Mehri Aboutalebi, Ph.D. Licensed Marriage , Family and Childrens Therapist License # MFC 47272

Limits of Services and Assumption of Risks:

Therapy sessions carry both benefits and risks .Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions. This consent is to certify that you (client) give permission to Dr.Mehri Aboutalebi MFT to provide psychotherapy treatment. You have a right to terminate the therapeutic relationship at any time without fault. 

Under most circumstances, all communication between you and your therapist is confidential. What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:

Duty to Warn and Protect

If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.

Abuse of Children, Vulnerable Adults, and elderly

If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.

Prenatal Exposure to Controlled Substances

Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.

Minors/Guardianship

Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers

Insurance companies and other third-party payers are given information that they request regarding services to the clients.

***While it is our legal responsibility to report any of the above, it is our ethical responsibility to help you through this trying time. Disclosure may also be required in certain legal proceedings. If you have concerns about the content of our sessions and any legal proceedings in which you are involved or expect to be involved (e.g., child custody cases), please let your therapist know. Before such disclosure is made, every reasonable effort will be made to appropriately resolve these issues or to notify the client.

When I agree to treat a couple or a family, I consider that couple or family (the treatment unit) to be the patient. 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-patient privilege on behalf of the patient (treatment unit). During the course of my work with a couple or a 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 If you are involved in one or more of such sessions with me, please understand that I may need to share information learned in an individual session with the entire treatment unit. I will use my best judgment 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 the 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 couple or family. 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 the family. If I am not free to exercise my clinical judgment 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. In the event of divorce, we agree not to use the therapy (progress) notes of Dr.Mehri Aboutalebi ,LMFT, against each other for any reason (e.g. child custody, divorce legal proceedings, etc

We, the members of the (couple/family or other 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, Dr.Mehri, Aboutalebi, LMFT, and that we enter couple/family therapy in agreement with this policy.

 
Psychological Services: Psychotherapy practices and services are varying according to specific conditions of patients. Because of that, there are many techniques that are applied by the professionals to be helpful for the patient. Psychotherapy session durations can be varied with respect to the problems. The patient accepts that telehealth psychotherapy practices may include mental health evaluation, consultation and planned therapy sessions with video and audio connection.

Risks: Sessions have both benefits and risks because the therapy mainly involves various parts of patients' lives. Patients may experience some undesirable feelings before, during and after the sessions. On the other hand, the therapy will provide solutions to problems and uncomfortable situations. Hence, the patient accepts that he/she can benefit from telehealth psychotherapy sessions; however, the result is not certain and cannot be guaranteed.

Confidentiality: Personal information of patients will be kept private and that is an obligation by the governmental laws. The health care provider will not responsible for any exposure caused by the location or network connected by the patient before, during and after telehealth psychotherapy sessions.

Rights: The patient can withdraw or withhold the consent at any time and this will not affect the future practices and treatment.

Sessions are 50 minutes in length and begin at the scheduled appointment time. If you arrive late, your session will be shorter. If you must cancel a session, please let your therapist know at least 24 hours in advance. You will be responsible for the full fee of any session canceled with less than 24 hours notice. Appointments must be canceled via voice mail or text. For psychotherapy to be most effective, clients must not be under the influence of intoxicating substances. If your therapist feels it necessary, you may be asked to reschedule your appointment for another time; this will be considered a late cancellation.

You may email, text or leave message on your therapist voicemail at any time. Please be aware that therapists may not retrieve messages until their regular office hours Monday to Friday from 10am to 6am. If you have a life-threatening emergency, please dial 911.

All services are billed at the standard rate. Clients pay for services at the beginning of each session, unless other arrangements have been made. Please notify your therapist if any problems arise that affect your ability to make timely payments.

I have read, understand and agree to the information, guidelines and office policies stated above.

If a couple or a family additional signatures below: