Informed Consent

Psychotherapy & Life Skills

5655 College Ave.
Ste. 315B
Oakland, CA 94618

Phone: 415.378.7506


Welcome to my practice. Your first few sessions with a Therapist can be very overwhelming, for many reasons. That’s why I try to let you know how my practice works previous to and outside of your sessions. This document contains important information about my professional services and business policies that you need to know. This is why taking the time to read through the information is so important. We can discuss any questions you have about the procedures, and I will also be reminding you of things, so you have a chance to get used to them as we move forward. When you sign this document, it will represent an agreement between us.


Generally, I will schedule one 50-minute session per week at a set time we agree on, although sessions may be longer or more frequent (I do not see Clients less than 1X/week until they have been in Therapy with me for at least a year). The time scheduled for your appointment is assigned to you and you alone. If you need to cancel a session, it is required that you provide 48-hours’ notice. If you miss a session without canceling, or cancel without 48-hours’ notice, you are still financially responsible for the session.
As a courtesy, I attempt to reschedule unavoidable last minute cancellations by phone at a different time within the same week, but this cannot be guaranteed.

Professional Fees

Amount~ The standard fee for Individual sessions, which generally last for 50 minutes, is $175 and the month’s fees are collected by the 5th or the Client’s first session of the month, whichever comes first. Fees for sessions with more than one person or of a longer duration are $200 and above depending on what’s being discussed.

How~ I take cash, checks, Zelle (No fees) credit cards & FSA cards, (Square + fees) and (PayPal + fees). I do offer an invoice/ superbill each month upon request. It’s best to speak to your insurance company before we begin so you know what you need me to include for reimbursement.

When~ I email a reminder the last week of each month with the total for the upcoming month. This is a reminder to arrange for payment and an opportunity to check your calendar for dates you need to reschedule with me or cancel altogether during that month. Since these will be dealt with by email, they will not take your valuable Therapy time and you will have a record to check should your forget a rescheduled time. If for some reason a check is returned for insufficient funds, I charge the usual $35 fee.

In addition to weekly appointments, it is my practice to charge this amount (after discussing it with you) on a prorated basis for other professional services that you may require such as; report writing, repeated telephone conversations that are required in urgent situations, attendance at meetings or consultations with other professionals which you have requested, or the time required to perform any other service which you may request of me. But there will be no outside fees charged without prior discussion.

Psychological Services

Therapy is a relationship between people that works in part because of the clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to create change. As a Client in psychotherapy, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. I, as your Therapist, have corresponding responsibilities to you. These respective rights are described in the following section.

Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, Psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things that we discuss outside of sessions. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the Therapist you select. If you have questions about my procedures, we should discuss them whenever they arise.


My payment policy is fee-for-service only. I do not accept payment directly from insurance companies and therefore I am not on any managed care or preferred provider plans. However, this is not a comfortable decision I have made lightly or without serious thought. Clients sometimes have questions about why I do not accept insurance payments and I would like to discuss it with you, if you want to know, as it was made with my Clients’ well-being in mind and as the direct result of harm caused by my involvement with Insurance panels in the past.

Dual Relationships

Therapy never involves sexual, business, or any other dual relationships that could impair my objectivity, Clinical judgment, or Therapeutic effectiveness or could be exploitative in nature. Please discuss this with me if you have questions or concerns.

Discussing Goals Reached, Closure, and Follow-up

Deciding when to stop our work together is meant to be a mutual process. Given the reputation of Traditional Therapy to fall back on its inherent power structure including pathologizing “Patient’s” behavior when broaching this topic: I am supportive of Clients’ growth and inevitable progression to less sessions, taking a break, and leaving Therapy all together. This is success! So as we begin, one of the things we will talk about is how you might know in the future that you would be finished for the time being, so there is already a plan in place. Even though things can and do change, I think it is helpful to have a blueprint to refer to in moving forward. Before we stop, we will discuss how you would know if or when you might want to come back or whether a regularly scheduled “check-in” might work best for you. If it is not possible for you to phase out of therapy, I recommend that we have closure on the Therapy Process with a Transition session. If finances are a problem I would rather have one Closure session without finances involved than none at all.

Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about my treatment recommendations as we work together, I Strongly encourage you to express them so that we can resolve them. If during our work together I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If you request it and authorize it in writing, I may 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, I will assist you in finding someone qualified. You have the right to terminate treatment at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer.


Law generally protects the confidentiality of all communications between a Client and a Psychologist and I, as your Therapist, cannot and will not tell anyone else what you have discussed or even that you are in therapy without your written permission. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA.

With the exception of certain specific situations described below, you have the right to confidentiality of your therapy. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time. There are, however, several exceptions in which I am legally bound to take action even though that requires revealing some information about a client’s treatment. If at all possible, I will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:

  1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If I believe a Client is threatening serious bodily harm to another, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a Client threatens harm to him/herself or another, I may be required to seek hospitalization for the Client, or to contact family members or others who can provide protection.
  2. If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, I am required by law to file a report with the appropriate state agency.
  3. In response to a court order or where otherwise required by law.
  4. To the extent necessary, to make a claim on a delinquent account via a collection agency.
  5. To the extent necessary for emergency medical care to be rendered. Finally, there are times when I find it beneficial to consult with colleagues as part of my practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.

Confidentiality of E-mail, Voice mail and Text Communication

E-mail, voice mail, and text communication can be accessed by unauthorized people, compromising the privacy and confidentiality of such communication. Although the circumstances are unlikely in which such a breach would take place, it is important to remember that the possibility of a breach does exist. Please notify me at the beginning of treatment if you would like to avoid or limit in anyway the use of any or all of these communication devices. Please do not contact me via e-mail or texts for emergencies!

Contacting Me

I am often not immediately available by telephone as I do not answer the phone when I am with Clients. If you need to contact me between sessions, please text (which is NOT confidential and are erased regularly because of the risk of the phone being stolen) or leave a message for me at 415-378-7506. I try to check my texts between sessions, voice mails 2x/day, and emails at least 1X/ day in the morning unless I am out of town which you would be informed of in advance. If we spend more than 20 minutes on the phone, I might suggest that we turn it into an extra session. If you feel the need for many phone calls during a week and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. If it’s a difficult time requiring additional sessions/week, we may need to discuss some alternative financial solutions until things settle. This generally includes a brief reduction of your fee. If an urgent situation arises, please indicate it clearly in your message to me, especially that you need a return call immediately. If your situation is an acute emergency and you need to talk to someone right away, contact the closest 24-hour emergency psychiatric service.

Other Rights

You have the right to lodge a complaint against me at any time you wish with the Board of Behavioral Science. You may contact the board online at, or by calling (916) 574-7830. If you are unhappy with what is happening in Therapy, I hope you’ll talk with me immediately so that I can respond to your concerns. Often, learning to speak up in these ways is part of why people seek Therapy in the first place. You have a right to trust that your Therapist has the ability to hear you, ask questions, be present for your emotions, and to make appropriate repair.

Empathic misses happen in all relationships, and in Therapy you have the right to be guided professionally through this process. You have the right to considerate, safe, and respectful care, without discrimination any kind. You have the right to ask questions about any aspect of the Therapy and about my specific training and experience.