TEMENOS Informed Consent for Treament

Informed Consent for Treatment

Temenos Center of Integrative Psychology - A DBA of The Family Guidance and Therapy Center (Tax ID: 27-3179020)
Welcome to Temenos Center of Integrative Psychology
Thank you for choosing Temenos Center of Integrative Psychology. We are committed to providing you with quality care, including psychotherapy and Ketamine-Assisted Psychotherapy (KAP). This document explains the nature of our services, potential benefits and risks, and policies for participation in treatment. Please read this consent carefully, and feel free to ask any questions.

Your signatures indicate that you understand and agree to these terms and conditions.
Client Name*

First NameLast Name

1. Welcome and Ownership Disclosure
Thank you for choosing Temenos Center of Integrative Psychology, a DBA of The Family Guidance and Therapy Center.

Ownership Disclosure: Temenos Center of Integrative Psychology is owned by Jennifer Palmiotto, LMFT. The corporate office is located at:
3555 Kenyon Street, Suite 101, San Diego, CA 92110.
Client Confirmation*

I acknowledge that I have been informed of the ownership and corporate details of the practice.
Client Initials*

2. Consent to Treatment by Temenos Team Professionals
The Temenos Center of Integrative Psychology consists of a team of licensed medical doctors, mental health professionals, and support staff who collaborate to provide care.
- Assignment of Professionals: Clients will be matched with Temenos medical and mental health professionals based on clinical appropriateness and availability.
- Employment Status: All Temenos team members are employees of the organization.
Client Confirmation*

I consent to be treated by medical doctors and mental health professionals who are part of the Temenos team.
Client Confirmation*

I understand that all team members are employees of the organization.
Client Initials*

3. Consent for Psychotherapy Services
Psychotherapy involves working collaboratively with a licensed mental health professional to address emotional, psychological, and behavioral concerns. The therapeutic process may include discussions of personal challenges, goals, and interventions designed to promote growth and well-being.

Benefits
- Increased self-awareness
- Improved coping strategies and emotional regulation
- Relief from symptoms such as depression and anxiety
  Enhanced relationships and personal growth
Risks
- Emotional discomfort when discussing difficult topics
- Temporary increases in distress as challenging issues are addressed
- Unpredictable outcomes
Client Confirmation*

I understand the nature, benefits, and risks of psychotherapy.
Client Initials*

5. Emergency and Safety Procedures
Transportation
- You must arrange for safe transportation home following a ketamine session with a trusted adult, family member, or certified ride service.
- You may not operate a vehicle or heavy machinery for the remainder of the day.
Medical Emergencies
- During ketamine sessions, a licensed medical doctor will be present to monitor your safety. If a medical emergency occurs:
  - Emergency protocols will be implemented.
  - Emergency medical services (EMS) will be contacted if necessary.
Aftercare Expectations

Following a ketamine session:
1. Emotional Processing: Expect heightened emotionality and introspection. Journaling, mindfulness, and rest are encouraged.
2. Diet and Hydration: Avoid alcohol and recreational substances for at least 24 hours. Eat lightly and hydrate well.
3. Avoid Major Decisions: Delay making significant life changes for 24–48 hours as cognitive processing normalizes.
Client Confirmation*

I agree to arrange safe transportation and will not operate a vehicle after my session.
Client Confirmation*

I understand and agree to the safety and emergency procedures.
Client Confirmation*

I agree to follow the aftercare expectations outlined above.
Client Initials*

6. Integration Therapy Recommendations
Integration therapy is an essential part of KAP to solidify gains and reinforce insights.

Timing: We recommend scheduling your first integration session 24–48 hours after your ketamine session to take advantage of the brain’s increased neuroplasticity.

Frequency: Continued integration sessions are encouraged to maximize therapeutic outcomes.

Goals: Integration helps translate insights into actionable changes in your thoughts, emotions, and behaviors.
Client Confirmation*

I understand the importance of integration therapy and agree to participate as recommended.
Client Initials*

7. Financial Policies
Fees
- Medical/Psychosocial Intake: $350/hour (1-1.5 hours based on medical complexity)
- Mental Health Intake (50 minutes): $200
- Prescription Fee: $150
- Preparatory Session: $200/hour
- Ketamine Administration Sessions: $850 (Deposit due upon schedule at 50%)
- Integration Sessions: $200
Notice of Fee Changes:
- Fees are subject to change over time.
- Any changes to fees will be communicated to clients in advance and agreed upon prior to implementation.
Payment Policies
- Payments are due at the time of service
- Cancellations with less than 24 hours’ notice will incur the full session fee
- Cancellations with more than 24 hours notice can be rescheduled
Client Confirmation*

I understand that fees may change and that I will be informed and asked to agree to any changes before they are applied.
Client Confirmation*

I accept the current fee structure as outlined above.
Client Confirmation*

I agree to the financial policies and understand my payment responsibilities.

8. Acknowledgement & Consent
Client Confirmation*

I have read and understood the Informed Consent for Treatment.
Client Confirmation*

I consent to receive psychotherapy and/or Ketamine-Assisted Psychotherapy as outlined above.
Client Signature

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Informed Consent for Treatment