CONSENT FOR TREATMENT

Notice of Business Policies and Privacy Practices

Rose Junie Therapy

Rosalisa D. Abito, LMFT / Founder and Clinical Director

4105 East Broadway Ste 205, Long Beach, CA 90803

rosejunietherapy.com

This document contains important information related to our professional services and business policies, as well as your rights and responsibilities as a patient and a client of this Practice. Signing this document will represent an agreement between you and us, your "Therapist Provider." The information provided herein regarding our policies for protecting the privacy of confidential medical information is provided as required by law. 

GENERAL INFORMATION

Information about Your Therapist Provider

This Practice is conducted by Junie Abito & Associates, a marriage & family therapy corporation (sometimes referred to in this Consent as its dba "Rose Junie Therapy" or the "Practice"), which is owned by Rosalisa D. Abito, its President.

Your individual therapist, Rosalisa D. Abito, is a California Board Licensed Marriage and Family Therapist, LMFT #105987.

Risks and Benefits of Therapy

Psychotherapy (i.e., "therapy") is not easily described in general statements. It varies depending on the personalities of the therapist and patient and the particular problems you bring forward. Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you are encouraged to consider the things we talk about both during and between our sessions.

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 commit to it. Therapy often leads to better relationships, solutions to specific or lifelong problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Therapy involves a significant investment of time, money, and energy, so you should think carefully about making this commitment. If you have questions or concerns about the work involved, you can discuss them with your therapist whenever they arise. In general, it would be important for you to discuss your concerns and attempt to address them directly. If you decide at any time that your work is unsatisfactory, your therapist would be happy to help you determine the best course of action to take, e.g., stop treatment altogether, or begin treatment with another provider.

Sessions

Your therapist will typically conduct an initial evaluation lasting 1 to 3 sessions. During this time, you and your therapist can decide if they (i.e., your therapist) are the best person to provide the services that you need. If both of you do decide to work together in psychotherapy (or all participants in the case of couples or family therapy), one 50-minute session will be scheduled on a regular basis (e.g., weekly or bi-weekly) at a time upon which both of you agree.

Contacting Your Therapist 

Your therapist will make every effort to return messages within 48 hours (or by the next business day) but cannot guarantee the calls will be returned immediately. We are unable to provide 24-hour crisis service. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911, or go to the nearest emergency room.

Termination of Therapy

Your therapist reserves the right to terminate therapy at their discretion. Reasons for termination include but are not limited to: untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, your needs being outside of the therapist's scope of competence or practice, or you are not making adequate progress in therapy. You also have the right to terminate therapy at your discretion. Upon either party's decision to terminate therapy, your therapist will generally recommend that you participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. 

PAYMENT AND CANCELLATION

Professional Fees

The fee for sessions with your designated therapist is $450 per 50-minute session, which is also your therapist's regular hourly rate. For couples and family therapy, the fee per session is $450 per 50-minute session. Clients are responsible for paying all fees associated with the services provided, and any outstanding balances or invoices from previous sessions must be settled before scheduling any new appointments.

In addition to regular appointments, your clinician's hourly rate is charged for other professional services you may need, and the charges can be broken down and pro-rated for periods of less than one hour (this does not include the early cessation of regularly scheduled sessions). These additional services may include: report writing, extended sessions, extended telephone conversations, collateral sessions, attendance at meetings or coordination of care with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request. Your therapist reserves the right to adjust their fees and hourly rates periodically, and you will be informed in advance.

Important notice: While we understand the importance of letters of recommendation, the completion of disability forms, requests for an extended leave of absence from work, and other workplace accommodations, unfortunately, we cannot fulfill these types of requests as they are outside our domain of authority.

Billing and Payment for Services

Unless otherwise agreed upon, payment is expected at the time of service. Please note your therapist does not accept insurance. If paying for your services would create a financial burden on you, your therapist may be willing to negotiate a reduced fee, according to our sliding fee scale, based upon your current income, which you may be asked to verify by your last two paycheck stubs or your income tax statement from the previous year. Payment schedules for other professional services will be determined at the time they are requested. If you fail to make payments according to your agreement or at the time of service and your account becomes delinquent (60 days after the date payment was due), then you agree to allow this Practice to attempt recovery of all fees through a collection agency or small claims court. 

Unless stated otherwise, all EMDR intensives and upfront payments for bundled EMDR sessions must be used within 30 days of purchase. Please note that all prepaid sessions must be used and will not be reimbursed for any reason, as stated in this consent. 

Cancellation Policy

When an appointment is scheduled, this time is set aside specifically for you. Therefore, once an appointment is scheduled, you are responsible for the time reserved unless you provide at least 48 hours advance notice of cancellation. Kindly note that your therapist's policy differs from the 24-hour policy that other therapists commonly use. A notice of less than 48 hours notice for any reason will be considered a late cancellation.  A late cancellation or missed appointment does not allow that time to be reserved for another patient. Therefore, you will be charged your usual session fee in the event of a late cancellation or missed/no-show appointment; similarly, your late arrival or early cessation of a session will not be pro-rated. Late cancelation and no-show fees are not rendered services and, therefore, not eligible for reimbursement and will not be included on your superbill.

Insurance Reimbursement

For you and your therapist to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Please note that we are not currently accepting insurance, but we would be happy to provide you with a "superbill" that you can submit to your health insurance provider, should you choose to do so. However, we will not submit the superbill directly to your insurance provider, and we cannot guarantee whether your insurance provider will reimburse you for your treatment. You are responsible for paying for our services yourself, and to the extent you plan to make a claim for reimbursement, it is your responsibility to understand the limits of your insurance coverage. 

You should also be aware that a "superbill" contains confidential information pertaining to your treatment. Should you request a superbill, you hereby authorize Rose Junie Therapy to provide information that, in its sole discretion, may relate to your claim for reimbursement. Should you elect to submit a superbill, this information will become part of the insurance company files and will probably be stored in a computer file. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. Please contact your insurance company if you have any questions regarding your rights to privacy and limitations to confidentiality regarding your mental health records. 

PROFESSIONAL RECORDS AND CONFIDENTIALITY

How the Information in Your Record is Utilized

All therapists and staff members associated with this Practice follow these policies regarding your privacy. The laws of California and the standards of the mental health profession require that we keep treatment records. The information in your medical record is utilized in various ways. Your therapist will use it to plan your treatment and keep a record of the significant issues that are addressed in treatment. The information is also used to coordinate your treatment with other professionals or provide information to significant others or family members; information is only provided to those you have given us permission in writing to communicate with regarding your treatment.

Authorizations For Release 

In general, the law protects the privacy of all communications between a patient and a therapist, and we can only release information about your treatment to others with your written permission. In order to release any information to another party (your attorney/non-healthcare provider/uninvolved family member), your therapist will ask that you sign an Authorization to Release Information. You may revoke this Authorization at any time. If you participate in couples therapy, your therapist will not disclose confidential information about your treatment to a third party unless all person(s) who participated in the treatment with you provide their written authorization to release information; subject, however, to the exceptions to confidentiality below.

Marital/Couples Therapy "No-Secrets Policy"

Please note that during marital/couples therapy, your therapist adheres to a "no-secrets" policy. This implies that when you participate in marital/couples therapy, your therapist may use and share any relevant information obtained during the Gottman assessment phase, individual communication, or sessions with your partner that could aid in therapy progress. By engaging in marital/couples therapy, you are hereby granting your therapist authorization to utilize and share any such information with your partner for the purpose of facilitating progress in therapy.

Patient Litigation

The information disclosed by you, our client, as well as any records created, is subject to the psychotherapist-patient privilege. Your therapists will not voluntarily participate in any litigation, or custody dispute in which you, and another individual or entity, are parties. Therapists in this   Practice will generally not write or sign letters, reports, declarations, or affidavits to be used in a client's legal matter; and will not release records or provide testimony unless compelled to do so by court order; or as identified by a properly served legal subpoena. However, it is ultimately our patients/clients who hold the psychotherapist-patient privilege and who have the right to waive the privilege for litigation or other purposes. 

You should address any concerns you might have regarding the psychotherapist-patient privilege with your attorney. In particular, you should be aware that you might be waiving the psychotherapist-patient privilege if you make your mental or emotional state an issue in a legal proceeding and that your therapist may be served a subpoena to produce records or testimony. We will generally comply with a properly served subpoena unless we receive notice that you or your legal representative intend to object to or "quash" the subpoena by asserting the psychotherapist-patient privilege. We will wait a reasonable amount of time up until the subpoena due date in order to allow you or your legal representative an opportunity to assert the privilege, and in certain limited circumstances (e.g., a minor without representation), we will assert the privilege on behalf of a patient.

If you become involved in legal proceedings that require your therapist's participation, you will be expected to pay for your therapist's time at their regular hourly rate.

Exceptions to Your Confidentiality

There are some exceptions to your protection, and in general, your therapist will provide information from your record when required to do so by local, state, or federal law. In most legal proceedings, you have the right to prevent your therapist from providing any information about your treatment. However, in some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order the release of records from or the testimony of your therapist if they determine that the issues demand it. 

There are some situations in which your therapist is legally obligated to take action to protect others from harm, even if your therapist   has to reveal some information about a patient's treatment. For example, if they believe that a child, a person over age 65, or a disabled person is being abused or mistreated, they may be required to file a report with the appropriate governmental agency. 

If the therapist believes that a patient poses a serious risk to someone, they are 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 to harm him or herself, the therapist may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection.

In the interest of patient wellness and to facilitate the substitution of therapists, therapists working for this Practice may share information about patients with each other, and we are all bound by the rules of confidentiality. Your therapist may also occasionally find it helpful to consult other professionals outside of this Practice about your case or to coordinate your treatment with your other healthcare providers (Primary Care Physician, psychiatrist, etc.). During a consultation, the therapist is obligated to avoid revealing your identity. The consultant is also legally bound to keep the information confidential. On the other hand, when coordinating treatment with your other healthcare providers, it is necessary to disclose your identity to ensure you are receiving proper care. Similarly, the requirement to obtain your prior authorization to provide information may be waived in emergency situations, and the opportunity to consent may be obtained retroactively.

If a situation occurs that requires your therapist to disclose information without your written permission,   your therapist may nonetheless decide, based on their professional judgment and the surrounding circumstances, to discuss it with you before taking any action.

YOUR RIGHTS REGARDING INFORMATION IN YOUR MEDICAL RECORD

Right to Inspect and Copy

You (or your legal, personal representative) are entitled to receive a copy of your medical record unless your therapist believes that receiving that information would be harmful to you or anyone else. Because these are professional records, they can be misinterpreted by and/or upsetting to untrained readers. If you wish to see your records or receive a copy of your records, you are required to submit a written notice to that effect, and your therapist would expect to discuss your request with you in person. If we deny you access to your records, you can request to speak with an independent mental health professional about your request. Your request for an independent review of your request should also be made in writing; in certain limited cases, you are not entitled to an independent review. If you are provided with a copy of your medical record information (or another party pursuant to your Authorization to Release Information request), we may charge a fee for any costs associated with that request. In most cases, your copies must be given to you within 30 days, but this can be extended another 30 days if you are given a reason.

Right to Amend

If you believe that the information in your record is incorrect or incomplete, you may request that your therapist amend that information. It is our practice to accept this sort of request in writing and that any information you may wish to add to your record also be provided to your therapist in written form. In most cases, your record should be changed within 60 days.

Right to an Accounting of Disclosures

You have the right to request an "Accounting of Disclosures." This is a list of the disclosures we have made of medical record information. That information is listed on the Authorization to Release Information and will be provided to you at your written request. You should expect to receive this within 60 days.

Right to Request Restrictions

You have the right to privacy and to request a restriction or limitation on the health information we use or disclose about you for any matter aside from treatment, payment, or healthcare operations. As noted above, we will not release your confidential information without your written permission. Any restrictions to your Authorization to Release Information should be specified on the Authorization.

Right to Request Confidential Communications

You have the right to request that your therapist communicate with you only in certain ways. For example, you can ask that your therapist not leave a telephone message for you or that they only contact you at work or by mail.

Provider's Psychotherapy Notes

You do not have the right to access a provider's psychotherapy notes. Psychotherapy notes are notes taken by a mental health professional during a conversation with the patient and kept separate from the patient's medical and billing records. The Privacy Rule also does not permit the provider to make most disclosures of psychotherapy notes about you without your authorization.

Grievance/Complaints Regarding Treatment/Privacy Rights

The Board of Behavioral Sciences  receives and responds to complaints regarding services provided within the scope of practice of licensed marriage and family therapists, licensed clinical social workers, and licensed professional clinical counselors. You may contact the board at www.bbs.ca.gov or by calling 1-(916)-574-7830.

You have the right to a paper copy of this Consent to Treatment document, and you may request one when you sign the original for your medical record. Rose Junie Therapy reserves the right to change its policies as outlined herein. If they change, you will be informed of that change and will be provided with a copy of the current document if desired.