Note: The following questions are intended to gather information about the parent.

ACKNOWLEDGEMENT OF FEE ARRANGEMENT: I understand and agree that The Center for Professional Counseling provides fee for service counseling. I understand that my fee per session will be set during the intake appointment and that I am contractually obligated to pay this agreed upon fee before the start of each session.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client􏰃s) written permission, except where disclosure is required by law.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; or where a client presents a danger to self, to others, to property, or is gravely disabled.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by the custodian of records. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. The Center for Professional Counseling (“The Center”) and all its counselors will not release records to any outside party unless authorized by all family members who were part of the treatment.

Emergencies: If there is an emergency during our work together where your counselor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychological care, s/he will do whatever s/he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, the law permits The Center for Professional Counseling to contact the person whose name you have provided on the intake form as the emergency contact, without your verbal or written consent.

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct The Center for Professional Counseling, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the Psychotherapy Notes will not be disclosed to your insurance carrier. Neither The Center and/or its counselors have any control or knowledge over what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance.

Legal Issues: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), you agree to pay the fee of $125.00 per hour for any expert witness and/or court appearance made by a representative of The Center on your behalf. Further, you agree to pay $25.00 per letter written on your behalf for legal, medical, educational, or social service matters.

Consultation: Your Counselor may be an MFT (Marriage and Family Therapist) registered associate or trainee, by law, he/she will consult regularly with licensed mental health professionals regarding his/her clients. We will use your health information to make decisions about the provision coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. CPC is a general practice counseling agency and is not a crisis or urgent care behavioral health entity. CPC may refer client(s) in need of a higher level of care to other organizations or private practice therapist who could better treat the presenting issue(s) and diagnosis. Confidentiality is fully maintained.

Considering all of the above exclusions, if it is still appropriate, upon your request, The Center for Professional Counseling will release information to any agency/person you specify after you complete and sign The Authorization to Release Information Form provided by The Center.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact your counselor between sessions, please leave a message at (818) 761-2227, your counselor will provide you with their personal and confidential voice mail box number at your first session. Your call will be returned as soon as possible. Your counselor checks his/her messages a few times a day, unless s/he is out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone immediately, you can call Olive View / UCLA Medical Center at (818) 364-1555 or 9-1-1.

PAYMENTS & FEES: YOUR OUT OF POCKET FEE WILL BE DETERMINED DURING THE INTAKE BASED ON YOUR INCOME DOCUMENTS AND ABILITY TO PAY AND IS CONTRACTUALLY AGREED UPON AT THAT TIME TO BE PAID IN FULL AT THE TIME OF EACH VISIT. THE INTAKE FEE IS A NON-REFUNDABLE ONE TIME FEE. Your out of pocket fee will be re-evaluated as your financial circumstances change. The Center􏰃s full fee for counseling is $125.00 per session. You will fully cooperate with this process of collection as it pertains to you.

MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of The Center for Professional Counseling and you. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Los Angeles County, California in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, The Center for Professional Counseling can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys􏰃 fees. In the case of arbitration, the arbitrator will determine that sum.

CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, aminimum of 24 hours (1 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

RETURNED CHECKS: If the bank returns any of your checks made payable to The Center for Professional Counseling unpaid, you will be responsible for the amount of the check and an additional $25.00 service charge.

Dual Parent Consent 

The Center requires consent for treatment from both parents, unless custody or other legal circumstances negate it.  To expedite treatment, the parent submitting this form presently can direct the other parent to the stand-alone consent form here: 

https://form.jotform.com/thecenterpro/minor-consent

The Clinical Team will receive their submission and attach it to the file.