1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE Telehealth by Simple Practice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in.

By signing this document, I acknowledge:

1. Telehealth by Simple Practice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Simple Practice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by Simple Practice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by Simple Practice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by Simple Practice Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. By signing this form, I certify: • That I have read or had this form read and/or had this form explained to me. • That I fully understand its contents including the risks and benefits of the procedure(s). • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

1. As updated January 1st, 2023, APPOINTMENTS AND CANCELLATIONS please remember to cancel or reschedule 48 hours in advance. You will be responsible for the entire fee if cancellation is less than 48 hours. The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist for time to be scheduled in advance. Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

TELEPHONE ACCESSIBILITY. If you need to contact me between sessions, please leave a message on my voicemail or a text. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION. Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it. 

PAYMENT & FEES. Please have your payment ready before the session begins. Payments must be in full at the time of session unless otherwise arranged. Fees are subject to increase with at least a 2-week advanced warning of any fee increase. Acceptable forms of payment are Credit and Debit cards. 

INSURANCE. If asked, I will provide a monthly “superbill”/invoice/receipt for you to submit to your insurance provider for possible reimbursement. Please understand that your insurance is an arrangement made between your carrier and yourself with reimbursement coming directly to you if provided by your insurer. It is your responsibility to understand what your reimbursement may be for services rendered by an “out of network provider.” 

ELECTRONIC COMMUNICATION. I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so.

2. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

(2) All existing confidentiality protections are equally applicable.

(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.

(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

3. TERMINATION. Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

1. Welcome to my office. As a Registered Marriage and Family Therapist I am governed by various laws and regulations and by the code of ethics of my profession. The Ethics Code requires that I make you aware of specific office policies and how these procedures may affect you. 

Patient Rights. Our relationship is strictly voluntary and you may leave the psychotherapy relationship any time you wish. Please keep in mind that ending relationships can be difficult and closure is very important when moving on. Given this, I request that you give at minimum two weeks’ notice so we can conclude on a healthy and positive note. Some risks and benefits of therapy; “you might feel worse, before you get better.” “Therapy may not work or may not accomplish the stated or intended goals.” “Relationships may change in unpredictable ways (e.g. divorce).” Termination policy: As stated above: Please keep in mind that ending relationships can be difficult and closure is very important when moving on. Given this, I request that you give at minimum two weeks’ notice so we can conclude on a healthy and positive note. Therapist has the right to terminate treatment for reasons including Non-payment of fees, ethical conflicts, therapist illness or retirement, therapist personal problem. The Department of Consumer Affairs’ Board of Psychology receives and responds to questions and complaints regarding the practice of psychology. If you have questions or complaints, you may contact the
Board at www.psychology.ca.gov, email bopmail@dca.ca.gove or calling 1866-503-3221.

Limits of Confidentiality. Sessions between psychotherapist and patient are strictly confidential, except under certain legally defined situations involving threats of harm to self or others, and situations of child abuse, elder abuse, or abuse of otherwise dependent individuals. If I suspect you are a danger to others, I am required by law to notify the police and to inform any intended victim(s). In the case of possible harm to yourself, I am ethically bound to inform your nearest relative, significant other, or to otherwise enlist methods to prevent your harm to self or suicide. In instances of child abuse, elder abuse, or dependent other abuse, I must notify the proper authorities. *In order to provide a high level of care, your case will be periodically discussed at consult meetings with other licensed therapists for clinical review and improvement. *Sessions may not be audio or video recorded without the exclusive consent of all parties involved, including that of your therapist (me). It is a felony to record a confidential conversation without the written consent of all involved parties.

2. If you know you will likely be engaged in a lawsuit (i.e. divorce or custody lawsuit) it is your responsibility to advise me of this possibility as soon as possible. If the court subpoenas my services and thus the services of Dana Julian, LMFT you will be charged the hourly rate of $300. per hour for the duration my services are required for the legal case, including any prep-time required. You will be billed for any costs incur related to your legal case including any necessary airfare, car or taxi transportation, hotel, phone, or legal assistance required.

Payment & Fees. Please have your payment ready before the session begins. Payments must be in full at the time of session unless otherwise arranged. Fees are subject to increase with at least a 2-week advanced warning of any fee increase. Acceptable forms of payment are Credit Cards in client portal. If at any time services such as letter writing or extra signatures are needed, there will be a $75 charges for signatures and $250 for any letter writing. 

Insurance. If asked, I will provide a monthly “superbill”/invoice/receipt for you to submit to your insurance provider for possible reimbursement. Please understand that your insurance is an arrangement made between your carrier and yourself with reimbursement coming directly to you if provided by your insurer. It is your responsibility to understand what your reimbursement may be for services rendered by an “out of network provider.” 

Telephone Accessibility & Emergency Procedures. I will return calls within 24 hours should you need to contact me between sessions. If you have a therapeutic emergency and I am out of town or unreachable for more than a few hours, contact my colleague Jackie Shapin, LMFT 818 875-0879. If it is a true, life-threatening emergency, call 911 for help or go to your nearest emergency room. In the event of a phone call beyond 10 minutes, you will be charged for that session/portion thereof at your usual hourly fee. Text and Email communications will be used for setting, changing, or canceling appointments but not for the discussion of clinical issues. Any emails written to me, shall be addressed in session and will not necessarily be answered. 

Appointments & Cancellation Policy: Sessions are 50 minutes long. If you need to cancel or reschedule an appointment, please notify me as soon as possible, at least 48 hours in advance, so that I might fill the hour. If there is 48-hour notice, you will not be charged. If there is NOT 48 hours’ notice, you WILL be charged the full session fee. If you are running late and do not text or call to let me know, I will wait no longer than 15 minutes after the hour. This is necessary because a professional time commitment is set aside and held exclusively for you. I have read, understood, and agreed to the conditions stated above:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. The Therapeutic Process You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: 

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm. 

2. If a client threatens grave bodily harm or death to another person. 

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years. 

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. 

5. Suspected neglect of the parties named in items #3 and #4. 

6. If a court of law issues a legitimate subpoena for information stated on the subpoena. 

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.