Informed consent - Disclosure Statement & Agreement for Services Anat Fein, MA LMFT 21760 Stevens Creek Blvd., Suite 202 Cupertino, CA 95014 (408)-310-0800 [email protected]Fees Fees are payable by cash, check or credit/debit card at the time that services are rendered. The fee for service is $ 150.00 for individual/conjoint/couple/family/ therapy session (Approx. 50 min in length) and $200.00 for an extended EMDR session (Approx. 75 min in length). Phone consultations longer than 20 minutes are charged for as a full session. Fees are subject to change. I will notify you of any change no less than 30 days in advance. You are responsible for payment, regardless of your submission of statements to your insurance plan for reimbursement. I do not work directly with insurance companies. Any special financial arrangements agreed upon at the onset of therapy (e.g. monthly payments and sliding scale) are available to clients only as long as they attend therapy on a regular basis. Cancellation Policy Your session time is reserved especially for you. If you need to cancel please do so at least 24 hours in advance, or you will be charged for the missed session. Frequent cancelations will result in loosing your regular timeslot. I reserve the right to terminate our relationship after 3 missed appointments. Sliding scale does not apply to missed sessions that were cancelled less than 24 hours in advance. Contact and Availability You may text me or leave a message on my confidential voicemail (408-310-0800). You may also email me at [email protected] Due to limitations of the Internet I cannot guarantee that information transmitted will remain confidential. In the event of an emergency involving a threat to your safety or the safety of others, call 911 or go to the ER. Confidentiality All communications between us will be held in strict confidence unless you provide written permission to release information about your treatment. In addition, I will not disclose information communicated privately by one family member to any other family member without written permission. However, I utilize a “no-secrets” policy when conducting family or marital/couple’s therapy. This means that I am permitted to use information obtained in an individual session that you may have had with me, when working with other members of your family. There are exceptions to confidentiality: I am required to report suspected child, elder or dependent adult abuse, and may be required or permitted to break confidentiality when a patient presents a serious danger to him/herself or others. A federal law known as The Patriot Act of 2001 requires therapists in certain circumstances, to provide FBI agents with records or documents, and prohibits the therapist from disclosing the contact with the FBI to the patient. California Law, Evidence Code Section 1020 (Breach of Duty) allows therapists to turn unpaid debts, including client’s identity, to collection services. Minors and Confidentiality: Minors (under 18) have the right to confidentiality. It is important for the process of therapy that they be able to trust me. However, parents/guardians who authorize their child’s treatment are often involved in the treatment. I will use my professional judgment when therapy is discussed with parents. I can only break confidentiality when I believe not doing so would put your child in immediate danger. Please note that teen’s use of cannabis and alcohol is usually not considered an immediate danger. However, parents are advised to stay involved in their teen’s daily life and maintain a careful balance between privacy and safety. Frequent substance use interferes with brain development and may interact with prescription medications. About the Therapy Process Therapists and patients are partners in the therapeutic process. Your feedback is always welcome. You have the right to agree or disagree with my recommendations. I will support and facilitate the process of decision- making. However, I cannot make decisions for you. Due to the varying nature and severity of problems of different patients, I am unable to predict the length of your therapy or to guarantee a specific outcome or result. I do not accept litigation-related cases at this time. The information you provide is for therapy purposes only, and should not be affected by an expectation that I would testify on your behalf. If you intend to subpoena your therapy records or use the information given to me during therapy for your legal purposes (e.g., custody evaluations, personal injury claims), I am not the right therapist for you. Termination of Therapy You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referrals, changing your treatment plan, or terminating your therapy. Your signature indicates that you have carefully read and have received a copy of this agreement, and that you understand its contents. Please ask me to address any questions or concerns that you have about this information before you sign.Name of Patient*Relation to patient (if applicable)Signature*Date* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email (optional) This iframe contains the logic required to handle Ajax powered Gravity Forms.