1. Introduction
This agreement provides important information regarding the practices, policies, and procedures of Family Guidance and Therapy Center ("FGTC") and clarifies the professional relationship between you (or your family) and your therapist. If you are the parent/guardian of a minor client, you must consent to treatment before services begin. Please read this document carefully, ask questions about anything unclear, and initial each section to indicate your understanding.
2. Practice Information
FGTC is a licensed mental health corporation providing a range of therapeutic services. Services are delivered by multiple clinicians, including:
- Licensed Marriage and Family Therapists (LMFTs)
- Licensed Professional Clinical Counselors (LPCCs)
- Associate Marriage and Family Therapists (AMFTs)
- Associate Professional Clinical Counselors (APCCs)
- Behavioral Therapists / Developmental Therapists
- Other licensed mental health professionals practicing within the scope of their California licenses
The practice owner is Jennifer Palmiotto, LMFT #47375. Services may be provided by any qualified clinician within FGTC based on availability, clinical appropriateness, and client needs. Clients will be informed of the name, license type, and license/registration number of the clinician providing care. Associate-level clinicians will provide services under supervision consistent with BBS requirements.
3. Group Practice & Provider Assignment
Group Practice Structure: FGTC is a group practice with multiple clinicians. You may receive services from more than one provider during your care.
Assignment and Change of Provider: Your assigned clinician may change due to availability, clinical needs, administrative reasons, or your request. Whenever reasonably possible, changes will be discussed in advance.
Licensure & Supervision Disclosure: You will be informed of the name, license type, and California license/registration number of your clinician. Associate-level clinicians (APCCs, Behavioral/Developmental Therapists as applicable) will provide services under supervision, consistent with BBS requirements.
Client Choice: You may ask questions about any provider’s credentials, request a different provider, or decline services without penalty.
Continuity of Care: FGTC will make reasonable efforts to maintain continuity of care; however, continuity cannot be guaranteed due to provider leave, illness, licensure changes, or separation from the practice.
Confidentiality Within the Group Practice: Your clinical information may be shared among authorized FGTC providers and staff for treatment, supervision, quality assurance, and administrative purposes, in compliance with HIPAA and California confidentiality laws.
4. Therapist Background and Qualifications
At your request, your therapist will discuss their professional background, training, experience, and orientation. You may ask questions about their professional qualifications at any time.
5. Professional Services Rendered
FGTC provides psychotherapy for individuals, families, couples, and groups, including RDI consultation, educational, or behavioral services.
6. Process of Psychotherapy
Therapy typically includes an initial assessment, treatment planning, and ongoing sessions. Session participants are determined by your individualized treatment plan. You may ask questions about your treatment at any time.
7. Risks and Benefits of Therapy
Therapy is a collaborative process. Benefits may include improved coping, self-understanding, emotional regulation, and relationship functioning. Therapy may also involve temporary discomfort, including strong emotions, recall of unpleasant experiences, or changes in personal relationships. Outcomes vary and cannot be guaranteed. Active participation, honesty, and willingness to engage are essential to progress.
8. Professional Consultation
Therapists consult with other professionals for clinical, ethical, or legal guidance. Identifying information about clients will not be revealed during such consultations.
9. Records and Record Keeping
Records are maintained in compliance with ethical and legal standards. They are stored securely and kept for at least 7 years after the termination of therapy or the minor turning 18. Records may be requested in writing.
Practice Management Software: FGTC uses HIPAA-compliant, secure software (Central Reach) for documentation, scheduling, and billing.
10. Electronic Communication and Telehealth
Email, text, voicemail, and e-fax are not fully secure. By consenting, you accept the risk of potential breaches. Do not use these methods for emergencies.
Telehealth: Telehealth (video/audio) is voluntary and provided only when the client is physically in California. Risks include technical failures or privacy breaches. Benefits include accessibility and convenience. You may withdraw consent at any time. Telehealth sessions are subject to the same confidentiality protections and limits as in-person therapy.
Video or audio sessions will not be recorded unless discussed with the client and written consent is obtained.
11. Confidentiality, Exceptions, and Minors
Confidentiality: All communications are confidential unless you provide written authorization. In family/marital therapy, information is only shared with participants who consent.
Exceptions:
- Suspected child, elder, or dependent adult abuse
- Imminent risk of harm to self or others
- Court orders
- Other legal requirements
Minors: Minor clients’ information is generally confidential. Parents/guardians may be involved in treatment and informed about progress as appropriate and within the therapist’s professional judgment.
12. Fees and Financial Responsibility
Session Fees: Fees vary by clinician level and licensure. You will be informed of the clinician’s rate prior to services. Insurance copayments, deductibles, or uncovered services are your responsibility.
Standard Session Time: Approximately 50 minutes; additional time billed pro-rata.
Telephone, Email, and Third-Party Communications: Brief check-ins are included; longer communications (e.g., coordination with schools or providers) billed at standard rate.
Reports, Letters, and Treatment Planning: Required by insurance when billing; fees may apply for additional documentation outside insurance requirements. Contact Carol, office administrator, at carol@familyguidanceandtherapy.com for specific plan-related fees.
Insurance Responsibility: You are responsible for clarifying coverage and EOBs. If your insurance does not pay or denies a claim, you are financially responsible for the balance. FGTC cannot guarantee reimbursement.
Returned/Declined Payments: May incur a $35 administrative fee; all balances must be resolved before the next session unless other arrangements are made.
13. Cancellation and No-Show Policy
24-Hour Notice Required: Leave notice on voicemail (619-600-0683) or email (cancel@familyguidanceandtherapycenter.com).
Late Cancellation Fee: Less than 24-hour notice: $50.
No-Show Fees:
- Behavioral Health Direct Care (e.g., ABA therapy, direct behavioral services): $75
- Parent Training or Licensed/Associate Provider Sessions (LPCC, LMFT, APCC): $100
- Fees may be billed or added to your next session.
14. Therapist Availability & Emergency Protocols
Voicemail is available 24/7. Therapists aim to return messages within 24 hours or by the next business day. Therapists do not provide 24-hour crisis service. In emergencies, call 911, 988, or go to the nearest emergency room.
15. Termination of Therapy
Either client or therapist may terminate therapy. Reasons for therapist-initiated termination include non-payment, lack of participation, or treatment outside clinician scope. Termination sessions are generally offered to facilitate closure and referral.
16. Participation in Litigation
Therapists generally do not participate in litigation or custody disputes, except as required by law or with prior agreement. Required court appearances or records may incur fees at standard rates.
17. Psychotherapist-Patient Privilege
Information shared in therapy is protected under psychotherapist-patient privilege. This may be waived if you make your mental/emotional state an issue in legal proceedings.
18. Questions or Complaints
If issues cannot be resolved with FGTC, contact the California Board of Behavioral Sciences (BBS):
Website: www.bbs.ca.gov
Phone: (916) 574-7830
19. Acknowledgment
By signing, you acknowledge that you have read, understand, and agree to the terms of this agreement, including group practice policies, telehealth, fees, confidentiality, and risks/benefits. You consent to participate in psychotherapy services at FGTC.