Legal · Treatment Consent

Treatment Consent

Effective date: [TBD]. Last updated: [TBD]. Pasadena Clinical Group · 301 N. Lake Ave STE 600, Pasadena, CA 91101 · (626) 354-6440.

READ CAREFULLY BEFORE SIGNING. This document is the informed-consent agreement for psychotherapy services with Pasadena Clinical Group ("the Practice"). It describes the nature of treatment, mandatory limits to confidentiality under California and federal law, your rights, and important provisions including arbitration of disputes and a limitation of liability. Sign only if you have read, understood, and agree to all terms.

1. Voluntary participation; right to terminate

Psychotherapy is voluntary. You have the right to terminate treatment at any time, for any reason, with or without notice. You also have the right to ask questions about the work, methods, recommendations, qualifications of your clinician, alternatives, and any other concern at any time. You may decline any specific intervention without prejudice to your continued care.

2. Nature of services; benefits, risks, alternatives

The Practice provides outpatient couples-focused psychotherapy. Modalities used may include the Gottman Method, Emotionally Focused Therapy (EFT), Integrative Behavioral Couple Therapy (IBCT), Discernment Counseling, and the Psychobiological Approach to Couple Therapy (PACT). The Practice does not provide medication management, psychiatric emergency services, court-ordered evaluations, custody evaluations, fitness-for-duty evaluations, or forensic services.

Potential benefits include relief of psychological distress; improved communication; better coping strategies; increased self-understanding; and improvements in relational functioning.

Potential risks include experiencing uncomfortable emotions (sadness, anger, fear, frustration, grief); recalling difficult memories; short-term increases in distress as issues are addressed; relational changes that may include separation or divorce; and the surfacing of issues that one or both partners may have preferred not to discuss. Outcomes are not guaranteed. Psychotherapy is a clinical, not predictive, process. Therapists practice within accepted standards of care; they do not promise particular results.

Alternatives include no treatment, individual therapy, group therapy, religious or community-based counseling, support groups, self-help resources, and treatment by other providers. Your clinician will discuss alternatives appropriate to your situation.

3. Confidentiality and its mandatory limits — California and federal law

Communications between you and your clinician are generally confidential and protected by HIPAA (45 C.F.R. Parts 160 and 164), the California Medical Information Act (Civil Code § 56 et seq.), the California psychotherapist-patient privilege (Evidence Code §§ 1010–1027), and, where applicable, the Lanterman-Petris-Short Act (Welfare & Institutions Code § 5328 et seq.) and 42 C.F.R. Part 2 (substance-use disorder records covered by federally assisted programs). However, California and federal law require or permit disclosure without your authorization in specific circumstances:

• Tarasoff duty to warn/protect (Civil Code § 43.92; Tarasoff v. Regents of the Univ. of Cal., 17 Cal. 3d 425 (1976); Ewing v. Goldstein, 120 Cal. App. 4th 807 (2004)) — when a client communicates a serious threat of physical violence against a reasonably identifiable victim or victims, the clinician must take reasonable steps to protect the intended victim, which may include warning the victim and law-enforcement agencies.
• Child Abuse and Neglect Reporting Act (CANRA) (Penal Code §§ 11164–11174.3) — known or reasonably suspected child abuse or neglect must be reported to a child-protective or law-enforcement agency.
• Elder and Dependent Adult Abuse (Welfare & Institutions Code §§ 15630–15637) — known or reasonably suspected abuse, neglect, abandonment, isolation, abduction, or financial exploitation of an elder (65+) or dependent adult must be reported to Adult Protective Services or law enforcement.
• Imminent danger to self. If the clinician determines that you present a serious and imminent risk of suicide or other self-harm, the clinician may take steps to ensure safety, including contacting emergency services, hospital admission, or notifying a person in a position to assist.
• Court order or subpoena. Information may be disclosed pursuant to a valid court order or subpoena, after the Practice has taken reasonable steps to assert applicable privileges and notify you when permitted.
• Billing, payment, healthcare operations. Limited information (diagnosis, dates of service, procedure codes) is disclosed to insurers and payment partners in the ordinary course of billing.
• Other HIPAA permitted disclosures. See our Notice of Privacy Practices for the full list.

4. Couples therapy — no-secrets policy

In couples therapy, the relationship is the client. The clinician may meet briefly with one partner alone for clinical reasons (history-gathering, safety screening, or stabilization). Information disclosed by one partner during an individual contact is not held secret from the other partner: clinically relevant content may be discussed in joint sessions, and the clinician may, in the clinician's judgment, decline to continue couples work if a secret obstructs the work. Each partner consents to this no-secrets policy at intake. If a partner needs a confidential individual therapy relationship, the Practice will refer to an outside individual clinician; the Practice does not blend individual and couples work for the same client.

5. Records, retention, and access

The Practice maintains a clinical record of services. Under California law, clinical records are retained for at least seven (7) years from the last date of service for adult clients, and for minors until at least one year past the age of majority (Bus. & Prof. Code § 4980.49 for LMFTs; Cal. Code Regs. tit. 16 for psychologists). After the retention period, records are destroyed in a HIPAA-compliant manner. You may request access to or copies of your records under HIPAA (45 C.F.R. § 164.524) and California Health & Safety Code §§ 123100–123149.5; reasonable copying fees may apply. Psychotherapy notes (as defined in 45 C.F.R. § 164.501) receive heightened protection and are not part of the standard medical record.

6. Insurance authorization

If you use insurance, you authorize the Practice to release the minimum necessary information (diagnosis, dates of service, CPT/procedure codes, treatment plan summary) to your insurer, its agents, and applicable case-management and utilization-review entities for purposes of billing, payment, and benefits coordination. You acknowledge that information so disclosed becomes part of your insurance record and may be subject to re-disclosure outside the protections of HIPAA. If a balance remains after insurance, you remain personally responsible for it.

7. Telehealth services

If any session is conducted by telehealth, the separate Telehealth Agreement applies and is incorporated here by reference. California Bus. & Prof. Code § 2290.5 governs telehealth informed consent.

8. Communication outside session; technology limitations

Email, text messages, voicemail, and other electronic communications are not fully secure and may be intercepted, retained, or accessed by unauthorized parties. The Practice uses these channels primarily for scheduling and administrative matters. Do not include sensitive clinical content, crisis information, or PHI in email or text. By using these channels, you knowingly accept the inherent privacy and confidentiality limitations. The Practice does not monitor any electronic channel after office hours and is not a substitute for emergency services.

9. Minors and minor consent

The Practice's primary scope is adult couples. If services involve a minor, California Family Code § 6924 permits minors aged twelve (12) or older to consent to certain mental-health services if the minor is, in the clinician's professional judgment, mature enough to participate intelligently in services and meets statutory criteria. When a minor is treated, the clinician will discuss with the minor and the parent/guardian the scope of confidentiality, mandatory reporting, and the handling of information shared by either party. A parent or guardian of a minor under 12 generally consents to and may access mental-health information for that minor, subject to clinician discretion to withhold disclosures that would have a detrimental effect on the therapeutic relationship under Health & Safety Code § 123115.

10. Fees, cancellations, and financial responsibility

Session fees, late-cancellation fees, no-show fees, court-related fees, and other financial terms are set out in the Office Policies, which are incorporated here by reference. Federal No Surprises Act disclosures are at No Surprises Act / Good Faith Estimate. You are financially responsible for charges not paid by insurance.

11. Recording prohibition

You may not audio- or video-record any session, in person or via telehealth, without the prior written consent of the clinician (and, in couples work, of the other partner). Unauthorized recording is a violation of California Penal Code § 632 and may subject you to civil and criminal liability.

12. Termination of services

The Practice may terminate services for any of the following reasons: (a) clinical determination that services are not appropriate or not helpful; (b) failure to participate in treatment, including repeated no-shows; (c) non-payment after reasonable opportunity to cure; (d) threats, harassment, or violence toward any clinician, employee, or other person; (e) ethical or legal conflict; (f) closure or relocation of the Practice. The Practice will, where appropriate, provide referrals and reasonable transition support consistent with applicable ethical standards.

13. Acknowledgement, limitation of liability, and dispute resolution

By signing this consent (in the office or electronically), you acknowledge that you have read, understood, and agreed to its terms; that you have had the opportunity to ask questions; and that your signature is given voluntarily.

You agree that, to the maximum extent permitted by California and federal law, all disputes arising out of or relating to your use of the website, your engagement with the Practice, or these consent terms — except claims for clinical malpractice or professional negligence (which are governed by the California Medical Injury Compensation Reform Act ("MICRA") and California Code of Civil Procedure § 364) and other claims that California law expressly does not permit to be arbitrated — are subject to the limitation of liability, indemnification, and mandatory mediation followed by binding individual arbitration provisions of the Practice's Terms & Conditions, including the class-action and jury-trial waivers therein. Mediation and any arbitration shall be venued in Los Angeles County, California, before JAMS (or the AAA where JAMS is unavailable). Nothing in this Consent waives your right to file a complaint with the California Board of Psychology, the Board of Behavioral Sciences, the U.S. Department of Health and Human Services Office for Civil Rights, or other regulatory bodies, or your rights under MICRA.