This form provides you with information about my practice. Please read it in its entirety and sign at the end to indicate that you have read and understood it, and that you consent to treatment.

Confidentiality

The meetings between a patient and his or her psychotherapist are confidential and legally privileged. Information discussed in session will not be released to anyone without your written permission, except where disclosure is required by law. There are important situations when I am legally and ethically required to release certain information. These include the following situations:

1. Threat to Others: Confidentiality is limited if you (or one of your immediate family members) communicate to me that you pose a serious threat of violence against someone. In this case, I have the duty to contact the police and warn the intended target of the violence.

2. Suspicion of Abuse: Confidentiality is limited if I have reasonable suspicion of past or present child abuse, elder abuse or abuse of a dependent adult. In this case, I have a legal requirement to contact the Social Services agency in the county where the suspected abuse occurred.

3. Legal Proceedings/Subpoenas: Confidentiality is limited during a legal proceeding, if your records are required to be released as evidence. This may occur during a legal proceeding by or against you. If your mental status is the issue of litigation, the defendant may have the right to enter your therapy record and my testimony into evidence.

4. Emergency Situations: Confidentiality is limited if there is an emergency situation in which I believe you may be a danger to yourself or others, or to property, or you are gravely disabled. In this case, I will take necessary steps to ensure your safety, including but not limited to contacting your family members or law enforcement. Law enforcement officials may have you involuntarily hospitalized.

5. Refusal to Pay Fees Owed: Confidentiality is limited if you refuse to pay fees for services rendered. If this occurs, I will release only information that is necessary for fees to be collected. I will alert you by mail if I intend to release your information to a collections agency in order to give you a chance to pay your outstanding balance.

Release of Information and Records

California Law requires that I keep appropriate treatment records during treatment and for at least seven years after the termination of treatment. Treatment records include, but are not limited to, your contact information and brief notes on each session including date, time, session length, fee, mental status, diagnosis, assessment, intervention and goals. The following situations relate to release of records that do not involve emergency situations or legal requirements.

1. Authorization for Release of Information: If you would like me to release information about your therapy or your records to a third party, I will ask you to sign an authorization giving me permission to do so. On occasion, verbal consent will suffice until proper written authorization can be obtained. I will not release information about your therapy or record to a third party without written or verbal authorization by you unless it is required by law (see previous section, “confidentiality”).

2. Your Right to Review Your Record: You have a right to review your therapy record. If you wish to review it, you may give me a written request for a copy or summary of your record. Your right to review your record may be limited in certain legal or emergency situations if I assess that releasing your records to you would be harmful in any way. In this case, you may request that I release your record to another appropriate mental health professional of your choice.

3. Health Insurance: “Authorization to release information” (see above) also applies to release of private health information to insurance companies. Please be aware that, once I release information about you to your insurance company, I have no control over what your insurance company does with it or who is able to access it. This information may reduce your ability to obtain health or life insurance or to get a job, and may be entered into the National Medical Data Bank.

4. Family Therapy Authorization: If you see me for family therapy or couples therapy, then all of the adults involved in therapy must consent to release therapy records to an outside party.

5. “No Secrets” Policy: If you see me for couples or family therapy, confidentiality does not apply between family members or between spouses. I have a “no secrets” policy, which means that I ask you to be willing to share information with one another rather than making me a secret keeper. I will work with you on finding appropriate ways to share sensitive information with your family members.

6. Parental Rights to Review Records: If the client is a minor under the age of 18, then either parent has the right to review the therapy records, regardless of physical or legal custody.

7. Limited Confidentiality for Minors: In order to create an environment of trust between myself minor clients under the age of 18 (teens), I extend a limited degree of confidentiality to teens. I do not generally share details of sessions with parents, unless I feel that there is a safety risk. Rather, I will give parents updates on their teen’s progress and discuss how they may help their teen to reach his or her goals. I also do occasional joint sessions in which both parent and teen can meet together with me to discuss the teen’s progress and share pertinent information. At this time, I will encourage the teen, rather than myself, to share with the parent(s) about his or her therapy.

8. Consultation: I regularly consult with other professionals about my therapy clients. The purpose of this is to improve quality of care and ensure against ethical problems. During these consultations, client’s identities are kept anonymous and confidentiality is maintained.

Emergency Procedures

If you have an life-threatening emergency situation between sessions, please leave me a message on my confidential voicemail at (408) 327-9367, and then hang up and dial 911 or Emergency Psychiatric Services at (408) 885-6100. I check my voicemail several times per day when I am in the office and I return messages within 24 hours. I do not return calls on Sunday or Monday, or when I am out of town. If I am out of town, I will designate a back-up therapist who will see you while I am gone if you have a non-life-threatening emergency. I will leave contact information about this person on my outgoing voicemail message. Please do not contact me via fax or email for emergency situations as I do not check these on a daily basis.

Length and Frequency of Sessions

1. Frequency of sessions: I believe that therapy benefits greatly from a consistent relationship between therapist and client. For this reason, I recommend that you see me on a weekly basis so that we may get to know each other and you can build trust in me and the therapy process. In many cases, I see clients twice per week due to the severity of their symptoms. I do see clients less frequently in certain circumstances where there are only mild symptoms or the client simply wants brief advice on certain relationship issues or other concerns.

2. Length of session: Sessions usually last 50 minutes. On occasion, for family or couples therapy, I do double sessions, which last 1 hour and 40 minutes, in order to give more time to multiple family members.

3. Guarantee for your time slot: If you see me once or twice per week, you are guaranteed (barring emergencies) to have that time slot reserved for you. If you see me less frequently than once per week, your time slot cannot be guaranteed, as priority for scheduling goes to those who see me more frequently. In this case, I will give you one week advance notice if I have to change your appointment time on a given day.

4. Cancellation of session by therapist: I may cancel sessions due to attending trainings, going on vacation, illness or other emergencies. If I plan to cancel a session with you, I will give you two weeks advance notice of the cancellation. You will be offered to reschedule if you choose. If I become ill or have an emergency, I will give you as much advance notice as possible so that you can plan accordingly.

Payment

1. Fee: My fee for services is $125 per 50 minute session. Bills are to be paid at the end of each session. Checks will be made out to Jessica Farber, Psy.D.

2. Victim Witness: I am approved to accept Victim Witness Compensation from the State of California for people who are eligible in that program.

3. PPO Insurance Reimbursement: I am not contracted with any insurance companies, but many of my clients have had success in obtaining reimbursement from their PPO insurance companies for a portion of my fee. If you are interested in pursuing this option, you first need to contact your insurance company to see if they provide compensation for services by an “out-of-network provider.” Then I ask that you pay my fee to me up front, and at the end of each month I will provide you with a detailed statement/receipt that you can submit to your insurance company in order to receive reimbursement from them for part of the fee.

4. Sliding Fee: If you have trouble affording my full fee, I may have a sliding fee slot available. Sliding scale fee is decided on an individual basis, taking into account income, family size and financial obligations. My sliding fee range is $75-$125 per 50 minute session. If you are unable to afford my fee, I will be happy to provide you with other referrals for lower fee treatment through my clinic, which has fees as low as $10 per session.

Office Hours and Cancellation Policy

My office hours are currently on Tuesday through Saturday. My office is located at 3880 South Bascom Avenue, suite 111, San Jose, CA 95124. I receive mail in suite 202. Once we agree to meet and an hour is reserved for you, you are responsible for payment for that session. If you cannot keep a scheduled appointment, you must provide me with 24 hours advance notice to cancel or reschedule your appointment, to avoid being charged for a missed session. If you cancel less than 24 hours in advance of a session, you will be charged for that session. I do reserve the right to make some exceptions to this rule upon my discretion, if the session can be rescheduled within the next two business days after the canceled appointment. However, if you fail to call and cancel (“no show”) you will be charged for the missed session. Please be courteous and provide me with as much advance notice as possible if you plan to be out of town or cannot keep a future appointment for any reason.

Consent for Minor Clients

California law stipulates that only one parent is required to consent to the treatment of a minor child. However, my policy is to receive consent from both parents, whether they are married, separated or divorced. Having agreement among parents about treatment is helpful to facilitate reaching therapeutic goals. In addition, even noncustodial parents have the legal right to access their children’s therapy records. Therefore, I will ask both parents to attend the initial session, or if this is not possible, to have a phone conversation and obtain consent in writing from the parent who cannot attend.