CONSENT FOR TREATMENT

CONFIDENTIALITY: Information disclosed in sessions is considered confidential and will not be revealed to anyone without your written permission, except where disclosure is permitted by law and deemed to be in the best interest of the client. The following are exceptions to confidentiality:

1)When there is reasonable suspicion of child, elder or dependent abuse or neglect;

2)When the client presents a serious danger of violence to others or property of others;

3)When the client presents a serious danger of harm to himself or herself;

4)Pursuant to a lawfully issued subpoena.

Additional exceptions include:

Minors: When minors (under the age of 18) are seen in therapy, the parent or guardian holds the legal privilege regarding release of information.

Groups: Group therapy participants are expected to honor and respect the privacy and confidentiality of other group members. However,confidentiality can not be guaranteed.

Consultation: On occasion, I seek consultation with colleagues in order to improve and enhance treatment on a specific case. However, identifying information will not be revealed.

CANCELLATIONS: A 24-hour advance notice of cancellation for scheduled appointments is appreciated. You will be responsible for the entire session fee if you do not cancel a scheduled appointment. There will be a $25 fee for sessions canceled with less than three (3) hours notice. A message may be left at (661) 809-8554.

EMERGENCIES: You may leave a message at (661) 809- 8554 at anytime and your call will be returned as soon as possible. Matters than need immediate attention should be directed to either the Crisis Stabilization Unit, which is open 24-hours a day, at (661) 868-8000, or 911.

PAYMENT FOR SERVICES: Your fee will be ______per 50 minute session, andis to be paid at the beginning of session; checks are to be made payable to Charree Kashwer. Additional services (court appearances, third-party reports, phone therapy sessions, psychological assessment, etc.) will also be billed at the hourly rate.

Additional Billing-Related Information & Policies:

a. Client accounts are not to accrue an unpaid balance for more than two sessions. After two sessions of unpaid balances, services may be withheld until the account is paid in full. I reserve the right to submit past-due accounts to a collection agency or pursue matters in a small claims court.

b.My fee-schedule is reviewed annually and, after notification, may be altered.

c. There will be a $20 service charge for each non-sufficient fund (NSF) check, and fee repayment, along with the service charge, is to be paid by CASH or MONEY ORDER only. Two, or more, NSF checks may, depending on the circumstances, require that all future fees be paid by cash or money order.

INSURANCE AND OTHER CONTRACTUAL REIMBURSEMENT:

______Services will be provided and charged directly to the client, not to an insurance or contracted organization. Client is expected to pay fees as indicated above and assumes full responsibility for obtaining reimbursement from their insurance or contracted organization, if applicable. Monthly insurance statements may be provided, upon request, which may be submitted to the insurance carrier. OR

______Therapist will bill insurance company for fee reimbursement. Client is responsible for co-payments and fees for missed appointments or late cancelations, as well as fees that the insurance company will not cover (e.g. court appearances).

CLIENT CONTACT INFORMATION

Client’s Name:______DOB:______

For Minors, Name of Parent(s):______

Address:______

number/streetcity zip

Home Phone: ( ) ______May I leave a message? Y / N

Cell Phone: ( ) ______May I leave a message? Y / N

Work Phone: ( )______May I leave a message? Y / N

Email: ______May I email you? Y / N

Would you like to receive a text message reminder of scheduled appointments? Y / N

Emergency contact: ______

Name Phone Relationship

INSURANCE INFORMATION

Insurance Company:______Phone Number: ______

Member ID#:______Group #:______

Insured’s Name:______DOB:______

Authorization #: ______# of Sessions Authorized:______Co Pay:$______

I read, understand, and accept the conditions stated in this consent.

Client’s SignatureDate

Parent/Guardian Signature (if client is under 18) Date

Therapist’s SignatureDate

1