Valerie Lamke, MS, MFT 2101 Geer Road, Suite 102A Turlock, CA 95382 (209) 262-4387

INFORMED CONSENT

PSYCHOTHERAPY is a process of discussing issues that are causing distress for a person in their relationships at home, work, school, or in the community. We will analyze your issues through 3 lenses: an emotional lens; a behavioral lens; and a relationship lens. From this information you will build insight into your problems. We will also create a treatment goal and a treatment plan to eliminate, reduce, or cope better with your issues. I am a Licensed Marriage Family Therapist, and am trained to diagnose mental health issues. I treat mild to moderate symptoms. If a client has moderate to severe symptoms, I may refer you to another office, such as a psychiatrist or physician to further evaluate and treat your symptoms.

CONFIDENTIALITY is a key part to achieving optimal results in a therapeutic relationship. As a clinician, I am not going to reveal your identity or any information about you to others without your written consent. If I see you in public, I will not approach you, however, you may say hello to me first. All of your information is kept in a secured chart. However, there are occasions that warrant clinicians to keep people safe and your identity and information may be shared:

1. I am a Mandated Reporter by the State of California and must report reasonable suspicion of child abuse or neglect, elder abuse or neglect, or dependent adult abuse or neglect.

2. If a client poses a potential threat of harm to themselves or others, I report to 911 and a 5150 may occur, which is a 3 day hold in a behavioral health facility.

3. By Court Order, (including the Patriot Act), a judge can access your records.

4. Minimum necessary for 3rd Party Billing which may include discussing your case with an assigned Case Manager.

OFFICE POLICIES are designed to keep clear and reasonable boundaries between the clients and this office. Each session is approximately 45-55 minutes in length and scheduled on a weekly basis. There is a 15 minute travel allowance, however, if you arrive more than 15 minutes late, it is considered a no show appointment and will be cancelled. Some insurances will pay for up to 2 no show appointments, but some do not, and you will be charged for the appointment directly at the contracted rate. To cancel an appointment, please call the office with a 24 hour advance notice. If a pattern of either late or missed appointments occur, the therapist may terminate the client and refer them back to their insurance panel or give 3 referrals to other offices. There is no waiting room in this office, so please make childcare arrangements. Office hours 9:00-5:00 Mon-Fri. This is not a crisis facility, and there is no after-hours care; in the event of a crisis please contact 911 or go to Valerie Lamke, MS, MFT 2101 Geer Road, Suite 102A Turlock, CA 95382 (209) 262-4387 your nearest emergency room. For Urgent Care call the Warm Line at (209) 558-4600. Please no outside food or drink during session.

FINANCIAL AGREEMENT is made at the beginning of the first session. Your INSURANCE PROVIDER is ______and you will be charged at the contracted amount. Your INSURANCE MEMBER NUMBER is ______and you have confirmed that you have a copayment of $ ______and have ______sessions authorized in this office. If your check is rejected by your bank, you will incur a service charge of $35. If there is any unpaid balance this office may use the small claims court process for recovery. If for any reason your insurance plan becomes ineligible, you will be responsible for charges incurred in this office.

NO SECRETS POLICY: It is understood when working with couples/families that any information given to the therapist is an acknowledgement that this information can be shared at the therapist’s discretion with the other participating family members.

ELECTRONIC FILING: Your chart papers will be scanned and held in a secured electronic format. Your information will be kept for 7-10 years, then deleted in accordance with legal and professional guidelines.

If you are seeking SSI disability, this is not the right office for you; you will need to schedule with a psychiatrist for an evaluation.

By signing this document you acknowledge that you understand the terms of this office and are giving your CONSENT FOR TREATMENT and have access to the office HIPPA forms on the website:www.valerielamkemft.com.

______

Print name Date

______

Signature

______

Print name Date

______

Signature