Therapist-Client Agreement


Welcome! This disclosure agreement will answer most of your questions about my practice. Please feel free to ask additional questions to clarify anything during your initial/intake session.

So, what is therapy? And how does it work? Therapy is a collaborative process between myself, the counselor, and you, the client. We will work on solving emotional problems so that you may live a more fulfilling and happier life.

I provide non-emergency psychotherapy services by scheduled appointment. If I believe your psychotherapy issues are above my level of competence, or outside of my scope of practice, I am legally required to refer, terminate, or consult.

Risks and Benefits/Limitations of Service

Therapy is an intensely personal process, which can bring unpleasant memories or emotions to the surface. There are no guarantees that therapy will work for you. The process of change is often difficult and may exacerbate your symptoms initially because of repressed issues and systematic dynamics. Sometimes in psychotherapy, things get worse before they get better. However, over time, most people report seeing an improvement. The most important factor for success in therapy is good communication between you and me. If at any time you feel your needs are not being met, I invite you to express these concerns so that we may work through them. However, not all therapy is effective. If you have been in therapy for several weeks or months, and it does not feel like you are making progress, please let me know. It may be that you would do better with a different approach to therapy, or even with a different therapist. As therapists, we know that we cannot be everything to everybody, and we are comfortable helping you make a change if needed.

Client’s Rights

You are entitled to information from me about my approach to therapy, techniques, and the duration of therapy. You have the right to terminate therapy at any time.

Fee

My fee is $149 per 45 minute session (in-person or online/remote)

Appointments

Appointments are typically scheduled once a week, every week at an agreed upon time.

Payment

All major credit cards and debit cards are accepted forms of payment. Payment must be paid in advance, either by credit or debit card, or services cannot be provided.

Insurance

I accept Inland Empire Health Plan (IEHP)

Cancellation Policy

I require 24-hour notice to cancel or reschedule an appointment. Appointments canceled within less than 24 hours will be charged the full rate for that appointment. Please note that all Monday appointments will require Friday notification. I will make reasonable efforts to reschedule sessions, which are canceled in a timely manner.

Electronic Communication/Social Media

Clients may choose to email, text or utilize social media to contact their therapist. While these modes of communication, while protected with passwords specifically chosen by the therapist, they cannot be guaranteed as confidential forms of communication.

Treatment Planning

Periodically, client and therapist will assess progress toward treatment goals. It can be mutually beneficial if termination is discussed in advance. In the event that 30 days have passed since the last scheduled appointment, it will be assumed that treatment is terminated. A client may choose to re-engage in the therapy process at any time but must contact the therapist to re-establish treatment services.

Confidentiality

By law and professional ethics, our sessions are strictly confidential. Generally, no information will be shared with anyone without your consent and release of information. However, there are a number of exceptions to confidentiality. See below:

  • Consultation with a colleague when I feel this is necessary for guidance regarding any issues that come up in therapy. In the event that I consult with another therapist, no identifying information such as your name would be released.

  • I am required to report any suspected incident of child or elder abuse or neglect to law enforcement.

  • I am required to report any threat of imminent physical harm by a client to law enforcement and to the persons(s) threatened.

  • I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others.

  • I am ordered by the court to testify or release records

  • There is a release of information given by you, the client.

In Case Of An Emergency

If you are experiencing a true emergency situation, please dial 911 or check yourself into the nearest emergency room immediately, if your personal safety or mental health is at stake14

Therapist-Client Agreement *
Client's Signature *
Client's Signature
Today's Date *
Today's Date