Introduction 

This Agreement is intended to provide the patient with important information regarding the practices, policies and procedures of Tiffany Thomas, Licensed Marriage & Family Therapist #122564 (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it. 

Therapist Background and Qualifications 

Tiffany Thomas, M.A., CADC-II, LMFT graduated from Antioch University in December 2018. She completed over one year of training at Counseling West where she learned how to approach the therapeutic work from a depth and psychodynamic perspective. Tiffany has been counseling those seeking a more meaningful life since 2011 when she began working with those who struggle with substance abuse as a certified substance abuse counselor. When she is not working in private practice, Tiffany works as a Division Director for specialty programs (Prevention and Outreach, Substance Use, Domestic Violence) at a local non-profit.

Tiffany’s theoretical orientation can be described as primarily Psychodynamic with additional skill building when appropriate. The variety of skill building could be, but is not limited to, Cognitive Behavioral skills, Anger Management skills, Mindfulness skills, Anxiety Decreasing skills, Parenting skills etc. according to what each patient could benefit from. Tiffany views each person’s unique circumstances from an attachment lens, and considers the impact of any early childhood trauma.

Risks and Benefits of Therapy 

Psychotherapy is a process in which therapist and patient discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so that the  patient can experience his/her life more fully. It provides an opportunity to better, and more deeply understand oneself, as well as, any problems or difficulties Patient may be experiencing. Psychotherapy is a joint effort between Patient and Therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. 

Participating in therapy may result in a number of benefits to Patient, including, but not limited to, reduced stress and anxiety, a decrease in 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 Patient, 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 Therapist will challenge the Patient’s perceptions and assumptions, and offer different perspectives. The issues presented by Patient may result in unintended outcomes, including changes in personal relationships. Patient should be aware that any decision on the status of his/her personal relationships is the responsibility of Patient. 

During the therapeutic process, many patients 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. Patient should address any concerns he/she has regarding his/her progress in therapy with Therapist. 

Professional Consultation 

Professional consultation is an important component of a healthy psychotherapy practice. 

As such, Therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, Therapist will not reveal any personally identifying information regarding Patient.  

Records and Record Keeping 

Therapist may take notes during session, and will also produce other notes and records regarding Patient’s treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist. Therapist will not alter his/her normal record keeping process at the request of any patient. Should Patient request a copy of Therapist’s records, such a request must be made in writing. Therapist reserves the right, under California law, to provide Patient with a treatment summary in lieu of actual records. Therapist 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. Therapist will maintain Patient’s records for ten years following termination of therapy. However, after ten years, Patient’s records will be destroyed in a manner that preserves Patient’s confidentiality. 

Confidentiality 

The information disclosed by Patient is generally confidential and will not be released to any third party without written authorization from Patient, except where required or permitted by law. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release. 

Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse; when a patient makes a serious threat of violence towards a reasonably identifiable victim, or when a patient is dangerous to him/herself or the person or property of another.  

In couples and family therapy, or when members are seen individually, confidentiality does not apply between the couple or among family members engaged in treatment with me. Therapist will use clinical judgment when revealing info. Therapist will not release records to any party unless authorized in writing to do so by all adults who were part of treatment unless compelled to do so by law/valid court order. If coming for family or couples therapy please sign below that you agree to the confidentiality limits and understand that Therapist won’t withhold info between parties involved in treatment.

*SIGN HERE if coming as a couple/family and you understand: _______________________________________________

Unexpected Therapist Absence

In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for an Executor to inform you of my status and ensure your continued care in accordance with your needs. Please let me know if you would like the names of my Executor and Secondary Executor. You authorize the Executor and Secondary Executor to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.

Patient Litigation 

Therapist will not voluntarily participate in any litigation, or custody dispute in which Patient and another individual, or entity, are parties. Therapist has a policy of not communicating with Patient’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Patient’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Patient, Patient agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made him/herself available for such an appearance at Therapist’s usual and customary hourly rate of $150.00.

Psychotherapist-Patient Privilege 

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

Fee and Fee Arrangements 

The usual and customary fee for service is $135.00 per 50-minute session for individuals. The fee for couples and families is $150 for 50 minutes or $200 for 80 minute sessions. Sessions longer than 50 minutes/80 minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. 

From time-to-time, therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. 

Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, credit/debit card and Zelle. 

Insurance 

Therapist does not currently accept insurance. If you have health insurance and would like to try to get reimbursed for sessions, therapist will provide patient with a statement or superbill, in which patient can submit to the third-party of his/her choice to seek reimbursement of fees already paid. Please consult with your policy regarding the rate of reimbursement. Therapist is unable to guarantee reimbursement.

Appointment Scheduling and Cancellation Policy 

Sessions are typically scheduled to occur one time per week at the same time and day if possible. Therapist may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. Patient is responsible for payment of the agreed upon fee for any missed session(s). Patient is also responsible for payment of the agreed upon fee for any session(s) for which Patient failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at (818)533-8672.

If Patient is more than 10 minutes late to any scheduled session, it will be considered a “no show” and Patient will be responsible for payment for that session. 

Therapist Availability 

Therapist’s office is equipped with a confidential voice mail system that allows patient to leave a message at any time. 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. Therapist is unable to provide 24-hour crisis service. In the event that Patient is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room. If the therapist is unavailable due to vacation or medical/sick leave, another therapist will be assigned to cover in the therapist’s absence. 

Suicide Hotline: 800-273-8255 

Termination of Therapy 

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, conflicts of interest, failure to participate in therapy, patient needs are outside of Therapist’s scope of competence or practice, or Patient is not making adequate progress in therapy. Patient has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, therapist will generally recommend that Patient 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. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to patient.  If a patient misses 3 sessions in a row, therapist will remove patient from scheduled appointments and close patient’s file as well as notify patient that he/she will need to contact therapist to reinstate treatment, if desired.

Notice to Patients

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of Marriage and Family Therapists. You may contact the Board online at www.bbs.ca.gov or by calling (916) 574-7830. 

Acknowledgement 

By signing below, Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Therapist, and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold 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.