INFORMED CONSENT

INTRODUCTION
This agreement is intended to provide you (herein "Client") with important information regarding the practices, policies and procedures of North Valley Marriage and Family Counseling, Inc., dba North Valley Counseling (herein "North Valley Counseling"), so that you can make an informed choice as to whether to participate in psychotherapy services. 

If client is a minor child, this agreement outlines the practices, policies and procedures to be provided by North Valley Counseling for a minor child (herein "Client") and is intended to provide parents or legal guardians (herein "Representative"), with important information so that you can make an informed choice as to whether the minor child should participate in services. Any questions or concerns regarding the contents of this agreement should be discussed with your therapist/counselor prior to signing it.

THERAPIST DISCLOSURE

Your therapist is either a Licensed Marriage and Family Therapist, a Licensed Clinical Social Worker, a Marriage and Family Therapist, Associate or a Clinical Social Worker, Associate. 

If your therapist is a Marriage and Family Therapist, or a Licensed Clinical Social Worker, they have completed a master degree or higher and are licensed by the Board of Behavioral Science (BBS).

If your therapist is a Marriage and Family Therapist Associate, or a Licensed Clinical Social Worker Associate, they have completed a master degree or higher and are registered with the Board of Behavioral Science (BBS). They are also gaining hours of experience toward licensure and are supervised by a licensed therapist. The BBS, is part of the California Department of Consumer Affairs (DCA).  

Please note which therapist you have been assigned to by locating the name on the list below:  

Adrienne Wilson, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 106740.

___________

Cliff Jacobson, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 79264.

___________

Erin Feulner, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 108041.

___________

Hailey Nantt, MS, Marriage & Family Therapist Associate (AMFT).

Registration number is AMFT 127468.

Supervised by Jaclyn Grace, a Licensed Marriage & Family Therapist (LMFT 100395).

___________

Jaclyn Grace, MA, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 100395.

___________

Lynn Hinkley, Associate Clinical Social Worker.

Registration number is ASW 93880.

Supervised by Jaclyn Donegan, a Licensed Marriage & Family Therapist (LMFT 100395).

___________

Lora Besser, MA, Licensed Clinical Social Worker (LCSW).

Her license number is 69726.

___________

Tami Keeney, MS, Licensed Marriage and Family Therapist (LMFT).

License number is MFC 42582.

THERAPIST BACKGROUNDS AND QUALIFICATIONS

Your therapist/counselor is a licensed therapist or registered associate who holds a master's degree or higher and works with children, and/or adolescents, adults, and families. Your therapist/counselor works with people in individual, and/or group, family, and/or group sessions. Your therapist/counselor also conducts collateral sessions, when appropriate to aid in the treatment of individuals (ex. Meeting with parents to discuss a minor child). Your therapist/counselor's theoretical orientation can be described as "eclectic" meaning that your therapist pulls from a variety of theories to best meet the needs of particular clients.

POLICY REGARDING CONSENT FOR THE TREATMENT OF A MINOR CHILD

North Valley Counseling generally requires the consent of both parents prior to providing any services to a minor child. There are exceptions to this rule (ex. Whereabouts of one or both parents is unknown and it is clinically appropriate that client receive services). In these cases, North Valley Counseling reserves the right to provide services to a minor as provided by law. If any question exists regarding the authority of client's representative to give consent for services, North Valley Counseling will require that the representative submit supporting legal documentation, such as a custody order, prior to the commencement of services.

RISKS AND BENEFITS OF THERAPY
Therapy/counseling is a process in which therapist/counselor and client discuss a myriad of issues, events, experiences, and memories for the purpose of creating positive change so client can experience his/her life more fully. It provides an opportunity to better, and more deeply understand one-self, as well as, any problems or difficulties client may be experiencing. Counseling/therapy is a joint effort between the client and therapist/counselor. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. When a client is a minor, the best outcome can be achieved when his/her parents, guardians, or other caregivers are supportive of the therapeutic process.

Participating in counseling/therapy may result in a number of benefits to the client, including, but not limited to: reduced stress and anxiety, decreased negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of client, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above.

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which the therapist/counselor will challenge the client's perceptions and assumptions, and offer different perspectives. The issues presented by the client may result in unintended outcomes, including changes in personal relationships. Clients should be aware that any decision on the status of their personal relationships is the responsibility of the client.

During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. Clients should address any concerns they have regarding their progress in therapy with their therapist/counselor.

PROFESSIONAL CONSULTATION

Professional consultation is an important component of a healthy practice. As such, your therapist/counselor regularly participates in clinical, ethical, and legal consultation with appropriate professionals, in which some personal details about sessions may be discussed. 

RECORDS AND RECORD KEEPING
Your therapist/counselor may take notes during sessions, and will also produce other notes and records regarding client's treatment. These notes constitute the therapist/counselor's clinical and business records, which by law, your therapist/counselor is required to maintain. Such records are the sole property of North Valley Counseling. Your therapist/counselor will not alter his/her normal record keeping process at the request of any client. Should client request a copy of said records, such a request must be made in writing. North Valley Counseling reserves the right, under California law, to provide client with a treatment summary in lieu of actual records. North Valley Counseling also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. North Valley Counseling will maintain client's records for ten years following termination of therapy. However, after ten years, client's records will be destroyed in a manner that preserves client's confidentiality.

CONFIDENTIALITY
The information disclosed by client is generally confidential and will not be released to any third party without written authorization from client, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse, when a client makes a serious threat of violence towards a reasonably identifiable victim, or when a client is dangerous to him/herself or the person or property of another.

For minor clients, representatives should be aware that therapist/counselor is not a conduit of information from client. Services can only be effective if there is a trusting, confidential relationship between therapist/counselor and client. Although representative can expect to be kept up to date as to client's progress in therapy, he/she will typically not be privy to detailed discussions between therapist/counselor and client. However, representative can expect to be informed in the event of any serious concerns therapist/counselor might have regarding the safety or well-being of client, including suicidality.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, therapist/counselor does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). North Valley Counseling believes that adding clients as friends or contacts on these sites can compromise client's confidentiality and therapist's/client's respective privacy. It may also blur the boundaries of the therapeutic relationship. Any questions or concerns regarding these policies should be discussed with therapist/counselor prior to consenting for services.

ELECTRONIC COMMUNICATION

North Valley Counseling cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If client prefers to communicate via email or text messaging for issues regarding scheduling or cancellations, therapist/counselor will do so. While therapist/counselor may try to return messages in a timely manner, therapist/counselor cannot guarantee immediate response and requests that client does not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

CLIENT LITIGATION
Therapist/counselor or other North Valley Counseling representatives will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Therapist/counselor or other North Valley Counseling representatives 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. North Valley Counseling will generally not provide records or testimony unless compelled to do so. Should therapist/counselor or other North Valley Counseling representatives be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving client, client agrees to reimburse North Valley Counseling for any time spent for preparation, travel, or other time in which therapist or other North Valley Counseling representatives has made him/herself available for such an appearance. This time will be billed at your counselor's usual and customary rate per hour.

PSYCHOTHERAPIST-CLIENT PRIVILEGE
The information disclosed by client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between therapist/counselor and client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the client is the holder of the psychotherapist-client privilege. If therapist/counselor or other North Valley Counseling representatives received a subpoena for records, deposition testimony, or testimony in a court of law, therapist/counselor or other North Valley Counseling representatives will assert the psychotherapist-client privilege on client's behalf until instructed, in writing, to do otherwise by client or client's representative. Client should be aware that he/she might be waiving the psychotherapist client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns they might have regarding the psychotherapist-client privilege with their attorney.

When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor's counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with their attorney. Client or representative, should be aware that they might be waiving the psychotherapist-client privilege if they make their mental or emotional state an issue in a legal proceeding. Client or representative, should address any concerns they might have regarding the psychotherapist-client privilege with their attorney.

CONTACT IN THE COMMUNITY 
If therapist/counselor and client see each other accidentally outside of the therapy office, therapist/counselor will not acknowledge client first. Your right to privacy and confidentiality is of the utmost importance and North Valley Counseling does not wish to jeopardize your privacy. However, if you acknowledge therapist/counselor first, therapist/counselor will be more than happy to speak briefly with you, but we feel it's appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

TERMINATION OF THERAPY
Your therapist/counselor 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, client needs are outside of therapist/counselor's scope of competence or practice, or client is not making adequate progress in therapy. Client or representative has the right to terminate therapy at his/her discretion. Upon either party's decision to terminate therapy, therapist/counselor will generally recommend that client 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. Your therapist/counselor will also attempt to ensure a smooth transition to another therapist by offering referrals to client or client's representative.

YOUR SATISFACTION IS OUR GOAL

If you are unhappy with the counseling you have received, you are encouraged to discuss the matter with your specific counselor. Your counselor can change their approach or refer you to another counselor. You may also call Cliff Jacobson, Clinical Director of North Valley Counseling @ 530-828-8235, to discuss a remedy. 

NOTICE TO CLIENTS

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.gov, or by calling (916) 574-7830.

ACKNOWLEDGEMENT
By signing below, client or client's representative acknowledges that they have reviewed and fully understand the terms and conditions of this agreement. Client or client's representative agrees to abide by the terms and conditions of this agreement and consents to participate in services with therapist/counselor. Moreover, client or representative agrees to hold North Valley Counseling free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

Please do not sign this agreement if you do not understand what this agreement entails.

BY SIGNING BELOW (electronically or by hand), I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

AGREEMENT FOR SERVICE

INTRODUCTION
This agreement is intended to provide you (herein "Client") with important information regarding the contractual and financial agreement for therapy/counseling at North Valley Marriage & Family Counseling Inc., dba North Valley Counseling (herein "North Valley Counseling"). If client is a minor child, this agreement is intended to provide parents or legal guardians (herein "Representative"), with the same important information regarding the contractual and financial agreement with North Valley Counseling. 

Any questions or concerns regarding the contents of this agreement should be discussed with your therapist prior to signing it.

Your therapist/counselor is one of the following persons:

Please note which therapist you have been assigned to by locating the name on the list below:

Hailey Nantt, MS, Marriage & Family Therapist Associate (AMFT).

Registration number is AMFT 127468.

Supervised by Jaclyn Grace, a Licensed Marriage & Family Therapist (LMFT 100395).

___________

Lynn Hinkley, Associate Clinical Social Worker (ACSW).

Registration number is ASW 93880.

Supervised by Jaclyn Donegan, a Licensed Marriage & Family Therapist (LMFT 100395).

___________

Erin Feulner, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 108041.

___________

Jaclyn Grace, MA, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 100395.

___________

Lora Besser, MA, Licensed Clinical Social Worker (LCSW).

License number is LCSW 69726.

___________

Adrienne Wilson, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 106740.

___________

Cliff Jacobson, MS, Licensed Marriage and Family Therapist (LMFT).

License number is LMFT 79264.

___________

Tami Keeney, MS, Licensed Marriage and Family Therapist (LMFT).

License number is MFC 42582.

FEE AND FEE ARRANGEMENTS
The usual and customary fee for services varies depending on the counselor you are working with. 

(Please note which therapist you have been assigned to and the corresponding fees below:)

Hailey Nantt, AMFT

Fee is $130.00 per 60 minute session.

___________

Lynn Hinkley, ACSW

Fee is $130.00 per 60 minute session

___________

Erin Feulner, LMFT

Fee is $150.00 per 60 minute session

___________

Jaclyn Grace, LMFT

Fee is $150.00 per 60 minute session

___________

Lora Besser, LMFT

Fee is $150.00 per 60 minute session

___________

Adrienne Wilson, LMFT

Fee is $150.00 per 60 minute session for individual sessions and $180.00 per 60 minute session for couple/family sessions 

___________

Cliff Jacobson, LMFT

Fee is $150.00 per 60 minute session for individual sessions and $180.00 per 60 minute session for couple/family sessions 

___________

Tami Keeney, LMFT

Fee is $150.00 per 60 minute session for individual sessions and $180.00 per 60 minute session for couple/family sessions

Sessions longer than 60 minutes are charged for the additional time pro-rata.

Client or client's representative is expected to pay for services at the time services are rendered. North Valley Counseling accepts cash, checks, and major credit cards.

North Valley Counseling reserves the right to periodically adjust this fee. Client or client's representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with third-party payors, or by agreement with North Valley Counseling.

From time-to-time, your therapist may engage in telephone contact with client or client's representative for purposes other than scheduling sessions. Client or client's representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, your therapist may engage in telephone contact with third parties at client's or client's representative's request. Client or client's representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Please note that face-to-face sessions are highly preferable to phone or video sessions. However, in the event that you are out of town, sick, or for other reasons, cannot attend in person, phone sessions and video sessions are available. 

If a true emergency situation arises, please call 911 or any local emergency room.

INSURANCE
North Valley Counseling is not a contracted provider with any insurance company. Upon request, we can provide a statement, which can be submitted to the third-party of your choice to seek reimbursement of fees already paid. North Valley Counseling provides this statement as a courtesy and we make no claim about whether or not third party payers will reimburse fees. We also do not generally become involved should a client have trouble being reimbursed for services.

CANCELLATION POLICY

We have a no-show and late-cancelation fee. 

Client or client's representative is responsible for payment of the agreed upon cancellation fee of one half of session fee for any missed (no-show) session(s). Client or client's representative is also responsible for payment of the same fee, for any session(s) for which your therapist was not given at least a 24 hour notice of cancellation. Notice of Cancellation should be left on your therapist's voice mail at:

Adrienne Wilson 

(530) 588-6797

___________

Cliff Jacobson

(530) 828-8235

___________

Erin Feulner 

(530) 230-8317​

___________

Hailey Nantt 

(530) 712-3832

___________

Jaclyn Grace 

(530) 433-4354 

___________

Lynn Hinkley 

(916) 293-7082

___________

Lora Besser

(530) 828-3832

___________

Tami Keeney

(530) 433-9061 

THERAPIST AVAILABILITY
Your therapist's phone number is a confidential voice mail system that allows client or client's representative to leave a message at any time. Your therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Your therapist is unable to provide 24-hour crisis services. 

In the event that client is feeling unsafe or requires immediate medical or psychiatric assistance, client or client's representative should call 911, or go to the nearest emergency room.

TERMINATION OF THERAPY
Your therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, frequent cancellations of scheduled sessions, conflicts of interest, failure to participate in therapy, client needs are outside of therapist's scope of competence or practice, or client is not making adequate progress in therapy. Client or client's representative has the right to terminate therapy at his/her discretion. Upon either party's decision to terminate therapy, your therapist will generally recommend that client 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. Your therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to client or client's representative.

ACKNOWLEDGEMENT

Please do not sign this agreement if you do not understand what this agreement entails.

By signing below, client or client's representative acknowledges that they have reviewed and fully understand the terms and conditions of this agreement. Client or client's representative agrees to abide by the terms and conditions of this agreement. Moreover, client or client's representative agrees to hold North Valley Counseling free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

BY SIGNING BELOW (electronically or by hand), I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

With the expansion of electronic therapy (video, phone. etc.), we are required to inform you about the rules governing tele-therapy. Even though you may not be doing therapy via electronic means, we ask that you answer the following in case that changes. 

Please read the following disclosures below & sign this document to indicate you understand & agree with these tele-therapy policies. This disclosure expands the Informed Consent document and/or the Agreement for Services document, with regard to sessions conducted via internet or telephone. 

RIGHT TO WITHHOLD/WITHDRAW CONSENT

Just like with face to face sessions, you have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment.

CONFIDENTIALITY 

The laws that protect the confidentiality of your medical information also apply to tele-therapy. As such, you understand that the information disclosed by you during the course of therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the general Informed Consent and Agreement for Services documents.

RISKS & CONSEQUENCES OF TELE-THERAPY

You understand that there are risks and consequences from tele-therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of North Valley Counseling (Our system is encrypted & HIPPAA compliant) that: the transmission of your information could be disrupted or distorted by technical failures and/or the transmission of your information could be interrupted by unauthorized persons.

APPROPRIATENESS OF TELE-THERAPY

You understand that tele-therapy based services may not be as complete as face-to-face services. You also understand that if you would be better served by another form of therapeutic services (e.g. face-to-face services) your therapist may suggest that you switch to a different form of therapy.

BENEFIT VS RISK

Just like face to face sessions, you understand that you may benefit from tele-therapy, but that results cannot be guaranteed or assured. In fact, you understand that there are potential risks and benefits associated with any form of therapy, and that despite your efforts and the efforts of your therapist, your condition may not improve, and in some cases may even get worse.

TELE-THERAPY IS NOT AN EMERGENCY SERVICE

Just like face to face therapy, you accept that tele-therapy does not provide emergency services. If you are experiencing an emergency situation, you understand that you can call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.

RESPONSIBILITY TO PROVIDE A DIGITAL CONNECTION & A PRIVATE PLACE

You understand that you are responsible for (1) providing the necessary telecommunications equipment and internet access for your tele-therapy sessions, (2) the security of information on your device, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for your tele-therapy session.

ACKNOWLEDGEMENT

By signing below, client or the client's representative acknowledges that they have reviewed and fully understand the terms and conditions of this agreement. Moreover, client or the client's representative agrees to hold the therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

PLEASE ELECTRONICALLY SIGN BY ENTERING YOUR NAME AND TITLE BELOW: