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Cynthia L. Robles, MFT


    Cultivating Skills for Healthy Relationships
Counseling Multi-Cultural Couples and Families


Se habla espanol
MFC 24511

(951) 440-0435

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OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

The process of therapy/evaluation

Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Ms. Robles will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth, or experiencing anxiety, depression, insomnia, etc. Ms. Robles may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that may cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Ms. Robles is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches may include behavioral, cognitive-behavioral, interpersonal, family or couple therapy.

Discussion of treatment plan

Within a reasonable period of time after the initiation of treatment, Ms. Robles will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Ms. Robles' expertise in employing them, or about the treatment plan, please ask questions. You also have the right to ask about other treatments for your condition and their risks and benefits.

Confidentiality

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the notice of privacy practices that you received with this form.

When disclosure IS required by law

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also notice of privacy practices form).

When disclosure may be required

Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Ms. Robles. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Ms. Robles will use clinical judgment when revealing such information. Ms. Robles will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.

Litigation Limitation

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf will call on Ms. Robles to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Cancellation

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

Payments and insurance reimbursement

Clients are expected to pay the standard fee of $110.00 for individual sessions and $120.00 for couples or family sessions per 45-50 minute session at the end of each session or at the end of the month unless other arrangements have been made. Telephone conversations, site visits, report reading, requested consultation with other professionals, release of information, reading records, longer sessions, travel time, and so forth, will be charged at the same rate, unless indicated and agreed otherwise. Please notify Ms. Robles if any problem arises during the course of therapy regarding your ability to make timely payments.

Clients who carry Insurance will be billed out to the Insurance company as a courtesy and any copays, deductible, denial and co-insurance is the clients responsibility. As was indicated in the section "Health Insurance and Confidentiality of Records," you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.

Health Insurance and Confidentiality of Records

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Ms. Robles only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the psychotherapy notes will not be disclosed to your insurance carrier. Ms. Robles has no control or knowledge over what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies' computers and soon will also be reported to the Congress-approved National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data have been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

Emergencies

If there is an emergency during our work together, or in the future after termination, where Ms. Robles becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the police, hospital, or the person whose name you have provided on the biographical sheet.

Telephone and emergency procedures

If you need to contact Ms. Robles between sessions, please leave a message on the answering machine (951) 440-0435 and your call will be returned as soon as possible. Ms. Robles checks her messages a few times a day (but never during the nighttime), unless she is out of town. Ms. Robles checks the messages less frequently on weekends and holidays. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call the 24-hour Riverside County crisis hotline (951) 686-4357, the Police (911), or the 24-hour Riverside County psychiatric emergency number, (951) 358-4881

Confidentiality of e-mail and fax communication

It is very important to be aware that e-mail communication can be relatively easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify Ms. Robles at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes in emergency situations.

Consultation

Ms. Robles may consult with other professionals regarding her clients; however, the client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained. Considering all of the above exclusions, if it is still appropriate, upon your request, Ms. Robles will release information to any agency/person you specify unless Ms. Robles concludes that releasing such information might be harmful in any way.

Mediation and arbitration

All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Ms. Robles and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Riverside County, California in accordance with the rules of the American Arbitration Association, that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Ms. Robles can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys' fees. In the case of arbitration, the arbitrator will determine that sum.

Termination

As set forth above, after the first couple of meetings, Ms. Robles will assess if she can be of benefit to you. Ms. Robles does not accept clients who, in her opinion, she cannot help. In such a case, she will give you referrals that you can contact. If at any point during psychotherapy, Ms. Robles assesses that she is not effective in helping you reach the therapeutic goals, she is obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Ms. Robles will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, Ms. Robles will assist you in finding someone qualified, and, if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, Ms. Robles will offer to provide you with names of other qualified professionals whose services you might prefer.

Dual relationships

Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Ms. Robles' objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. Temecula is a moderate sized community and clients may know each other and Ms. Robles from the community. Consequently, you may bump into someone you know in the waiting room or into Ms. Robles out in the community. Ms. Robles will never acknowledge working therapeutically with anyone without his/her written permission. It is your responsibility to communicate to Ms. Robles if a dual relationship becomes uncomfortable for you in any way. Ms. Robles will listen carefully and respond accordingly to your feed back. Ms. Robles will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.