation of agreements when it seems like there is an impasse (no agreement), and there can be accountability and outside support for when the process gets hard. There are also risks associated with collaboration, to include that clients may feel betrayed by the therapist, clients may feel the therapist is biased, and in rare cases, information shared may be used in Court and this could result in a change to the custodial schedule. Information typically shared includes, but is not limited to: identifying treatment goals, identifying progress on treatment goals, identifying barriers to achieving treatment goals, assessment, prognosis, and safety concerns. The therapist will never give an opinion or make a recommendation as to what should happen with custody or visitation.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matter which may be of a confidential nature, you agree that should there be legal proceedings, neither you nor your attorney(s), nor anyone else acting on your behalf, will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Termination: The therapist holds the right to terminate coparenting counseling if it is not effective, or worse, becoming an environment for ongoing abusive behavior (ex: verbal abuse or coercive/controlling behaviors). If the therapist terminates therapy, the therapist will email both parents explaining why therapy is being terminated, along with referrals to additional resources to support your family. Either parent may terminate therapy at any time, although it is requested that this is a thoughtful process, and the therapist will provide suggestions if either parent would like therapy to end. If one parent wants to terminate therapy, but the other therapist wants to continue, the coparenting counseling will be terminated.
If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified therapists. You may also choose someone on your own or from another referral source. Should we not have a co-parenting session for eight consecutive weeks, unless other arrangements have been made in advance and for legal and ethical reasons, I must consider our professional relationship discontinued.
Payment for Services: You will be provided with a separate fee agreement outlining your personal responsibility for payment. A credit/debit card is required to schedule an appointment. Treatment will not commence until there is agreement about how all the fees will be paid. It is expected that the fee be paid at the time that services are rendered unless other arrangements have been made. If payment is not received by BOTH responsible parties, no future appointments will be scheduled until the balance is paid. Should one (or both) parents fall behind on payment, the therapist will suspend treatment and send an email to both parents indicating that treatment is suspended due to non-payment.
Insurance Reimbursement: I do not accept insurance payments. I can provide you with an invoice/statement.
Scheduling: Together we will determine the best time and day for all participating. Unless we are terminating therapy, it is expected that we will schedule and confirm the next session at the conclusion of each session. If a session is cancelled or missed, you will be responsible for communicating such cancellation via email to your therapist or firstname.lastname@example.org. Additionally, this means working with your co-parent to ensure they are aware of the need to cancel. Together we will reschedule.
Cancellation/Rescheduling: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 2 business days is required for any rescheduled or cancelled appointment. Should you cancel outside of this policy (meaning cancellation less than 2 business days), I will charge your card on the day the appointment was scheduled. The full fee will be charged to the person who cancels or no-shows to the appointment outside of this policy; example: the full fee of session would be charged to the person who cancels or no-shows, even if they typically only pay half of the fee. If there is a cancellation, need to reschedule, or a no-show, you are responsible communicating this information.
Emails and Longer Documents: I request that emails are limited. If emails include more than scheduling or logistical concerns, I request you schedule an appointment of which you will be responsible for paying the full session fee. If you send me a lengthy email or forward me a lengthy email, please acknowledge in the first line that you are aware of my policy to charge for emails and that you are aware of the fees associated with it.
Beyond court orders, I also charge for reviewing documents, such as custodial evaluations. You will be charged my prorated fee for any time spent reviewing collateral documents and emails.
Collateral Contacts: Participating in therapy when the court is involved often requires that professionals collaborate to best support your family. Please anticipate that this will be a part of the therapeutic process. Phone calls with attorneys, mediators, and other therapists will be charged at my pro-rated fee. This is often necessary for the therapeutic process. This could cause you to incur both attorney fees as well as my fee for the phone call. I will notify you at least 24 hours prior to the call, and I will charge your card my pro-rated fee immediately following the call.
Treatment Plans and Letters/Reports: The development of a written treatment plan to be distributed to families and attorneys is done at the fee of $190. The fee for a written report is $300. The letter/report needs to be requested at least 3 weeks before it is needed, and it will not be released until payment is received. Any letter/report will be provided to all adult clients, or the parent(s) with legal custody, regardless of who pays for the report.
Request for Records: I do not release my records or session notes, but I will provide a treatment summary. The fee for the treatment summary is $300. Any requests for records will be billed at my hourly rate. The person who requests the records or summary will be billed for the entire amount unless other arrangements have been made. Any records or treatment summary will be provided to all adult clients or the parent(s) with legal custody, regardless of who pays.
Phone Calls: If you need to contact me between sessions, please schedule a time. Any calls over 7 minutes will incur fees at my pro-rated rate. I will remind you of this during the call.
Emergency Procedures: If you have a medical or psychological emergency, please call 9-1-1 or go to the nearest hospital. You can schedule a session or phone call with me using the client portal. Otherwise, I am not available for emergency support.
Court Appearances and Depositions: My fee for depositions and court appearances is $300.00 per hour, which includes travel time and waiting time prior to offering testimony. Preparation prior to offering testimony is billed at the rate of $300.00 per hour. Court appearances or depositions are billed at a minimum half-day rate of $1500.00 (which consists of $1200.00 for a half-day of time including the $300.00 for 1 hour of file review prior to testifying). If I am asked to offer expert testimony either at a deposition or in court, I expect that my fee will be paid at least one week before my testimony. I will bill for any additional charges (such as if I am asked to remain for another half-day of testimony) and expect that any outstanding fees will be paid within 7 days. If I am asked to reserve time in my schedule for either a deposition or court appearance, I must receive a cancellation notice at least 72 hours (3 business days) in advance for my reserved time not to be billed to the responsible party. Such a policy is necessary, as I am typically canceling ongoing psychotherapy clients to make myself available. Even if the court appearance is cancelled, you may still be charged for any prep work I do prior to receiving the cancellation notice.
Social Media: Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, LinkedIn, etc.) unless done through a professional social media account. I will never acknowledge our professional relationship on a professional social media account, and please use your own judgment and comfort level if/when interacting with me on a professional social media account. I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up.
Recording Sessions: No part of the sessions are allowed to be recorded by anyone, including audio or visual recording. This also applies to any sessions delivered via telehealth (ex: teams). Recording the session will result in immediate termination.
Electronic Communication: I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. However, many clients in a court involved context request and prefer communication through electronic means (text, email). By signing this form, you are agreeing to the use of electronic communication along with its inherent risks. If you do not agree to electronic communication, you must let me know immediately.
Services by Electronic Means/Telehealth: Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
Telehealth is not the best fit for all clients and families, and I reserve the right to decline the use of telehealth services. Additionally, I also reserve the right to terminate telehealth services if circumstances change and the use of telehealth services no longer becomes the most appropriate form of service delivery.
Confidentiality: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Consultation: Occasionally I may consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or identifying information.
Contact Outside the Office: If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
My practice includes working with children. All information disclosed by a child in a session is confidential unless it falls under the definition of legally mandated reporting described above. My stance is that it is important for parents to be included in the therapeutic process. Therefore periodically I will attain the child’s permission to disclose information pertaining to their progress so that I can update the parents or other caretakers.
Therapist Emergency/Unavailability: There may be a rare event where I am unavailable, become ill, or am otherwise incapacitated. I will make every effort to inform you in advance. If this happens, you will be offered a new appointment time once I am back in the office. If you are having a psychiatric emergency, you should go to the emergency room or call 9-1-1. If you are having a crisis related to your custody case, you may: consult with your attorney, contact the self help center at your local superior court, or contact child protective services or law enforcement (if there is an imminent safety concern).
Complaints and Concerns: It is very possible that at some point in our therapeutic work together, you may be dissatisfied with the services I am providing to you or your family. If this happens, I first request that you let me know your concerns so that we can try work through them and come to a solution that works for both of us. In the event that you feel your rights have been violated, you may contact the California Board of Behavioral Sciences 1625 North Market Blvd., Suite S200, Sacramento, CA 95834, Telephone: (916) 574-7830; www.bbs.ca.gov
Minors: If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Consent for Treatment: By clicking the button below, I acknowledge that I have read this document in its entirety. I have had the opportunity to ask questions about my treatment (and/or the treatment of my child), I understand the limits of confidentiality, and I understand that participation in treatment does not guarantee the outcome that I hope for and that it can at times (although rare) make problems worse. I have read and understand the above policies and the recommended course of treatment. I choose to receive therapeutic services and consent to participation.