Office Policies and Informed Consent for Treatment

Jessica Farber, Psy.D.
CA Licensed Psychologist, PSY 22360
3880 S. Bascom Ave., Suite 202, San Jose, CA 95124
Phone: (408) 981-8676, Fax: (408) 371-9193
www.DrJessicaFarber.com


This form provides you with information about my practice.  Please read all of it and when you come in for your first appointment, I will provide you with a page to sign 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.  This includes the online use of explicit images/videos of minors.  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 and 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 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 a life-threatening emergency situation between sessions, please leave me a message on my mobile phone at (408) 981-8676, and then hang up and dial 911 or Emergency Psychiatric Services at (855) 278-4204.  In order to maintain safety, psychiatric hospitalization is sometimes necessary.  If I am out of town, I will designate a back-up therapist who will see you while I am gone if you have an emergency.  I will leave contact information about this person on my outgoing voicemail message. Please do not contact me via voicemail at (408) 327-9367, 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 clients benefit greatly from a consistent relationship with their therapists.  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 see clients less frequently when there are only mild symptoms or financial constraints.
  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.
  3. Cancellation of session by therapist:  If I need to cancel a session due to a planned absence, I will give you two weeks 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 $200 per 50-minute session if you would like me to bill your insurance company directly.  My fee is $175 per session if you pay privately. Bills are to be paid at the end of each session.  I accept check, cash, credit card and debit card.  Checks should be made out to Jessica Farber, Psy.D.  
  2. California Victim Compensation Program: I accept payment through CalVCP from the State of California for people who are eligible in that program.   
  3. “Out of Network” PPO Insurance Reimbursement:  I am not contracted with any health insurance company.  I am willing to directly bill your health insurance company for services rendered as an “out-of-network provider.”  If you have a PPO insurance plan, please contact your insurance company to see if they provide compensation for services by an “out-of-network provider,” and how much of my fee they will cover, taking into account your deductible, copayments and covered fees.  The remainder of the fee is your responsibility.        
  4. Courtesy Adjustment for Low Income Clients: If you have trouble affording my full fee, I may adjust the fee due to your income level. Fee adjustments are determined on an individual basis.  If you are still unable to afford my fee, I can provide you with referrals for lower fee treatment through my clinic.  Trainees and Interns at CCC charge between $25-$90 per session.   


Cancellation Policy:  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 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.

Email and Text Messaging Consent: If you desire, you can communicate with me via email or text messaging.  By using these methods of communication, you are confirming that you are aware of the risks to your confidentiality that these communications hold.  All email and text messages are routed through computer servers that may allow other people access any private health information included in these messages.  Please be aware of these risks to your confidentiality and make decisions about these forms of communication in an informed way.

Consent for Minor Clients:  California law stipulates that only one parent is required to consent to the treatment of a minor client.  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.

Benefits and Risks of Therapy, and Scope of Practice:  By participating actively in therapy, you can receive benefits including improved relationships and the reduction of mental health symptoms such as depression or anxiety.  By changing your thoughts and behaviors, you may enjoy benefits beyond the scope of the problem for which you originally sought therapy.  During therapy, thinking about or talking about unpleasant situations or memories can be painful and lead you to feel sad, angry, worried or afraid.  Change may be fast, but more often occurs as a slow process.  There is no guarantee that therapy will yield positive or intended results.  During therapy, I will choose therapeutic interventions that apply to your unique situation, which may include behavioral, cognitive-behavioral (CBT), psychodynamic, family systems, humanistic, Eye Movement Desensitization and Reprocessing (EMDR) and psycho-educational interventions.  I do not provide medication consultation or prescription, child custody evaluation, legal advice or legal services, as these fall outside my scope of practice.      

Dual Relationships:  A dual relationship happens when a client and therapist have contact in another context besides therapy, for example, attending the same church.  Dual relationships are clearly unethical if they impair the therapist’s objectivity or clinical judgment or they are exploitive to the client.  Sexual contact between client and therapist is always illegal and unethical.  A non-exploitive, legal, dual relationship may be of benefit to a client in therapy.  If I find that I am in a dual relationship with you, I will discuss possible benefits and difficulties that may be involved.  It is your responsibility to communicate to me if the dual relationship becomes uncomfortable in any way.

Termination of Treatment:  Ideally, termination (or ending treatment) occurs when you feel that you have reached the goals for which you came to therapy.  During our first meeting, I will assess whether or not I can be of benefit to you.  If I feel that I cannot help you, I will refer you to a more appropriate treatment.  If, during the course of therapy, I feel that I am not helping you reach your therapy goals, or you are not compliant with treatment (including attending therapy sessions regularly), I will provide you with referrals to other professionals that may be able to serve you better.  You have the right to stop therapy at any time.  If you request it and sign an authorization, I would be happy to speak to your new therapist on your behalf to make the transition smoother.