Sandra Paolini, MFT (MFC 44530)
325 Cumberland St. Suite G Pittsburg, CA 94565
sandra@sandrapaolinimft.com
925-457-7230
Introduction: Welcome to my practice. I am a California licensed Marriage and Family Therapist. This document contains important information about my professional services and business policies, as well as information regarding your treatment. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document it will represent an agreement between us.
Professional fees: My hourly fee is $125.00/50 minute session; however, in circumstances of unusual financial hardship, I am willing to negotiate a sliding scale fee adjustment.
Meetings and Cancellations: The client is responsible for payment of the agreed upon fee for any missed session(s). Client is also responsible for payment of the agreed upon fee for any session(s) for which Client failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 925-357-7230. Text messages are also acceptable.
Insurance: Client is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Client is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is a contracted provider with the following companies: Cigna, Aetna, Magellan and Contra Costa Medi-cal and has agreed to a specified fee. If Client intends to use benefits of his/her health insurance policy, Client agrees to inform Therapist in advance.
Contacting me: I am often not immediately available by telephone, although when not available, my phone is voice mail activated. I monitor voice mail throughout normal working hours. I will make every effort to call you back within 24 hours with the exception of weekends and holidays. If you are unable to reach me and feel you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.
Minors and Confidentiality: If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from the parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information, I will discuss the matter with you, if possible and do my best to handle any objections you may have with what I am prepared to discuss.
Confidentiality: In general, law protects the privacy of all communications between a client and a therapist and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about our treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. Please be aware that all records as well as notes on sessions and phone calls can be subject to court subpoena under certain extreme circumstances.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child or an elderly or disabled person is being abused, I must file a report with the appropriate state agency.
If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking hospitalization for the client. If the client threatens to harm him/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help or provide protection.
I may occasionally find it helpful to consult other professions about a case. During the consultations, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that is important to our work together.
If you participate in marital or family therapy, I will not disclose information about our treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information, except in the circumstances limiting confidentiality as defined above.
Patient Litigation: Therapist will not voluntarily participate in any litigation, or custody dispute in which Client and another individual, or entity, are parties. Therapist has a policy of not communicating with Client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Client, Client agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made him/herself available for such an appearance at Therapist’s usual and customary hourly rate of $125.00 per hour
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Client Signature_________________________________________Date_______________
I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payor.
Client Signature_________________________________________Date_______________