Outpatient Services Contract

Welcome to my private practice. This document contains important information about my mental health services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them when we meet. When you sign this document, it will represent an agreement between you and Jill Boultinghouse, LMFT.

PSYCHOTHERAPY SERVICES
Psychotherapy is not easily described in general terms. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, you will have to work on things talked about both during sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time and energy, so you should be very careful about entering into therapy. If you have any questions about our procedures, you should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.

MEETINGS
We usually schedule one 45-50 minute session (one appointment lasting 45-50 minutes) per week at a time we agree on, although some sessions may be longer or more frequent. Once any appointment is scheduled, you will be expected to attend it unless you provide 24 hours advance notice of rescheduling/cancellation.

PROFESSIONAL FEES
Individual adult 45-50 minute sessions are $175 per 50 minute session for individual adults, $200 for minors, couples, families and EMDR clients. Once we schedule an appointment, you are responsible for the fees for that appointment unless you give 24 hours advance notice of cancellation or rescheduling. Payment is due at the time services are rendered. Cash and checks are accepted.

CONTACTING YOUR THERAPIST
I can be reached Monday - Friday 8am-5pm at 949-702-2360. If you have an emergency, please call 911.

PROFESSIONAL RECORDS
The laws and standards of my profession require that we keep treatment records. You are entitled to receive a copy of the records unless your therapist believes that seeing them would be emotionally damaging, in which case we will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in one of our therapist’s presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests.

MINORS
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 our policy to request an agreement from parents that they agree to give up access to your records. If they agree by signing this contract, your therapist will provide them only with general information about your work , unless the therapist feels there is a high risk that you will seriously harm yourself or someone else. In this case, the therapist will notify them of his/her concern. Before giving them any information, the therapist will discuss the matter with you, if possible, and do his/her best to handle any objections you may have with what he/she is prepared to discuss.

CONFIDENTIALITY
In general, the privacy of all communications between a patient and a psychotherapist is protected by law, and a therapist can only release information about your work to others with your written permission. But there are a few exceptions that we need to inform you about, even though they rarely occur in our clinic.

In most legal proceedings, you have the right to prevent me from providing any information about your 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.

There are some situations in which a therapist is legally obligated to take action to protect others from harm, even if he or she have to reveal some information about a patient’s treatment. For example, if a therapist suspects that a child, elderly person, or disabled person is being abused, he/she is required by law to file a report with the appropriate agency.

If a therapist believes a patient is threatening serious bodily harm to another, the therapist is required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens harm to himself/herself, the therapist may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors. You may contact the Board online at www.bbs.ca.govor by calling (916) 574-7830.

The Board has developed an FAQ—found online at
www.bbs.ca.gov/pdf/ab630.pdf—to provide more information about this requirement, including information on how unlicensed mental health counselors need to comply.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have when we meet. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not attorneys.

If you have any concerns about our work together, please feel free to address them directly with me.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during your therapeutic relationship with Strength in Support.