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Consent Forms & Practice Documents

CONSENT FORMS & PRACTICE DOCUMENTS

Shoshana Taubman, PsyD

Practice Location : 4 Country Club Plaza, Ste. G, Orinda, CA 94563
Phone/Voicemail: 510-619-8678
E-mail Address: admin@drshoshana.com

 

* 1. INFORMED CONSENT / TREATMENT AUTHORIZATION *

As we embark on this therapeutic journey together, it is important to recognize the unique nature of the therapeutic relationship in that it is highly personal and yet also a contractual agreement. Given this, it is important to establish a clear understanding of how our relationship will work and what can be expected. This Informed Consent / Treatment Authorization is an attempt to be as transparent as possible to ensure you are fully informed, prior to starting this journey.

Effective Date

This Agreement shall become effective upon the date of signing.

About My Practice

 

Practice Name

The name of my practice is Shoshana Taubman, PsyD.

 

Practitioner Background and Qualifications

I am licensed by the California Board of Psychology to practice psychology in the state of California. My license number is PSY21105. I have been in practice, as a Licensed Clinical Psychologist in the State of California, since 2006. Since 2006, I have gained extensive experience working with children, adolescents, young adults, parents, and families. My experience includes individual, family, group, and multi-family group psychotherapy, psychoeducation, psychosocial and diagnostic assessment, developmental evaluations, parenting consultation and support, and resource coordination.

 

Professional Services

I offer several services including psychotherapy, psychological assessment and evaluation, psychoeducational instruction, consultative services, and resource coordination. Psychotherapy may involve a single individual, the entire family, part of the family, group therapy, or multi-family group therapy. I do not provide child custody evaluations or recommendations, prescribe medication, or provide any legal advice, as these activities are beyond my scope of practice and scope of competence.

 

About Psychotherapy

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and the client, and the particular problems that are being addressed. There are many different methods I may use to deal with those problems. You are entitled to receive information regarding your/your child's individualized treatment plan, such as methods of therapy, the techniques used, and duration (if known).

 

Initial Intake Phase of Therapy

Therapy always begins with an initial intake assessment that typically includes the first 3 to 5 sessions. During this time, we will gather important background information that will help clarify the presenting concerns and illuminate the relevant strengths and relevant challenges as well as the resources that may be available for addressing those challenges. At the end of the assessment, I will be able to offer some initial impressions of what the ongoing treatment may entail, including, where relevant, who should attend and participate in the ongoing sessions. You should evaluate this information along with your impressions of how comfortable it feels to work with me. I will also inform you if I have reason to believe that I am not the right therapist for you/your child, and, if so, I will give you referrals to other practitioners who may be better suited to help you/your child.

 

Individualized Treatment Plan

Should therapy continue, an individualized treatment plan will be developed that will guide the ongoing therapy toward its intended outcome. Depending on your needs and concerns, we may use our follow up sessions to work on improving communication skills, problem solving skills, developing or strengthening coping strategies, learning to maintain positive interactions, practicing techniques, parenting skills training, or self-exploration.

 

Therapy "Homework" Assignments

Unlike a medical doctor visit, psychotherapy requires a joint effort between the client and therapist. Progress and success may vary depending upon the particular problems or issues being addressed and many other factors, including the willingness of the client to both participate actively in the sessions and also practice what we discuss during the session, between the sessions, while at home and in the community via therapy "homework" assignments.

 

Termination

You have the right to terminate therapy at your discretion. I too reserve the right to terminate your treatment at my discretion. I may terminate our professional relationship after appropriate discussion with you, unless such discussion is made impossible by your actions, such as should you refuse to attend therapy sessions.

 

Possible Reasons for Termination

Possible reasons for which I may terminate your treatment could include, but are not limited to, the following:

• it is reasonably clear that you/your child no longer need of or are no longer benefitting from the treatment I'm providing
• it is reasonably clear that treatment I'm providing is resulting in harm to you/your child
• you are in need of services that I am not able to provide
• our professional relationship is in any way putting my physical safety at risk
• in cases of treatment non-compliance or financial non-cooperation

 

Please be advised that for legal and ethical reasons, if you fail to schedule an appointment for three consecutive weeks, I must consider the professional relationship discontinued, unless other arrangements have been made in advance.

 

When Our Journey Comes to an End

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Upon either of our decision to terminate therapy, I will generally recommend that you/your child participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. I will also attempt to ensure a smooth transition to another therapist by offering referrals, if needed. If therapy is prematurely terminated for any reason or if at any time you request another therapist, I will provide you with a list of qualified psychotherapists to treat you/your child. You may also choose someone on your own or from another referral source.

 

Benefits & Risks of Psychotherapy

As with any healthcare procedure, there are risks and benefits associated with psychotherapy. There are many reasons that people participate in therapy. Psychotherapy provides an opportunity to develop a deeper sense of self-awareness, and a better understanding of any problems or difficulties an individual may be experiencing. Participating in psychotherapy may result in a number of benefits, including, but not limited to, improved interpersonal relationships, more effective conflict management, problem-solving skills, and communication skills, stronger coping abilities, reduced distressed, stress and anxiety, and improved self-confidence. Participating in psychotherapy might also at times lead to considerable discomfort. During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. This discomfort may also extend to other family members, as they may be asked to address difficult issues and family dynamics. There may be times in which I might challenge certain perceptions or assumptions, and offer different perspectives. There could also be unintended outcomes, such as changes in personal relationships. Personal growth and change may be easy and swift at times, but may also be slow and frustrating.

 

About Psychological Assessments

Psychologists provide assessments of various types to answer questions about an individual’s health and functioning and to assist in learning more about what they might need or benefit from.

Informal Psychological Assessment Procedures

At times, a psychologist may administer an informal assessment measure, such as a symptom checklist, adjunct to another service (e.g. psychotherapy), to help identify, quantify, measure, or clarify psychological symptoms or behaviors. When such informal assessment procedures are utilized in the course of providing psychotherapy, I will explain the procedure and the purpose for which it is being used and I will share the results or findings with you verbally, upon your request, during our sessions, but I will not prepare a formal written report of any results or findings.

 

"Formal" Psychological Testing and Evaluation

When the reason for referral involves a request for diagnostic clarification, such as in the case of a particularly complicated diagnostic picture, or information is needed to establish resource eligibility or inform another's provider's ongoing treatment plan, formal evaluation procedures, such as those involving standardized measures of cognition, behavior, and/or social-emotional functioning, may be indicated.

 

Initial Consultation

When I am asked to perform a formal psychological evaluation, prior to rendering any formal evaluation procedures, I will require that we meet for an initial consultation. The initial consultation will be used to gather important background information and discuss the specific question(s) or goal(s) the evaluation is intended to address to clarify whether formal evaluation procedures are required by the reason for referral, or whether the referral reason can be effectively addressed by a less formal alternative.

Initial Recommendations

Upon completion of this initial consultation, I will be able to provide my initial recommendations. If I determine that the reason for referral does not call for a formal psychological evaluation and that exclusively informal assessment procedures can be used to effectively address the question(s) or goal(s) for the assessment, I will share my findings with you. If you are in agreement with this findings, we can discuss whether you would like to resume services with your regular individual or family therapist, who could perform these informal assessment procedures, should you have one, or whether you like to proceed with scheduling additional follow up sessions with me for psychotherapy and/or to administer the recommended procedures.

 

Individualized Assessment Plan

In the event I determine that a formal psychological or developmental evaluation is indicated, I will prepare and provide you with an Individualized Assessment Plan. The plan will include a combination of procedures including, but not limited to, clinical interviews, behavioral observations, the selection, administration, and scoring of pertinent standardized tests and measures, preparation of a formal evaluation report, and feedback sessions. The plan may include consultation with other professionals and feedback to other professionals, should these additional services be requested and agreed upon. The plan, and any fees associated with its implementation, will be discussed, agreed upon, and documented on a service agreement form, prior to rendering any further assessment-related services.

 

Results Reporting and Feedback Sessions

Once all the necessary information has been collected, reviewed, and scored (where applicable), I will prepare a comprehensive written report, summarizing the findings, diagnostic impressions and conclusions, and treatment recommendations. As the final step in the assessment process, I will meet with you to review the findings and recommendations, and, in the case of an evaluation of a child/teen, may also meet with the child/teen, where appropriate, and depending on what is discussed and agreed upon. During the feedback session, I will also provide you with a copy of the final report. Please keep in mind that the comprehensive results report will include potentially sensitive information. Once it is in your possession, it will be your decision to share it with others, including, but not limited to, schools, physicians, and any other service providers.

Benefits & Risks of Psychological Assessment

As with any healthcare procedure, there are risks and benefits associated with psychological assessment. Some potential benefits include diagnostic clarification, learning more about the nature of your functioning including individual strengths and challenges, receiving appropriate treatment recommendations to maximize strengths and manage challenges, and receiving a formal report summarizing this information in writing. The evaluation may also result in confirmation of a qualifying diagnosis for medically or legally indicated resources. Although many individuals have an overall positive experience during the evaluation process, there are some risks. The person undergoing evaluation may experience discomfort, frustration, anxiety, or embarrassment during the process. It is possible that the evaluation will not answer all of your questions, and further evaluation may be needed, or the findings may result in you not qualifying for or being found eligible for desired resources and/or accommodations. While the assessment and treatment recommendations are based on best practices, you or others may not agree with the conclusions or may find them upsetting. It is your decision whether to follow the recommendations. Throughout the assessment process you have the right to inquire about the nature or purpose of all procedures. You also have the right to know the test results, interpretations, and recommendations.

 

About Confidentiality

I take your privacy very seriously and comply with Federal and California State laws regarding confidentiality of client information (that is, the privacy of the information you share with me).

Limits of Confidentiality

As a general rule, all information disclosed to me within our sessions is kept confidential and must not be revealed to anyone without your written permission. There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. I will also highlight situations where confidentiality is potentially, though not necessarily, at risk. If you wish to receive mental health services from me, you must sign this Agreement indicating that you understand and accept my policies about confidentiality and the following limits of confidentiality.

I am legally required to share a client's personal health information if:

1. I have reason to suspect that a child has been abused or neglected, I am required by California law to report the matter immediately to the California Department of Social Services.
2. I have reason to suspect that an elderly or incapacitated adult has been abused, neglected or exploited, I am required by California law to immediately make a report and provide relevant information to the California Department of Welfare or Social Services.
3. I have reason to suspect that a client may be a danger to themselves and the disclosure is necessary to minimize risk.
4. I have reason to suspect that a client may be a danger to others and the disclosure is necessary to minimize risk. In the case of danger to another, I am required by law to notify the police and take reasonable steps to warn the intended victim.
5. a client is “gravely disabled” (i.e., unable to take care of basic needs such as feeding self, getting home safely).
6. I am ordered to release confidential information by a court of law, at which time I will only release the minimum required to comply with the order protecting your confidentiality to the best of my ability.

I may also share a client's personal health information if:

1. I receive a written authorization to release the information to a specific individual or entity designated by the client.
2. a client is involved in a life-threatening emergency and I cannot ask permission, I will share information if I believe the client would have wanted me to do so, or if I believe it will be helpful to the client.
3. the disclosure is necessary for the purposes of securing payment from a client's designated third-party payer. Information regarding treatment, dates of services, diagnosis and treatment plans (and, in rare cases, the entire record) will be released to a third-party payer who has been designated by the client as the financially responsible party for a portion of or all fees associated with the client's treatment. This information will, at times, be shared by electronic transmission, including fax machines, e-mail, or cellular telephones. Despite my efforts, these transmissions cannot be guaranteed to be secure.
4. a client files a complaint or lawsuit against me, I may disclose relevant information, if necessary, for the purposes of defending myself.
5. At times I may share information about a client with professional colleagues for the purposes of professional consultation. Professional consultation is an important component of a healthy psychotherapy practice. As such, therapists regularly participate in clinical, ethical, and legal consultation with appropriate professionals in order to provide their clients with the best treatment possible. When consulting about a client, I make every effort to avoid revealing the client's identity. The consultant is also legally bound to keep the information confidential. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together. You may let me know at any time that you do not want your information shared in this way by contacting me in writing and from that point forward I will agree to your request to not share your information for consultation purposes.

 

If you are a minor:

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parent(s) what information is appropriate for them to receive and which issues are more appropriately kept confidential.

If you are the parent/legal guardian of a minor client:

If you are the client's Parent/Guardian, please keep in mind that psychotherapy can only be effective if there is a trusting and confidential relationship between the therapist and client. As such, it is important to understand that as your child’s therapist, I am not a conduit of the information your child may choose to share with me in confidence. In order to facilitate an effective and healing therapeutic environment, I ask that the minor client’s Parent(s)/Legal Guardian(s) respect the confidential nature of information disclosed in confidence by the minor client, during the individual portions of our sessions. That said, as your child’s Parent/Legal Guardian, you will be notified of any serious risk or safety concerns disclosed by your child, or, in the event any other serious concerns arise that involve your child’s safety and/or well-being, as long as it is reasonably feasible and appropriate to do so. You will also receive general information regarding the topics that are discussed with your child, the status of your child’s symptoms, treatment progress and recommendations, and anything else deemed to be in the best interest of your child’s and your child’s therapeutic process.

 

Third Party Payers

While you retain full responsibility for payment of any and all fees associated with your/your child's care with me, you may choose to seek reimbursement from a third-party payer, such as your insurance provider. Whether or not you secure reimbursement is between you and the third-party payer, who, pending the terms of your policy or contract, may require that I share privileged information relevant to the services I provide you, which could include, but is not limited to, diagnostic conclusions, a written substantiation for those conclusions, the dates of treatment, and a brief description of the services provided. This information will become part of the third-party payer/insurance company's files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.

 

Unplanned Encounters

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.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential issues, it is important that we discuss any questions or concerns you may have now or at any time in the future. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.
 

In the Event of a Concern

In the event of there is a concern or any other feedback regarding progress or any other aspect of treatment with me, I strongly encourage you, or anyone else involved in this treatment, to address any feedback, including concerns, openly and directly with me, during our sessions, as it may arise.

2. PRACTICE POLICIES AND PROCEDURES

Effective Date & Purpose: This Agreement shall become effective upon the date of signing. This Practice Policies and Procedures document contains important information about my professional services, procedures, and business policies, and outlines the terms of the professional therapeutic relationship between you and your child/teen, and me, Shoshana Taubman, PsyD

Appointments

I work with clients on an appointment basis only, either in person, as a face to face Office Appointment, or virtually, as a Telehealth Video Appointment. Clinical Telephone Appointments are also sometimes used, primarily for the purposes of providing parenting support, training, and/or consultation.


Appointment Duration

Appointments begin promptly at the time they are scheduled to begin, and end promptly at the time they are scheduled to end. The standard meeting time for the initial intake assessment appointment is 80 to 90 minutes. For follow up individual and/or family psychotherapy appointments, the standard meeting time is 50 to 60 minutes. Parenting support, education, and consultation sessions vary in duration, pending various factors.

 

Duration Adjustments - Therapist Initiated
If, during the course of an active session, it becomes evident that additional time may be needed, pending my availability and with your explicit verbal or written permission, a session may be extended, and the fee may be adjusted accordingly.

 

Duration Adjustments - Client Initiated

Requests to adjust the standard meeting time, may also be considered, if made at least 48 hours in advance of the appointment, pending factors including, but not limited to, the reason for the request, my availability, and whether the adjustment is deemed clinically appropriate.

 

Fees & Financial Responsibility

Fees are due at time of the appointment or at the time a request for other professional services is fulfilled. Since I do not participate in any managed care networks, nor am I associated with, or responsible to, your insurance or health plan, as the consenting party to your minor child’s treatment, you are responsible for payment of the full amount of any and all fees incurred by your child’s treatment.

 

Payment Options

Fees are payable by Cash, Personal Check, Cashier’s Check, Money Order, Credit Card, or Debit Card. If, for any reason, you are unable to pay a fee when it is due, the fee must be paid in full as soon as possible, and no later than 30 days after its due date. Please be advised that, until the fee has been paid in full, it may not be possible to schedule additional appointments or request additional services.

 

Fee Determination

Fees for a service are determined in advance, according to the amount of time that is reserved for the purposes of rendering the service, using the appropriate fee schedule. I reserve the right to raise my fees, when necessary and appropriate, and, when a fee raise is approaching, will provide you with a copy of my updated fee schedules and reminders, well in advance of holding you liable for payment of an increased fee. If my fees constitute a financial hardship, you may speak with me about whether you may qualify for a fee reduction. Requests for fee adjustments and exceptions for any other reason will be considered if enough advance notice is provided to effectively discuss and determine a reasonable and mutually acceptable arrangement.

 

Fees Schedules* (*subject to change)

 

Initial Intake Assessment Appointment [In Person or Video]

90 Minute Appointment with Parent(s) and Client Present - $200
or
30 Minute Appointment  for Parent(s) Only - No Charge
+ 60 Minute Appointment with Parent(s) and 
Client Present - $200

Additional Intake Assessment Appointments [In Person or Video]

60 Minute Appointments - $200
90 Minute Appointments - $275

Follow Up Individual and Family Psychotherapy Appointments [In Person or Video]

60 Minute Appointments - $200
90 Minute Appointments - $275


Parenting Training, Consultation, & Support Services [Telephone]

15 Minute Appointment - $40
30 Minute Appointment - $75
45 Minute Appointment - $110
60 Minute Appointment - $150

 

Complementary Services (No Charge)

Introductory 15 Minute Telephone Consultation for New Clients
Non-Clinical Telephone Encounters of 10 Minutes or Less

Other Professional Services

If other professional services are requested, the fee will be discussed and determined according to an estimation of the time it will require to fulfill your request. Other professional services, include, but are not limited to treatment summary letters, evaluative reports, and attendance at school or other meetings.
 

Cancellation Policy

Please keep in mind that, when you schedule an appointment or initiate a request another professional service, a portion of my schedule is reserved and held exclusively for you, to ensure I am able to provide you and your family with the highest possible quality of care. Accordingly, when you schedule an appointment or initiate a request for other professional services, you are accepting responsibility for payment of the associated fee, according to the time that is being reserved for its purpose.
 

Cancellations

If, after scheduling an appointment, you determine that you can no longer attend the appointment as it was scheduled and need to cancel or reschedule, you must notify me of your intent to cancel, by either e-mail, telephone, and/or voicemail, as soon as possible, and AT LEAST 48 HOURS before the scheduled start time of your appointment. Doing so will allow for time to make the appointment available to other clients who may need it, or make arrangements to use it for some other intended purpose.

 

No Shows

If you miss an appointment, without prior notice, or cancel, with less than the required 48 hours advance notice, your appointment will be considered a “no show.”

Late Arrivals

 

If you are running late, but can arrive at least 20 minutes before the end of your appointment, you can still be seen, but your appointment time may be reduced accordingly. If you arrive within 20 minutes of the end of your appointment, the appointment may be considered a “no show” and you may be asked to reschedule, without being seen.
 

Your Responsibility
Accordingly, unless you later notify me of your intent to cancel, with at least the required 48 hours advance notice, you are held responsible for the associated fee, according to the time that is being reserved, regardless of the following possible outcomes:


• You arrive on time and are seen for the maximum amount of time allotted for your appointment.
• You arrive on time, but are seen for less time than was allotted for your appointment, because less time was needed to address your concerns.
• Your appointment time was reduced, due to your late arrival.
• Your appointment is considered a no show because you arrived within 20 minutes of the time it was scheduled to end.
• Your appointment is considered a no show because you never arrive, without providing prior notice of your intent to cancel.
• Your request for another professional service is fulfilled, whether or not you are still in need of the service that had been requested.

 

*Important Notice About Courtesy Reminders*

While I do my best to send courtesy appointment reminders, via your preferred method of contact, in advance of each appointment, this policy remains in effect regardless of whether an appointment reminder has been sent or received. To ensure you remember your appointments, please consider scheduling your own appointment reminder, or posting a reminder to yourself in a location where you are likely to see it when needed in order to arrive to your appointments as they are scheduled.

Electronic Communication

In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with me.

Telecommunication

While I utilize a phone service, Telehealth Video Appointment service, and electronic health record that offers HIPAA-compliant features, I cannot guarantee the confidentiality of any form of communication which takes place through electronic media, including, but not limited to, voicemail, personal email, and text messaging. If you prefer to use such forms of electronic media for the purposes of any non-urgent, non-clinical, and non-therapeutic subject matter, such as for scheduling, rescheduling, and cancelling appointments, I will do so, according to your preference. However, please be advised that I cannot guarantee the confidentiality of electronic communication, and therefore electronic media should never be used for the purposes of communicating any sensitive, urgent, and/or clinical/therapeutic subject matter.

 

Communication Between Sessions

If you would like to contact me between sessions regarding a non-urgent, non-crisis question or concern, you may do so by telephone, voicemail, or e-mail, should you prefer. If your e-mail or voicemail requires a response, I will do my best to respond within 2 business days, according to my private practice schedule. Please be advised that since my private practice schedule often varies, 2 business days for my practice may equate to longer than 2 common business days for other businesses and private practices

 

Text Messaging

Because text messaging is a very unsecure and impersonal mode of communication, I do not text message to nor do I respond to text messages from anyone in treatment with me. So, please do not text message me unless we have made other arrangements.

 

E-Mail

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication.

 

Out of Office / Vacation Replies

In addition, while I make every effort to schedule out of office replies if a planned vacation or other planned activity will result in changes to my usual practice schedule, sometimes my schedule may vary due to unforeseen circumstances. As a result, regardless of whether an out of office reply is sent or received, it may take longer than 2 common business days for you to receive a response.

 

Social Media

Due to the importance of patient 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, LinkedIn, etc). 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 when we meet and we can talk more about it.

 

Websites

I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions.

 

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.

 

Web-Based Reviews

Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together

 

In the Event Of An Emergency

Please remember that electronic communication, which includes, but is not limited to, phone calls, voicemail, text message, email, and secure messaging, should never be used for the purposes of communicating an urgent, crisis, or emergency concern. If assistance is needed in the event of a mental health or medical crisis or emergency, or any other urgent situation, please do not attempt to contact me by any means, or wait for me to respond. Instead, please be advised of the following recommended safety procedures:
• call 911 (for general emergencies)
• call or text 988 (for mental health crisis support)
• go to the nearest emergency room, immediately, ok as soon as it is safe to do so

 

Special Considerations When Client Is A Minor

Keep in mind that psychotherapy is not intended to be a miracle cure, and that the changes you are seeking cannot be guaranteed. What I can guarantee is that I will do my best to support your child and family, in order to help your child and family make the gains necessary to be able to advance toward achieving important personal and family goals.

 

Your Role as the Client's Parent / Legal Guardian

If you are a parent/legal guardian of a minor, it is important to recognize that your child/teen will benefit most from psychotherapy when your child/teen’s caregivers and other family members are actively engaged in, and supportive of, the therapeutic process, along with your child/teen. For treatment to be successful, the minor client’s caregivers and other family members may need to work on strategies and recommendations discussed during our sessions, together with the minor client, not only during our sessions, but also at home and in the community.

Family Participation in Therapy

In addition, in the course of treatment with a child/teen, I may meet with a parent, legal guardian, or another family member, separately or together with the child/teen. Regardless of who may be participating in the child/teen’s treatment at any particular time, at all times, the child/teen is my client. In the event that I meet with a parent, legal guardian, or another family member, in the course of the child/teen’s treatment, I will make notes of the meeting in the child/teen’s treatment records. Please be advised that, any person or entity that has legal access to the child/teen’s treatment record, has the right to access the child/teen’s complete treatment records, including my notes pertaining to those meetings.

 

In the Event of a Disagreement

At times, the caregivers of a minor client and either the minor client or the therapist, may disagree about certain aspects of the minor client’s treatment. If such disagreements occur, I will do my best to listen carefully and try to understand your perspective, so that I can try to explain and help clarify my own perspective. Whether we resolve such disagreements, or agree to disagree, our primary focus should always be on your child’s therapeutic progress. Ultimately, the decision whether to continue your child’s therapy is and will always be yours, as your child’s Parent/Legal Guardian. If you, or another individual with the authority to make decisions about your child’s therapy, makes the decision to end your child’s therapy, unless there are extraordinary circumstances, I will honor that decision, and only ask that you allow me the option of meeting with your child for one final session, so that I can appropriately end the therapeutic relationship.

 

Circumstances of Separation and Divorce

When treatment involves a minor client, complications may arise if the minor client’s parents are experiencing a separation, divorce, and/or custody disagreements. To minimize these complications, I have found that is generally always best to include both parents in the minor client’s treatment, UNLESS there is sufficient reason to believe that it would not be in the child/teen’s best interest to do so. In the event you are separated or divorced from your child’s other parent, please notify me immediately. Except in cases of truly exceptional circumstances, please be aware that my policy is ensure that both parents are notified of the fact that I am meeting with the child. Should separated or divorced parents share custody, both custodial parents must provide their separate consent for the child's treatment, prior to commencing services involving the child. If there is a parent who is not in attendance, I will ask the parent who brought your child to therapy whether the non-attending parent is aware your child is obtaining services, and may require confirmation directly from the nonattending parent, prior to proceeding with the treatment.

 

Custody Disputes

It is important to note that my function in treating your child is centered only on the best interest of the child. I do not make recommendations related to custody. I acknowledge and respect that information given to me by one parent/guardian is only their perception of the truth and that there is always more than the “truth.” In working with children of divorce/separation, I avoid any involvement between households. It is always my goal to support a child to address problems directly to a parent if they are struggling with something in that parent’s household. In order to provide treatment for your child, I may involve your child’s stepparent/partner of your ex-spouse. Finally, if a parent has any concerns about safety in the other parent’s household they need to address it directly with a mediator, lawyer, or if needed, child protective services.

 

Parent/Legal Guardian Agreement to Not Use Minor's Therapy Information/Records in Custody Litigation

When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements. Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness.
 

To File A Complaint

Should you have a concern about my services, or any other aspect of my treatment of your child and/or family, I respectfully request and encourage you to speak with me about your concern directly, to allow me the opportunity to consider your concern, and explore whether there may be a way for me to address it, to your complete satisfaction. However, should you feel it is necessary to do so, you
may file a formal complaint about a licensed professional to the appropriate licensing board. Contact information for the California Department of Consumer Affairs – Board of Psychology is as follows:

 

California Department of Consumer Affairs - Board of Psychology

1625 North Market Blvd., Suite N-215
Sacramento CA 95834
www.psychology.ca.gov
Local Toll: (916) 574-7720
Toll-free: (866) 503-3221
Fax: (916) 574-8671

 

3. NOTICE OF PRIVACY PRACTICES

Effective Date & Purpose: The Effective Date of this Notice is 12/16/22. The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the legal guardian, the right to understand and control how your child’s personal health information (“PHI”) is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, I prepared this explanation of how I am to maintain the privacy of your child’s health information, how your child’s personal health information may be used and disclosed, and how you can get access to this information. Please review it carefully.
 

*I. My Pledge Regarding Health Information

Because I understand that information about your child’s health is personal, I am committed to protecting your child’s health information. I create a record of the care and services your child receives from me. I need this record to provide your child with quality care and to comply with certain legal requirements. This notice applies to all of the records of your child’s care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about your child. I also describe your rights to the health information I keep about your child, and describe certain obligations I have regarding the use and disclosure of your child’s health information. I am required by law to:
• Make sure that protected health information (“PHI”) that identifies your child is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about your child. The new Notice will be available upon request, in my office, and on my website.

 

*II. How I May Use And Disclose Your Child's Patient Health Information [PHI]

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations

Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your child’s protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your child’s mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

 

Lawsuits and Disputes

If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

*III. Certain Uses And Disclosures Require Your Authorization

1. Psychotherapy Notes

I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating your child.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.

 

2. Marketing Purposes

As a psychotherapist, I will not use or disclose your child’s PHI for marketing purposes.

 

3. Sale of PHI

As a psychotherapist, I will not sell your child’s PHI in the regular course of my business.
 

*IV. Certain Uses And Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, I can use and disclose your child’s PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your child’s PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. I may use and disclose your child’s PHI to contact you to remind you that your child has an appointment with me. I may also use and disclose your child’s PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

 

*V. Certain Uses And Disclosures Require You To Have The Opportunity To Object

1. Disclosures to family, friends, or others. I may provide your child’s PHI to a family member, friend, or other person that you indicate is involved in your child’s care or the payment for your child’s health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
 

*VI. You Have The Following Rights With Respect To Your Child’s PHI

1. The Right to Request Limits on Uses and Disclosures of Your Child’s PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your child’s health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your child’s PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your Child’s PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your child’s medical record and other information that I have about your child. I will provide you with a copy of your child’s record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your child’s PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your Child’s PHI. If you believe that there is a mistake in your child’s PHI, or that a piece of important information is missing from your child’s PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

 

4. INFORMED CONSENT FOR TELEHEALTH TREATMENT

Effective Date & Purpose: This Agreement shall become effective upon the date of signing. During your the course of your child's treatment with me, and where appropriate, there may be times at which my services are provided by telephone or videoconferencing. If and when this occurs, I will be responsible for the cost of the call to you and the cost associated with the platform that will be used to conduct telehealth services securely. You will be responsible for any costs associated with setting up the technology and environment needed to access, and effectively participate in, telehealth services. To access telehealth services you will need a quiet, private space; and an appropriate device (e.g., smartphone, laptop, iPad, or computer), with a camera, microphone and speakers; and a reliable internet connection.
 

What is Telehealth?

Telehealth involves the use of digital information and communication technologies, including but not limited to telephone communication, video conferencing, the Internet, facsimile machines, and e-mail, to deliver healthcare services and information from one location to another.

How is Telehealth used for psychotherapy?

When Psychotherapy takes place via Telehealth technologies it enables therapists to deliver their services remotely, so that a therapist and client can meet outside of a physical office setting. Telehealth psychotherapy is primarily delivered via the internet and therefore can be accessed using any device that is able to connect to the internet, such as a computer, laptop, tablet, or smartphone. Telehealth can include the use of both audio and video or audio only.

What are the potential benefits of Telehealth psychotherapy?

There are several potential advantages to using Telehealth, including, but not limited to:
• improved communication capabilities
• improved access to therapy
• provides convenient access to up-to-date information
• reduces the likelihood of your care being disrupted by things such as illness and/or transportation problems
• it reduces other potential barriers to care, such as travel time, travel cost, geographical distance, etc.

What are the potential risks of Telehealth psychotherapy?

While Telehealth offers several advantages, there are also potential disadvantages to Telehealth. These include, but are not limited to:
• your care may be delayed and/or disrupted due to technical difficulties and/or failures
• the chances of your care being interrupted by an unauthorized individual may increase when therapy occurs outside of the therapist's physical office
• the chances of a misunderstanding may also increase when important visual and/or auditory cues are distorted or lacking due to limitations associated with the technology device
• in the event of a cyber security or other security breach, personal medical information that is stored electronically may be unintentionally lost or may be accessed by an unauthorized individual

What limitations are associated with Telehealth psychotherapy?

A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the session provided. In addition, there may be some services for which telehealth is not appropriate or effective. I will consider and discuss with you the appropriateness of ongoing telehealth sessions, as necessary and appropriate.

In the event information technology is used for all, or a portion, of your child’s treatment, you need to understand that:

• telehealth services are completely voluntary and that you can withdraw this 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.
• none of the telehealth sessions will be recorded or photographed and you are not to make or allow audio or video recordings of any portion of the sessions.
• the laws that protect privacy and the confidentiality of client information also apply to telehealth, and that no information obtained in the use of telehealth that identifies you or your child will be disclosed to other entities without your consent.
• telehealth is performed over a secure communication system that is almost impossible for anyone else to access.
• any internet based communication is not 100% guaranteed to be secure.
• the therapist and practice will not be held responsible if any outside party gains access to your personal information by bypassing the security measures of the communication system.
• there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• a therapist and client may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.
• if there is an emergency during a telehealth session, emergency services and/or an emergency contact may need to be contacted.

 

By consenting to Telehealth psychotherapy, you must understand that, due to certain limitations associated with Telehealth, you are also agreeing to accept certain responsibilities that may not otherwise apply when psychotherapy exclusively occurs on-site at a therapist's office location, including by not limited to the following:
• Since my therapist cannot control my physical environment when services are being rendered outside of her physical therapy office, I understand that I bear a greater responsibility for ensuring my own confidentiality by taking care to join my Telehealth appointments from a safe, secure, and private location.
• I understand that I also accept responsibility for ensuring that reasonable measure have been taken to minimize potential interruptions that could disrupt the flow of the discussion and interfere with my ability to participate effectively in my appointment.
• Due to the inevitable possibility that technical difficulties may render my preferred method of communication inoperable, I understand that I am responsible for ensuring I have a secondary communication method readily available in case I may need it to contact my therapist so that I can advise her of my status.
• Since my therapist cannot provide any in-person assistance in the event a medical or psychiatric emergency occurs during the course of a Telehealth appointment, I understand I am responsible for ensuring I am familiar with the location and accessibility of the emergency services closest to the location from where I am planning to participate in the appointment.
• I also understand that, in the event a medical or psychiatric emergency occurs during the course of a Telehealth appointment, I also understand that therapist may decide to call emergency services and/ or my emergency contact.

5. CONSENT FOR MINOR USAGE OF SOFTWARE AND SERVICES

Introduction

If you are the parent or legal guardian of a client, who is a minor(herein, “Minor Client”), which means your child, the client, is under 18 years old, you must give your written permission and consent for your child to use the Power Diary Software and Services.
 

Terms and Conditions

You understand and agree, by signing this form, that your child’s use of the Power Diary Software and Services will be governed by the same terms of service that are applicable to your use of the Power Diary Software and Services. You agree that Shoshana Taubman, PsyD has your permission and consent to use the Power Diary Software and Services to schedule appointments, communicate with you and/or your child, the client, who is a minor, document and administer your child's care and treatment, utilize telehealth services, and all other actions in any way related to being your child's health provider.
 

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