child, teen and adult psychotherapy services in san diego ......child, teen, and adult psychotherapy...

Child, Teen, and Adult Psychotherapy

5230 Carroll Canyon Rd, Suite 110 San Diego, CA 92121

858-342-1304 thrivetherapystudio.com

NewClientInformationPacket

Welcometoyourfirstappointment.

Duringyourfirstsession,yourThriveTherapistwillbegettingtoknowyourchildandfamily.However,someofthisinformationismoreeasilygatheredinwriting.Theseformsaredesignedtohelpyourtherapistgettoknowyourchildandfamilysituationasquicklyaspossibleinordertomoveforwardwiththerapy.Pleaseanswerthequestionswithasmuchdetailasyoucanandencourageyourchildtoaddininformationwhendesired.Youcanalsomarkquestionsthatyoudonotunderstandandtheycanbeaddressedduringyoursession.Thankyou!Name:____________________________________________________________________Today’sDate:___________________________________________________

DateofBirth:______________________Age:_________Gender: Male Female Other-Specify_________________________________

Personcompletingthisform:__________________________________________RelationshiptoChild:__________________________________

Whoreferredyoutome?_____________________________________MayIcontactthemtothankthemforthereferral? Yes No

ParentInformation:

Parent#1

Name:

PhoneNumber:

Address:

Employer/Occupation:

Parent#2

Name:

PhoneNumber:

Address:

Employer/Occupation:

Arethereothercaregiversinvolved? Yes No Ifso,pleasedescribe:____________________________________________________

_________________________________________________________________________________________________________________________________________________

Areparentsseparatedordivorced? Yes No Ifyes,pleasedescribethecustodyarrangementandprovide

documentation:______________________________________________________________________________________________________________________________

ContactInformation:

PatientHomeAddress:_____________________________________________City:_____________________________State:__________Zip:________________

OKtocontact? OKtoleavemessage?

Telephone: Home:__________________________________________ Yes No Yes No

Cell:____________________________________________ Yes No Yes No

Work:__________________________________________ Yes No Yes No

EmergencyContact:__________________________________Relationship:__________________________PhoneNumber:__________________________

FinanciallyResponsiblePerson’sInformation

Name_____________________________________________________________RelationshiptoClient__________________________________________________

Phone(ifdifferentfrompreviouslyenteredinformation)_______________________________________________________________________________

Address(ifdifferentfrompreviouslyenteredinformation)____________________________________________________________________________

of 15

CurrentSituation:

Whatareyourmainreasonsforseekingtherapyforyourchild?(Beasspecificasyoucan)

Whendidthisproblemstart?

Arethereotherconcernsthatyouhaveregardingyourchild’sdevelopmentorcurrentfunctioning? Yes No

Ifso,pleasedescribe:

Pleasecheckiftherehasbeenanyrecentchangesinthefollowing:

Sleeppatterns Physicalactivitylevel Eatingpatterns GeneraldispositionBehavior Weight Focus Energylevel Nervousness/TensionOther(describe)______________________________________________________________________________________________________

Whatareyourmaingoalsincomingtotherapy? 1. 2. 3.

Whatdoyoubelieveareyourchild’smainstrengths?

Whatdoyoubelieveareyourchild’smainchallenges?

FamilyInformationandLivingSituation:

Parent/Step-parent/CaregiversInvolved(Pleaseprovidename,age,occupation,personality,briefstatementabout

relationshipwiththechildforeachpersonheavilyinvolvedinchild’slife)

1.

2.

3.

4.

Ifparentsaredivorced,howoldwasthechildwhentheydivorced?____________

Describehowithasaffectedhim/her:_____________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________

SiblingInformation:(Pleaseprovidename,age,briefstatementaboutrelationshiptochild)

1. ______________________________________________________________________________________________________________________________

2. ______________________________________________________________________________________________________________________________

3. ______________________________________________________________________________________________________________________________

4. ______________________________________________________________________________________________________________________________

Pleasedescribeyourchild’scurrentlivingsituation(house,apartment,sharedlivingspace,whoelseislivinginhomeetc.):

of 15

SchoolInformation:

NameofSchool:_______________________________________Child’sgradelevel:___________Teacher’sName:_________________________________

Pleasedescribehis/hergrades:_____________________________________________________________________________________________________________

Pleasecheckallthatapplytoyourchild’seducationbelow:

DocumentedLearningDisability IndividualizedEducationPlan(IEP) 504Plan

GiftedandTalentedProgram BehaviorSupportPlan SSTMeetings

SpecializedClassroomInstruction SpecializedSchoolorDayProgram RemedialClasses

HomeSchoolorAlternateLearningEnvironment TutoringServices Counseling(Schoolbased)

Other_____________________________________________________________________________________________________________________________

Pleasedescribeanyboxeschecked,givingasmuchdetailaspossible:

Howwouldyoudescribeyourchild’sfunctioninginschool?(ex.Getsalongwellwithothers,responsivetoinstruction,defiant,shy,outgoing,attendance,etc.)

Doesyourchildhaveanybehaviorproblemsinschool? Yes No


Doesyourchildhaveanyacademicproblemsinschool? Yes No


Howdoyoubelievetheschool/teacherviewyourchild?(Hyperactive,Timid,HighAchieving,Procrastinating,etc.)

Whatareyourchild’sacademicstrengths?

Whatareyourchild’sacademicchallenges?

MayIcontacttheteacherorschoolpsychologisttodiscussyourchild? Yes No

Ifso,pleaseincludethenamesandphonenumbersofanyschoolprofessionalsyouwouldlikemetoconsultwith:

_________________________________________________________ ___________________________________________________________

CurrentMedicalInformation:

Doesyourchildhavehealthinsurance? Yes NoInsuranceCompany:_______________________________________________

NameofPediatrician:________________________________________PhoneNumber:_______________________OKtocontact? Yes No

Whenwasyourchild’slastappointmentwithhis/herpediatrician?______________________________________________________________

Listanycurrenthealthconcerns:

Pleaselistallcurrentmedications(Name,dose,frequency,reason):

Doesyourchildhaveaspecialdiet(orhashe/sheinthepast)?

Ifso,pleaseprovidedetails:

of 15

Pleaselistanyadditionalvitaminsorsupplementsyourchildtakes:

Pleasedescribeanymedicalissuesorseriousinjuriesorillnesses(past,present):

MedicalandDevelopmentalHistory:

Wasthepregnancyplanned? Yes No Isyourchildadopted? Yes No

Pleasedescribeyourpregnancyandanyprenatalcomplications(includeanyunusualstressorsormedicalissuesforyour

child’smotherduringpregnancy):

Howoftenwereprescriptiondrugs,cigarettes,alcohol,illegaldrugsusedduringpregnancy(pleasedescribe):

Pleasedescribeyourchild’sbirthandanycomplications:

Pleasedescribeyourchild’sdevelopmentalmilestones(walking,talking,eating,toileting,etc.)

Pleasedescribeanyconcernsyoumayhavewithyourchild’seatingandsleeppatterns:

Whatmedicalconditionshasyourchildexperiencedsincebirth(checkallthatapply)?

Abdominalpain Allergies Anemia Appendicitis Thyroidproblems

Highfever Headinjury Tic Troublesleeping Brokenbone

Frequenturination Bronchitis Bedwetting Visionproblems Chestpain

Chroniccold/cough Constipation Chickenpox Dentalproblems Breathingdifficulties

Diarrhea Dizziness Seizures Earinfections EatingproblemsFainting Fatigue Asthma Frequentheadaches Hearingproblems

Heartproblems Measles Mumps Poorappetite Overeating

Mononucleosis Nosebleeds Diabetes Sorethroat UnusualmovementsSinusitis Stroke Tonsillitis Tuberculosis Lossofconsciousness

Whoopingcough Cancer Vomiting Surgeryorhospitalization

Other(describe)_________________________________________________________________________________________________________________Doesyourchildhaveanyhistoryofsignificanttrauma? Yes No

Ifso,pleaseprovidedetails:

Isthereanyhistoryofthefollowing?

PhysicalAbuse? Yes No SexualAbuse? Yes No

DomesticViolenceBetweenParents? Yes No

Ifyes,pleaseexplain:_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

PreviousTreatment

Hasyourchildeverseenacounselorortherapistinthepast? Yes No

of 15

Ifyes,howlongagoandwhydidtreatmentend?_______________________________________________________________________________

Hasyourchildeverreceivedapsychologicalordevelopmentalevaluation? Yes No

Ifyes,bywhomandwhen?________________________________________________________________________________________________________

Hasyourchildeverreceivedadiagnosisforapsychologicalordevelopmentaldisability? Yes No

Ifyes,whatwasthediagnosis?___________________________________________________________________________________________________

Pleaselistanyandallpreviouspsychologicalservicesyourchildhasreceived:

Pleaselistanyhistoryofmentalhealthissues,substanceabuseissues,ordevelopmentaldisabilitiesinyourchild’sfamily:

Ifyourchildhaseverexperiencedsuicidalthoughts/suicideattempt(s)oranyotherviolentbehavior,pleasedescribe(ages,reasons,circumstances,how,etc):Pleasecheckbehaviorsandsymptomsthatoccurtoyourchildmoreoftenthanyouwouldlikethemtotakeplace:

Aggression Anger Anxiety Avoidingpeople Avoidingschool

Bedwetting Boredom Cheating Crying Homeworkdifficulties

Cyberaddiction Depression Dieting Distractibility Dizziness

Eatingdisorder Druguse Fatigue Elevatedmood Focusproblems

Hallucinations Lying Cursing Hopelessness Impulsivity

Judgmenterrors Loneliness Irritability Lowself-esteem Heartpalpitations

Memoryimpairment Moodshifts Nightmares Panicattacks Phobias/fears

Sexualbehavior Sickoften Stealing Speechproblems Sleepingproblems

Suicidalthoughts Texting Trembling Throwingthings Tummyache

Socialmediaissues Worrying Yelling Withdrawing

Other:_________________________________________________________________________________________________________________________

Brieflydiscusshowtheabovesymptomsimpairyourchild’sabilitytofunctioneffectively:

SocialandBehavioralInformation:

Pleasecheckallthatapplyasitrelatestohowyourchildgetsalongwithotherpeople:

Aggression Harmsself Difficultymaking/keepingfriends

Underactive Tantrums Respectful

Hyperactive Runsaway Difficultyfinishingatask

Sadness Impulsivity Separationdifficulties

Oppositional Sensorysensitivities Troublewiththelaw

Inattentive Propertydestruction Self-stimulatorybehavior

Affectionate Arguingoften Shy/Withdrawn

of 15

Rigid/Controlling Friendly Leader

Submissive Other:__________________________ Other:________________________________

Pleasedescribeanyconcernsyouhaveregardingyourchild’ssocialandbehavioralfunctioning:

Doesyourchildgetteased? Yes No Doesyourchildteaseothers? Yes No

Doesyourchildexhibittantrums? Yes No

Pleasedescribeanybehavioralchallengesyouhavewithyourchildathome(challengingtimesofday,outbursts,homework

difficulties,etc):

Pleasedescribedisciplinestrategiesyouusewithyourchild?

Doyoufeelliketheyareeffective?

Leisure/RecreationalInterests:

Pleaselistanyandallcurrentandpastactivitiesthatyourchildengagesinregularly(ex:art, books, crafts, sports, clubs,

music, outdoor activities, church activities):

Whatareyourchild’shobbiesorspecialinterests?

Whatactivitiesdoesyourchildenjoythemost?

CulturalInformation:

Towhichculturalorethnicgroup,ifany,doesyourchildidentify?_____________________________________________________________________

Isyourchildexperiencinganyproblemsrelatedtoculturalorethnicissues? Yes No

Ifyes,pleasedescribe:_____________________________________________________________________________________________________________

Religious/Spiritual:

Howreligiousorspiritualisyourchild?(Circlethenumberthatdescribeshim/herbest)

1 2 3 4 5 6 7 8 9 10

Very Somewhat NotatallAreyouoryourfamilyaffiliatedwithaspiritualorreligiousgroup? Yes NoWhichgroup?_____________________________

Wouldyourchildpreferspiritual/religiousbeliefstobeincorporatedintotherapy? Yes No

Ifyes,pleasedescribe:_____________________________________________________________________________________________________________

Isthereanyotherinformationyouwouldlikemetoknow?

of 15




ConsenttoTreatmentandBusinessPolicies

WelcometoThriveTherapyStudio!Itisapleasuretohaveyouhereandtobeginourjourneytogether.YourThrivetherapistwilldoeverythingwithintheirprofessionalcapacitytoensureyourtreatmentisasproductiveaspossible.Thefollowingpagesdescribeinformationfornewclientswhodesiretherapyservices.Pleasereadeachsectionthoroughlyandcarefullyandfeelfreetodiscussanyquestionsorreactionsyoumayhavewithyourtherapist.Attheend,thereisasignaturepagetosignthatindicatesthatyouhavereadandunderstoodthematerial.Whenyousignthisdocument,itwillrepresentanagreementbetweenus.

TreatmentPhilosophyWeapproachtherapyfromacollaborative,humanisticapproach.Wetypicallyutilizebehavioralstrategies,supportivetherapy,playtherapy,relaxationandmindfulness,andcognitiverestructuringwithchildren.Yourtherapistwillexpecttoworktogethertowardsalleviatingtheissuesthatcausedyoutoinitiatetreatmentonbehalfofyourchild.Thismayinvolverecommendationsfordifferentparentingapproachestouseathomeaswellasotherservicesthatmightbehelpfulforyouandyourchild.Ourprimarygoalistohelpyourchildandyourfamilyasawholefunctionbetterwhileaddressingthespecificconcernsthatbroughtyoutotreatment.

PsychologicalServicesPsychotherapyisnoteasilydescribedingeneralstatements.Itvariesdependingonthepersonalitiesofthetherapistandclient,andtheparticularproblemsyourchildisexperiencing.Therearemanydifferentmethodswemayusetodealwiththeproblemsthatyouhopetoaddress.Psychotherapyisnotlikeamedicaldoctorvisit.Instead,itcallsforaveryactiveeffortonyourpart.Inorderforthetherapytobemostsuccessful,youwillhavetoconsiderthethingswetalkaboutbothduringandbetweenoursessions.

Psychotherapycanhavebenefitsandrisks.Sincetherapyofteninvolvesdiscussingunpleasantaspectsofyourlife,youmayexperienceuncomfortablefeelingslikesadness,guilt,anger,frustration,loneliness,andhelplessness.Insomesituations,aclient’sproblemsmaytemporarilyworsenafterbeginningtreatment.Theserisksaretobeexpectedandareanormalprocesswhenpeoplearemakingimportantandoftendifficultchangesintheirlives.Ontheotherhand,psychotherapyhasalsobeenshowntohavemanybenefits.Therapyoftenleadstobetterrelationships,solutionstospecificproblems,andreductionsinfeelingsofdistress.

Ourfirstfewsessionswillinvolveanevaluationofyourchildandfamily’sneedsduringwhichyouwillbeofferedinitialimpressionsofhowourworktogetherwillbehelpfulandsomeofthedifficultiesthatcouldbeaddressedthroughtreatment.Youshouldevaluatethisinformationaswellasyourimpressionsofhowcomfortableyouwillbeworkingwithyourtherapist.Therelationshipintherapyisofsignificantimportanceandassuch,shouldbecarefullyconsideredpriortoproceeding.Pleaseaddressanyconcernsyouhaveregardingtherapywithyourtherapist,whowillattempttoaddressthemdirectlyordeterminethebestcourseofactiontotake.

Becausepeopleoftendisclosetotheirtherapistsmanydeeplyfeltpersonalthoughtsandexperiences,therelationshipcanbecomeverycloseandimportant.Sometimesclientsandtheirfamiliescometowanttherelationshiptobecomemorethanatherapeuticrelationship.Althoughthesefeelingsareunderstandable,itisnecessaryforallclientstorecognizethattheirtherapistcannotatanytime,duringorafteryourcourseoftherapy,befriendsorengageinanybusinessendeavors.Shouldyoumeetyourtherapistbychanceonthe

of 15

streetoratasocialgathering,yourtherapistwillnotinitiatecommunicationtomaintainyourconfidentiality.Shouldyouapproachthem,conversationwillbekepttoaminimum.Eventhoughyoumightinviteyourtherapist,theywillnotattendfamilygatheringsorcommunityeventswithyou.Whiletalkingaboutsexualthoughtsorfeelingsmaybeapartoftherapyformanypeople,actualsexualrelationsbetweenclientsandpsychotherapistsareneveracceptable.Theseboundariesareimportantforethical,effectivepsychotherapy.Evenaftertherapyhasended,theseboundariesremaininplace.

Sessions Therapysessionswillbescheduledatbothofourconvenience.Typically,wewillbeginmeetingonceper

week.Astreatmentcontinues,wewilldecidecollaborativelywhenmoretimeisneededbetweensessions.

ProfessionalFeesPaymentsforservicesprovidedcanbepaidbycheck,creditcard,orcashandisrequiredatthebeginningofeverysession.

Inadditiontoregularappointments,Thrivechargesyourtherapyrateperhourforotherprofessionalservicesyoumightneed,thoughchargeswillbebrokendowninto15minuteincrementsofthehourlycostifthetherapistworksforperiodsoflessthanonehour.Otherservicesmayincludereportwriting,consultationwithotherauthorizedprofessionals,extendedtelephoneconversations,attendanceofmeetings,preparationofrecordsortreatmentsummaries,andtimespentperforminganyotherserviceyoumayrequest.Attimes,wemayengageintelephonecontactwithyouforpurposesotherthanschedulingsessions.Youareresponsibleforpaymentoftheagreeduponfeeforanytelephonecalllastinglongerthantenminuteseitherwithyouorwithanyauthorizedthirdparties.

Ifdeemedtherapeuticallyappropriate,sessionsmaytakeplaceinthehomeand/orcommunity.Additionally,observationsmayberequestedinachild’sschoolorothersetting,particularlywhenachildishavingbehavioralproblems.Theseobservationswouldonlyoccurwiththeconsentofthefamilyandthechild’sschooloralternatesetting.Observingbehaviorsintheirnaturalenvironmentcanbeextremelybeneficialandinformativeintreatmentandattimesleadstoimprovedbehavioralplanningandcollaborationwithotherprofessionals.Sessiontimebeginswhenyourtherapistleavestheofficetodrivetothegivenlocationandcontinuesuntiltheyreturntotheoffice.

LateAppointments Sessionsare45-50minutesinlength.Ifyouarelateforanappointment,youwillbeprovidedservicesforthe

remainderofthescheduledtimeandwillberesponsibleforthefeeoftheentiresession.

CancellationPolicyIfyouareunabletokeepyourappointment,weaskthatyoucancelassoonaspossible.Ifthisisdoneatleast24hourspriortoyourappointmenttime,therewillbenochargeforthecancellation.However,ifyoufailtoattendorcancelwithlessthan24-hournotice,youwillbechargedyourregularsessionfee.

BillingandPaymentforServices Clientsareexpectedtopayforservicesatthetimeservicesarerendered,includingco-pay.Weacceptcash,

checks,andmajorcreditcards.Therewillbea$50surchargeforeachreturnedcheck.

Ifyoufailtomakeapaymentfor2consecutivesessions,youwillbeunabletoscheduleanappointmentuntilpaymentismadeinfull.IfanylegalactionistakenagainstThrivesuchasneedingtoemployaprofessionalcollectionagencyand/orattorneytoenforcethisAgreement,youagreetopayforanylegalcostsaccruedbyThriveinsecuringpaymentforservices.

Yourtherapistwillassumethatouragreed-uponfee-payingrelationshipwillcontinueaslongasservicesareprovidedtoyou.Youhavearesponsibilitytopayforanyservicesyoureceive.Ifthereareanyproblemswith

of 15

charges,billing,orothermoneyrelatedconcerns,pleasebringthemtoyourtherapist’sattentionassoonaspossible.

InsuranceReimbursement Pleasebeawarethatmostinsurancecompaniesrequireaclinicaldiagnosis.Sometimeswehavetoprovide

additionalclinicalinformationsuchastreatmentplansandprogressionmadetowardtreatmentgoals,evenwhenengaginginoutofnetworkbilling.Thisinformationwillbecomepartoftheinsurancecompanyfilesandwillprobablybestoredinacomputer.Thoughallinsurancecompaniesclaimtokeepsuchinformationconfidential,wehavenocontroloverwhattheywilldowithitonceitisintheirhands.Wewillprovideyourinsurancecompanywithonlytheinformationrequiredinordertomeettheiradministrativeneeds.

Wewillbillinsuranceplansdirectlywhenable,however,ifweareunabletosubmitaclaimortheinsurancecompanypaysonlyaportionofthebillorrejectstheclaimentirely,thenyouareresponsibleforthetotalamountofbilledservices.Youretainallfinancialresponsibilityfortheservicesobtained.Ifyouhaveaco-pay,itisexpectedtobepaidatthetimeofservice.

YoushouldbeawarethatnotallThrivetherapistsacceptinsurance.Youcanrequestasuperbillfromyourtherapistandselfsubmittoyourinsurancecarrierforpossiblereimbursement.Pleasenotethatmanyinsuranceswillnotcoverservicesrendered,however,ifyouhavePPOinsurancewithOutofNetworkbenefits,youcansubmitthesuperbillforpossiblereimbursementofapercentageofthefeespaid.However,youareresponsibleforpayingallfeesupfrontwhetherornotyourinsurancereimbursesyou.

TerminationofTherapy Terminationisinevitableandpartofthetherapeuticprocess.Itshouldnotbedonecasuallyandisavaluable

partofourworktogether.Eitherofusmaywanttoterminateourworktogetherifwebelievethatitisinyourbestinterest.Wereservetherighttoterminatetherapyatyourtherapist’sdiscretion.Reasonsforterminationinclude,butarenotlimitedto,untimelypaymentoffees,failuretocomplywithtreatmentrecommendations,conflictsofinterest,failuretoparticipateintherapy,client’sneedsbeingoutsidethescopeofcompetenceorpractice,ortheclientnotmakingadequateprogressintherapy.Youalsohavetherighttoterminatetherapyatyourdiscretion.Ifeitherpartydecidestoterminatetherapy,werecommendthatwemeetforatleastonesessiontoreviewourworktogether,ourgoalsandaccomplishments,anyfurtherworktobedone,andouroptions.Thisprocessisintendedtofacilitateapositiveterminationexperienceandgivebothpartiestheopportunitytoreflectontheworkthathasbeendone.Wewillalsoattempttoensureasmoothtransitiontoanewtherapistbyprovidingreferralswhennecessary.

ClientLitigation Wewillnotvoluntarilyparticipateinanylitigation,orcustodydisputeinwhichyouandanotherindividual,or

entity,areparties.Wehaveapolicyofnotcommunicatingwithattorneysandwillgenerallynotwriteorsignletters,reports,declarations,oraffidavitstobeusedinalegalmatter.Wewillgenerallynotproviderecordsortestimonyunlesscompelledtodoso.Shouldwebesubpoenaed,ororderedbyacourtoflawtoappearasawitness,youagreetoreimburseyourtherapistforanytimespentforpreparation,travel,orothertimeinwhichwewereavailableforsuchanappearanceattherateof$300perhour.Timespentincourtorbeingdeposedwillbebilledat$350perhour.

RecordsandRecordKeeping Wearerequiredbylawtomaintainrecordsofyourtreatment.Wewillkeepprogressnotes,whichinclude

informationregardingtreatmentprogressandstrategiesusedinsession.SuchrecordsareThriveTherapyStudio’ssoleproperty.Shouldyourequestacopyofrecords,sucharequestmustbemadeinwriting.Wereservetheright,underCalifornialaw,toprovideyouwithatreatmentsummaryinlieuofactualrecords,ifdeemedmoreappropriate.Wewillmaintainyourrecordsfor10yearsafterterminationoftherapy.After10years,yourrecordswillbedestroyedinawaythatpreservesyourconfidentiality.

of 15

ConfidentialityIngeneral,theconfidentialityofallcommunicationsbetweenaclientandatherapistisprotectedbylawandwecanonlyreleaseinformationaboutourworktootherswithyourwrittenpermission.However,thereareanumberofexceptions.Inmostjudicialproceedings,youhavetherighttopreventyourtherapistfromprovidinganyinformationaboutyourtreatment.However,insomecircumstancessuchaschildcustodyproceedingsandproceedingsinwhichyouremotionalconditionisanimportantelement,ajudgemayrequiretestimonyifhe/shedeterminesthatresolutionoftheissuesbeforehim/herdemandsit.

1. Ifaclientisthreateningseriousbodilyharmtoanother,yourtherapistisrequiredtotakeprotectiveactions,whichmayincludenotifyingthepotentialvictim,notifyingthepolice,orseekingappropriatehospitalization.

2. Ifaclientthreatenstoharmhimself/herself,yourtherapistmayberequiredtoseekhospitalizationfortheclient,ortocontactfamilymembersorotherswhocanhelpprovideprotection.

3. Ifyourtherapistbelievesthatachild,anelderlyperson,oradisabledpersonisbeingabused,yourtherapistmustfileareportwiththeappropriatestateagency.

4. Ifyourtherapistassessesthepatienttobeadangertoself,orunabletotakecareofhimself/herself,theappropriateauthoritiesmaybenotified.

5. Intheeventoffailuretopayabillinreasonabletime,thenameofthepatientmaybegiventoacollectionagencytocollectpaymentormayberecordedinsmallclaimscourt.

6. Somelegalactionsinitiatedbythepatientorthepatient’sestatemayresultinthecourtorderingthereleaseofrecords.

7. Recordsandinformationregardingyourdiagnosisandtreatmentmustbesubmittedtoyourinsurancecarrierfordeterminationofbenefitsandauthorizationforcontinuedtreatment.

ProfessionalStatusStatementPleasenotethat,pursuanttothelawsoftheStateofCalifornia,clinicalworkdonebyPsychologicalAssistants,MarriageandFamilyTherapyinterns(MFTI),andSocialWorkInterns(ASW),mustbesupervisedbyalicensedclinician.ThismeansthatDr.EricaWollerman,alicensedpsychologist,maybereviewingyourrecordsandyourpsychotherapyifsheissupervisingyourtherapist.Telecommunication

Betweensessionsyourtherapistisavailablebyphone,fax,andemail.Pleasebeawarethatinformationcommunicatedthesewayswillbeheldwithasmuchconfidentialityaspossiblebutthattherearerisksinherenttothesemodesofcommunicationincludingbutnotlimitedtotheinformationbeingseen/heardbyindividualsotherthanthoseintended.

AgreementtoArbitrate

Itisunderstoodthatanydisputeastopsychologicalmalpractice,thatisastowhetheranypsychologicalservicesrenderedunderthiscontractwereunnecessaryorunauthorizedorwereimproperly,negligentlyorincompetentlyrendered,willbedeterminedbysubmissiontoarbitrationasprovidedbyCalifornialaw,andnotbyalawsuitorresorttocourtprocessexceptasCalifornialawprovidesforjudicialreviewofarbitrationproceedings.Bothpartiestothiscontract,byenteringintoit,aregivinguptheirrighttohaveanysuchdisputedecidedinacourtoflawbeforeajury,andinsteadareacceptingtheuseofarbitration.Allclaimsformonetarydamagesexceedingthejurisdictionallimitofthesmallclaimscourtagainstthepsychologistandthepsychologist’spartners,associates,association,corporationorpartnership,andtheemployees,agentsandestatesofanyofthem,mustbearbitratedincludingclaimsforlossofconsortium,emotionaldistressorpunitivedamages.Ademandforarbitrationmustbecommunicatedinwritingtoallparties.Eachpartytothearbitrationshallpaysuchparty’sproratashareoftheexpensesandfeesoftheneutralarbitrator,togetherwithotherexpensesofthearbitrationincurredorapprovedbytheneutralarbitrator,notincludingcounselfeesorwitnessfees,orotherexpensesincurredbyapartyforsuchparty’sownbenefit.Eitherpartyshallhavetheabsoluterighttoarbitrateseparatelytheissuesofliabilityanddamagesuponwrittenrequest.

of 15

ContactingYourTherapistYourtherapistoftenwillnotbeimmediatelyavailablebytelephoneaswedonotanswercallsduringmeetingsortherapysessions.Assuch,leavingavoicemailmessageistypicallythebestwaytoreachus.Ifyouleaveamessage,yourcallwillbereturnedbetween24-48hoursafteryoucall,dependingontheurgencyofthesituationandthedaythatyoucall.Generally,messagesarereturneddailyexceptSaturdays,Sundays,andholidays.Ifyourtherapistwillbeunavailableforanextendedtime,youwillbeprovidedwiththenameofacolleaguetocontact,ifnecessary.Ifyouarehavinganemergency,suchassuicidalthoughts,andyourtherapistdoesnotrespondquicklyenoughforyourneeds,pleaseeithercalltheAccessandCrisislineat1-888-724-7240orgotoahospitalemergencyroom.Ifyouareexperiencingamedicalemergency,call911.YoursignaturebelowindicatesthatyouhavereviewedtheinformationcontainedintheConsenttoTreatmentdocument,thatyouhavereceivedacopyofthedocument,andthatyouagreetoabidebyitstermsduringourprofessionalrelationship.Withyoursignatureyouareprovidingpermissiontoprovideyouand/oryourchildwithprofessionalservicesasamentalhealthclinician.__________________________________________________ __________________________________________________________________Signature PrintedName Date

__________________________________________________ __________________________________________________________________MinorSignature(age12+) MinorPrintedName(age12+) Date

of 15




ConsentforTreatmentofMinors

Minor’sInformation

Name:______________________________________________________________ DateofBirth:____________________

School:_____________________________________________________________ Grade:_______________

ThisdocumentcertifiesthatIgivepermissiontoThriveTherapyStudioforthepsychologicaltreatmentofmychild.Iunderstandthatthistreatmentmayincludeindividualtherapyandfamilytherapy.Inordertoensurecontinuityofcare,yourtherapistmayrequestthatyousignareleaseofinformationformtoconsultwithotherprofessionalsthatareinvolvedinyourchild’scareincluding:Pediatricians,SchoolPersonnel,andpasttherapyproviders.

Californiastatelawmandatesthereportingofcertaintypesofchildabuseincludingphysicalabuse,sexualabuse,unlawfulsexualintercourse,neglect,andemotionalandphysicalabuse.Allactualorsuspectedactsofchildabusewillbereportedtotheappropriateauthorities.

Ifparentsaredivorced,pleasespecifythecustodyarrangement:____________________________________________________________________________________________________________________________________________________________________________

*Pleasenote:Exceptinrarecircumstances,bothbiologicalparentsorallinvolvedguardiansandadoptedparentsneedtosignthisformpriortotreatmentbeginning.Pleaseaskyourtherapistforfurtherclarificationifneeded.

Parent#1

___________________________________________________________ ________________________________________________________________PrintNameofParent/Guardian(withlegalcustody) SignatureofParent/Guardian Date___________________________________________________________ ___________________________________________________________________StreetAddress City,State,Zip___________________________________________________________ ___________________________________________________________________HomePhone CellPhone

Parent#2

___________________________________________________________ ________________________________________________________________PrintNameofParent/Guardian(withlegalcustody) SignatureofParent/Guardian Date___________________________________________________________ ___________________________________________________________________StreetAddress City,State,Zip___________________________________________________________ ___________________________________________________________________HomePhone CellPhonePleaseaddadditionalParent/GuardianinformationandsignaturestothebackofthisformiftherearemorethantwoParent/Guardian(s)involvedandwithcustody.

of 15




CALIFORNIANOTICEFORM

NoticeofPsychologists’PoliciesandPracticestoProtectthePrivacyofYourHealthInformationThisnoticedescribeshowpsychologicalandmedicalinformationaboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.Pleasereviewitcarefully.ThisnoticeconformstotheFederalHealthInsurancePortabilityandAccountabilityAct(HIPAA)effectiveApril14,2003.ItalsoconformstotheHealthCarePrivacyLawsofCalifornia.1.DisclosuresforTreatment,Payment,andHealthCareOperations:Wemayuseordiscloseyourprotectedhealthinformation(PHI),forcertaintreatment,payment,andhealthcarepurposeswithoutyourauthorization.Incertaincircumstances,wecanonlydosowhenthepersonorbusinessrequestingyourPHIgivesusawrittenrequestthatincludescertainpromisesregardingprotectingtheconfidentialityofyourPHI.Tohelpclarifytheseterms,herearesomedefinitions:

• “PHI”referstoinformationinyourhealthrecordthatcouldidentifyyou.“TreatmentandPaymentOperations”

• “Treatment”iswhenweprovidetreatmentoranotherhealthcareproviderdiagnosesortreatsyou.Anexampleoftreatmentwouldbewhenyourtherapistconsultswithanotherhealthcareprovider,suchasyourfamilyphysicianoranotherpsychologist,regardingyourtreatment.

• “Payment”iswhenweobtainreimbursementforyourhealthcare.ExamplesofpaymentarewhenwediscloseyourPHItoyourhealthinsurertoobtainreimbursementforyourhealthcareortodetermineeligibilityorcoverage.

• “HealthCareOperations”iswhenwediscloseyourPHItoyourhealthcareserviceplan(forexampleyourhealthinsurer),ortoyourotherhealthcareproviderscontractingwithyourplan,foradministeringtheplan,suchascasemanagementandcarecoordination.

• “Use”appliesonlytoactivitieswithinourofficesuchassharing,employing,applying,utilizing,examining,andanalyzinginformationthatidentifiesyou.

• “Disclosure”appliestoactivitiesoutsideofourofficesuchasreleasing,transferring,orprovidingaccesstoinformationaboutyoutootherparties.

• “Authorization”meanswrittenpermissionforspecificusesordisclosures.

2.UsesandDisclosuresRequiringAuthorization:WemayuseordisclosePHIforpurposesoutsideoftreatment,payment,andhealthcareoperationswhenyourappropriateauthorizationisobtained.Inthoseinstanceswhenweareaskedforinformationforpurposesoutsideoftreatmentandpaymentoperations,wewillobtainanauthorizationfromyoubeforereleasingthisinformation.Wewillalsoneedtoobtainanauthorizationbeforereleasingyourpsychotherapynotes.“Psychotherapynotes”arenotesyourtherapisthavemadeaboutourconversationduringaprivate,group,joint,orfamilycounselingsession,whichwehavekeptseparatefromtherestofyourmedicalrecord.ThesenotesaregivenagreaterdegreeofprotectionthanPHI.Youmayrevokeormodifyallsuchauthorizations(ofPHIorpsychotherapynotes)atanytime;however,therevocationormodificationisnoteffectiveuntilwereceiveitinwriting.3.UsesandDisclosureswithNeitherConsentnorAuthorization:WemayuseordisclosePHIwithoutyourconsentorauthorizationinthefollowingcircumstances:

of 15

1. ChildAbuse:Wheneveryourtherapist,intheirprofessionalcapacity,hasknowledgeoforreasonablysuspectthatachildhasbeenthevictimofchildabuseorneglect,theymustimmediatelyreportsuchtoChildrenProtectionServices(CPS).Also,iftheyhaveknowledgeoforreasonablysuspectthatmentalsufferinghasbeeninflicteduponachildorthathisorheremotionalwellbeingisendangeredinanyotherway,theymayreportsuchtoCPSaswell.

2. ElderorDependentAdultAbuse:Ifyourtherapist,intheirprofessionalcapacity,haveobservedorhaveknowledgeofanincidentthatreasonablyappearstobephysicalabuse,abandonment,abduction,isolation,financialabuseorneglectofanelderordependentadult,oriftheyaretoldbyanelderordependentadultthatheorshehasexperiencedtheseoriftheyreasonablysuspectsuch,yourtherapistmustreporttheknownorsuspectedabuseimmediatelytoAdultProtectiveServices(APS)orthelocallawenforcementagency.

Yourtherapistdoesnothavetoreportsuchanincidentif:• Theyhavebeentoldbyanelderordependentadultthatheorshehasexperiencedbehaviorconstituting

physicalabuse,abandonment,abduction,isolation,financialabuseorneglect;• Theyarenotawareofanyindependentevidencethatcorroboratesthestatementthattheabusehas

occurred;• theelderordependentadulthasbeendiagnosedwithamentalillnessordementia,oristhesubjectofa

courtorderedconservatorshipbecauseofamentalillnessordementia;and• intheexerciseofclinicaljudgment,theyreasonablybelievethattheabusedidnotoccur.

3. HealthOversight:IfacomplaintisfiledagainstThriveoryourtherapistwiththeCaliforniaBoardofPsychology,theBoardhastheauthoritytosubpoenaconfidentialmentalhealthinformationfromusrelevanttothatcomplaint.

4. JudicialorAdministrativeProceedings:Ifyouareinvolvedinacourtproceedingandarequestismadeabouttheprofessionalservicesthatwehaveprovidedyou,wemustnotreleaseyourinformationwithout1)yourwrittenauthorizationortheauthorizationofyourattorneyorpersonalrepresentative;2)acourtorder;or3)asubpoenaducestecum(asubpoenatoproducerecords)wherethepartyseekingyourrecordsprovidesuswithashowingthatyouoryourattorneyhavebeenservedwithacopyofthesubpoena,affidavitandtheappropriatenotice,andyouhavenotnotifiedusthatyouarebringingamotioninthecourttoquash(block)ormodifythesubpoena.Theprivilegedoesnotapplywhenyouarebeingevaluatedbyathirdpartyorwheretheevaluationiscourt-ordered.Wewillinformyouinadvanceifthisisthecase.

5. SeriousThreattoHealthorSafety:Ifyoucommunicatetousaseriousthreatofphysicalviolenceagainstanidentifiablevictim,wemustmakereasonableeffortstocommunicatethatinformationtothepotentialvictimandthepolice.Ifwehavereasonablecausetobelievethatyouareinsuchacondition,astobedangeroustoyourselforothers,wemayreleaserelevantinformationasnecessarytopreventthethreateneddanger.

6. Workers’Compensation:Ifyoufileaworker'scompensationclaim,yourtherapistmustfurnishareporttoyouremployer,incorporatingtheirfindingsaboutyourinjuryandtreatment,withinfiveworkingdaysfromthedateofyourinitialexamination,andatsubsequentintervalsasmayberequiredbytheadministrativedirectoroftheWorker’sCompensationCommissioninordertodetermineyoureligibilityforworker’scompensation.

4.Patient’sRightsandPsychologist’sDuties:a. Patient’sRights:

i. RighttoInspectandCopy:Youareentitledtoreceiveacopyofyourmedicalrecordunlessyourtherapistbelievesthatreceivingthatinformationwouldbeemotionallydamaging.Becausetheseareprofessionalrecords,theycanbemisinterpretedand/orupsettingtountrainedreaders.Ifyouwishtoseeyourrecordsorreceiveacopyofyourrecords,werequirewrittennoticetothateffect,andwewouldexpecttodiscussyourrequestwithyouinperson.Ifwedenyyouaccesstoyourrecords,youcanrequesttospeakwithanindependentcolleagueofoursaboutyourrequest.Yourrequestforindependentreviewofyourrequestshouldalsobemadeinwriting.Ifyouareprovidedwithacopyofyourmedicalrecordinformation,wemaychargeafeeforanycostsassociatedwiththatrequest.

ii. RighttoAmend:Ifyoubelievethattheinformationwehaveaboutyouisincorrectorincomplete,youmayaskustoamendthatinformation.Itisourpracticetoacceptthissortofrequestinwriting,andthatanyinformationyoumaywishtoaddtoyourrecordalsobeprovidedtousinwrittenform.

iii. RighttoanAccountingofDisclosures:Youhavetherighttorequestan"AccountingOfDisclosures."Thisisalistofthedisclosureswehavemadeofmedicalrecordinformation.That

of 15

informationislistedontheAuthorizationToReleaseInformation,andwillbeprovidedtoyouatyourwrittenrequest.

iv. RighttoRequestRestrictions:Youhavetherighttoprivacy,andtorequestarestrictionorlimitationonthehealthinformationweuseordiscloseaboutyoufortreatment,paymentorhealthcareoperations.Asnotedabove,wewillnotreleaseyourconfidentialinformationwithoutyourwrittenpermission.AnyrestrictionstoyourAuthorizationToReleaseInformationshouldbespecifiedontheAuthorization.

v. RighttoRequestConfidentialCommunications:Youhavetherighttorequestthatwecommunicatewithyouonlyincertainways.Forexample,youcanaskthatwenotleaveatelephonemessageforyou,orthatweonlycontactyouatworkorbymail.

vi. ComplaintsRegardingPrivacyRights:Ifyoubelieveyourprivacyrightshavebeenviolated,youmayfileawrittencomplaintwithyourtherapist,orwithanindependentcolleagueoftheirs,orwiththeU.S.DepartmentofHealthandHumanServices,50UnitedNationsPlaza,Room322,SanFrancisco,CA,94102.YouhavespecificrightsunderthePrivacyRule.Wewillnotretaliateagainstyouforexercisingyourrighttofileacomplaint.

vii. Youhavetherighttoapapercopyofthisdocument,andyouwillbeofferedonewhenyousigntheoriginalforyourmedicalrecord.Wereservetherighttochangeourpoliciesasoutlinedherein.Iftheychange,youwillbeinformedofthatchangeandwillprovidedwithacopyofthecurrentdocumentifdesired.

b. Psychologist’sDuties:i. WearerequiredbylawtomaintaintheprivacyofyourPHIandtoprovideyouwithanoticeofour

legaldutiesandprivacypracticeswithrespecttoPHI.ii. Wereservetherighttochangetheprivacypoliciesandpracticesdescribedinthisnotice.Unlesswe

notifyyouofsuchchanges,however,wearerequiredtoabidebythetermscurrentlyineffect.iii. Ifwereviseourpoliciesandprocedures,wewillprovideyouwitharevisednoticeeitherinpersonor

bymail.

ACKNOWLEDGEMENTOFRECEIPTOFNOTICEOFPRIVACYPRACTICES

By signing this form, you hereby acknowledge receipt of this office’s Notice of Psychologists’ Policies and Privacy Practices that we have provided to you. This Notice of Psychologists’ Policies and Privacy Practices provides

information about how we may use and disclose your protected health information. We encourage you to read it in full.

This Notice of Psychologists’ Policies and Privacy Practices is subject to change. The most recent version will be on the

Thrive website at www.thrivetherapystudio.com. If we change the notice, you may obtain a copy of the revised notice from your therapist by contacting them via telephone or visiting our website.

If you have any questions about this Notice of Psychologists’ Policies and Privacy Practices, please contact us via

telephone at (858) 342-1304.

__________________________________________________ __________________________________________________________________Signature PrintedName Date

child, teen and adult psychotherapy services in san diego ......child, teen, and adult psychotherapy...

Documents