Consent for Treatment

Please correct the errors described below.

Dear Client,

The therapy relationship is a professional and confidential relationship. What is revealed in the setting is general protected by professional and ethical standards, to the extent that, with a few important exceptions, all material you disclose is confidential and cannot be released without your written consent. However, there are certain circumstances under which we are legally required to disclose information. We are required to disclose information in the following circumstances:

  • If there is a reasonable belief that child abuse has occurred.
  • If there is a reasonable belief that elder abuse has occurred.
  • if you make a threat to harm a third party.
  • If you post a risk to yourself or others.

You should also be aware that your confidentiality can be waived if you tender your mental condition in civil or criminal litigation. Thus, the decision of whether or not to tender your mental condition as an issue should be one you consult on with your attorney.

  • Patriot Act of 2001: in certain situations, therapists are required to provide the FBI with books or records and are prohibited from disclosing this to the client.

You should realize that in treating you we will endeavor to provide you with the best care possible. We will ask you to provide us with releases to obtain records from prior treating therapists because we are obligated by law to obtain such information. It is important to be sure that our therapy is consistent with what has taken place previously and that important facts leading to your diagnosis and care is not overlooked.

You should realize that we are on occasion required to furnish information to your insurance carrier concerning the conditions which are being treated. By signing this consent, you authorize us to disclose the information the insurance carrier requests.


The therapist reserves the right to terminate therapy at her discretion. Reasons include, but are not limited to:

Untimely payment of fees, failure to comply with treatment recommendations, the client's needs are outside of the therapist's scope of competence.

The client has the right to terminate therapy at their discretion.

Upon either person's decision to terminate therapy, the therapist will generally recommend that the client participate in at least one or more termination sessions. The therapist will also attempt to ensure a smooth transition to another therapist by offering referrals.

All professional services furnished are charged directly to the client. Clients are personally responsible for payment of all professional services.


Minors and Confidentiality

Communications between therapists and clients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child's treatment are often involved in their treatment. Consequently, your therapist, in the exercise of their professional judgement, may discuss the treatment progress of a minor client with the parent or caregiver. Clients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their therapist.


The Board of Behavioral Sciences receives and responds to complaints regarding services provided by individuals licensed and registered by the board. If you have a complaint and are unsure if your practitioner is licensed or registered, please contact Board of Behavioral Sciences at 916-574-7830 for assistance or utilize the board's online license verification feature by visiting www.bbs.ca.gov

I have read the above statements and understand what they say. To the extent that I have any questions, I have asked them of my therapist before signing this consent.

Consent to Treatment Part 2: FOR COUPLES AND FAMILIES ONLY

Please fill this out ONLY if you are being treated as a Couple or Family Only

if requested. This written policy is intended to inform you, the participants in family therapy or couples therapy, that when I agree to work with a couple or family, I consider that couple or family (the treatment unit) to be the client. For instance, if there is a request for the treatment records of the couple or the family, I will seek the authorization of all members of the treatment unit before I release confidential information to third parties. Also, if my records are subpoenaed, I will assert the psychotherapist-client privilege on behalf of the client (the treatment unit).

During the course of my work with a couple or family, I may see a smaller part of the treatment unit (e.g., an individual or two siblings) for one or more sessions. These sessions should be seen by you as a part of the work that I am doing with the family or the couple, unless otherwise indicated. If you are involved in one or more of such sessions with me, please understand that generally these sessions are confidential in the sense that I will not release any confidential information to a third party unless I am required by law to do so or unless I have your written authorization. In fact, since these sessions can and should be considered a part of the family or couples therapy, I would also seek the authorization of the other individuals in the treatment unit before releasing confidential information to a third party.

However, I may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with the entire treatment unit-- that is, the family or the couple-- if I am to effectively serve the unit being treated. I will use my best judgement as to whether, when, and to what extent I will make disclosures to the treatment unit, and will also, if appropriate, first give the individual or smaller part of the treatment unit being seen the opportunity to make the disclosure. Thus if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with an individual therapist who can treat you individually.

This "no secrets" policy is intended to allow me to continue to treat the client (the couple or family unit) by preventing, to the extent possible, a conflict of interest to arise where an individual's interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or family. If I am not free to exercise my clinical judgement regarding the need to bring this information to the family or the couple during their therapy, I might be placed in a situation where I will have to terminate treatment of the couple or the family. This policy is intended to prevent the need for such a termination.

(couple/family unit) being seen, acknowledge by our individual signatures below, that each of us has read this policy, that we understand it, that we have had an opportunity to discuss its contents with the therapist, and that we enter couples/family therapy in agreement with this policy.

Your information will be encrypted.

Loading...