Agreement


    As we began our work together, I would like to emphasize my understanding that your health care information is personal and I will be committed to protecting your health care information during the course of treatment. It is therefore important to clarify the confidential nature of the therapeutic relationship. All information between therapist and client is held strictly confidential and may not be disclosed without your written permission. There are several exceptions to this rule, that by law may require for me to disclosed your health care information. The following exceptions describe different ways that I may need to disclose information shared in the therapeutic relationship:
    • Should a client disclose to me any suspected child abuse, current or past, of a minor child, I am required by law (Section 11161.5 of the California Penal Code) to report this to the Department of Children and Family Services.
    • Should a client disclose to me any suspected elder/dependent adult abuse, I am required by law to report this to Adult Protective Services.
    • If I believe that a client truly intends to harm him/herself, I will first make every effort to enlist the client’s cooperation in ensuring his/her safety. If I am unable to do this, by law I may need to take further measures to insure the client’s safety without the client’s permission.
    • If I believe that a client actually intends to do physical harm to someone else, I must notify the police and the intended victim.
    • I appreciate your understanding and acceptance of my legal responsibility in the above situations and I would like to assure you that every effort is made to handle your treatment in a sensitive and caring manner. If you have any questions or concerns, please discuss them with me.

    Client Information


    Date of Birth*
    Today's Date*

    Is it okay to leave a message?


    Check any symptoms you have experienced in the last six months:
    Do you use drugs or drink alcohol?


    Consent For Services


    Therapy appointments: Therapy is scheduled for clients on a weekly basis. Therapy sessions are 50 minutes in length. I review notes, complete progress notes and prepare for my next scheduled appointment 10 minutes before the hour. It is beneficial for clients to arrive to sessions on time to obtain the 50 minutes. Cancellation Policy: Therapy appointments are reserved for each client on a weekly basis. Therefore should you need to cancel an appointment please do so within 24 hours in advance, otherwise a charge will be submitted. Insurance Reimbursement: I am not a provider with most insurance companies and therefore I am out of network on most insurance panels. Depending on your current insurance plan, you may be eligible to seek financial reimbursement for the weekly therapy services. I will be providing you with Statements of Professional Services that may be submitted to your insurance for reimbursement. Fees & Payments: All psychotherapy sessions are to be paid for at the time of the visit. Payment is usually collected at the end of each session. The undersigned client or responsible adult consents to and authorizes treatment services with Jennifer Dean, PhD, LCSW. These services may include individual psychotherapy, family therapy, couples therapy, case management, and other appropriate services.


    Good Faith Estimate


    You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises. Your signature acknowledges that you may ask your provider for a Good faith estimate.


      Agreement


      As we began our work together, I would like to emphasize my understanding that your health care information is personal and I will be committed to protecting your health care information during the course of treatment. It is therefore important to clarify the confidential nature of the therapeutic relationship. All information between therapist and client is held strictly confidential and may not be disclosed without your written permission. There are several exceptions to this rule, that by law may require for me to disclosed your health care information. The following exceptions describe different ways that I may need to disclose information shared in the therapeutic relationship:
      • Should a client disclose to me any suspected child abuse, current or past, of a minor child, I am required by law (Section 11161.5 of the California Penal Code) to report this to the Department of Children and Family Services.
      • Should a client disclose to me any suspected elder/dependent adult abuse, I am required by law to report this to Adult Protective Services.
      • If I believe that a client truly intends to harm him/herself, I will first make every effort to enlist the client’s cooperation in ensuring his/her safety. If I am unable to do this, by law I may need to take further measures to insure the client’s safety without the client’s permission.
      • If I believe that a client actually intends to do physical harm to someone else, I must notify the police and the intended victim.
      • I appreciate your understanding and acceptance of my legal responsibility in the above situations and I would like to assure you that every effort is made to handle your treatment in a sensitive and caring manner. If you have any questions or concerns, please discuss them with me.

      Client Information


      Date of Birth*
      Today's Date*







      Check any symptoms you have experienced in the last six months:

      Do you use drugs or drink alcohol?

      Consent For Services


      Therapy appointments: Therapy is scheduled for clients on a weekly basis. Therapy sessions are 50 minutes in length. I review notes, complete progress notes and prepare for my next scheduled appointment 10 minutes before the hour. It is beneficial for clients to arrive to sessions on time to obtain the 50 minutes. Cancellation Policy: Therapy appointments are reserved for each client on a weekly basis. Therefore should you need to cancel an appointment please do so within 24 hours in advance, otherwise a charge will be submitted. Insurance Reimbursement: I am not a provider with most insurance companies and therefore I am out of network on most insurance panels. Depending on your current insurance plan, you may be eligible to seek financial reimbursement for the weekly therapy services. I will be providing you with Statements of Professional Services that may be submitted to your insurance for reimbursement. Fees & Payments: All psychotherapy sessions are to be paid for at the time of the visit. Payment is usually collected at the end of each session. The undersigned client or responsible adult consents to and authorizes treatment services with Jennifer Dean, PhD, LCSW. These services may include individual psychotherapy, family therapy, couples therapy, case management, and other appropriate services.



      Good Faith Estimate


      You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises. Your signature acknowledges that you may ask your provider for a Good faith estimate.



        Agreement


        As we began our work together, I would like to emphasize my understanding that your health care information is personal and I will be committed to protecting your health care information during the course of treatment. It is therefore important to clarify the confidential nature of the therapeutic relationship. All information between therapist and client is held strictly confidential and may not be disclosed without your written permission. There are several exceptions to this rule, that by law may require for me to disclosed your health care information. The following exceptions describe different ways that I may need to disclose information shared in the therapeutic relationship:
        • Should a client disclose to me any suspected child abuse, current or past, of a minor child, I am required by law (Section 11161.5 of the California Penal Code) to report this to the Department of Children and Family Services.
        • Should a client disclose to me any suspected elder/dependent adult abuse, I am required by law to report this to Adult Protective Services.
        • If I believe that a client truly intends to harm him/herself, I will first make every effort to enlist the client’s cooperation in ensuring his/her safety. If I am unable to do this, by law I may need to take further measures to insure the client’s safety without the client’s permission.
        • If I believe that a client actually intends to do physical harm to someone else, I must notify the police and the intended victim.
        • I appreciate your understanding and acceptance of my legal responsibility in the above situations and I would like to assure you that every effort is made to handle your treatment in a sensitive and caring manner. If you have any questions or concerns, please discuss them with me.

        Client Information


        Date of Birth*
        Today's Date*







        Check any symptoms you have experienced in the last six months:

        Do you use drugs or drink alcohol?

        Consent For Services


        Therapy appointments: Therapy is scheduled for clients on a weekly basis. Therapy sessions are 50 minutes in length. I review notes, complete progress notes and prepare for my next scheduled appointment 10 minutes before the hour. It is beneficial for clients to arrive to sessions on time to obtain the 50 minutes. Cancellation Policy: Therapy appointments are reserved for each client on a weekly basis. Therefore should you need to cancel an appointment please do so within 24 hours in advance, otherwise a charge will be submitted. Insurance Reimbursement: I am not a provider with most insurance companies and therefore I am out of network on most insurance panels. Depending on your current insurance plan, you may be eligible to seek financial reimbursement for the weekly therapy services. I will be providing you with Statements of Professional Services that may be submitted to your insurance for reimbursement. Fees & Payments: All psychotherapy sessions are to be paid for at the time of the visit. Payment is usually collected at the end of each session. The undersigned client or responsible adult consents to and authorizes treatment services with Jennifer Dean, PhD, LCSW. These services may include individual psychotherapy, family therapy, couples therapy, case management, and other appropriate services.



        Good Faith Estimate


        You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises. Your signature acknowledges that you may ask your provider for a Good faith estimate.



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