<p> Alliant Couple and Family Clinic Specializing in Emotionally Focused Therapy 10065 Old Grove Road, Suite 102 San Diego, CA 92131 Phone: 858.547.9803 Fax: 858.527.0451 Email: [email protected] Web: alliantcoupleandfamilyclinic.org</p><p>Welcome to the Alliant Couple and Family Clinic San Diego</p><p>We want to welcome you to the Alliant Couple and Family Clinic (ACFC). You will be meeting with your counselor in a few minutes. The first 20 minutes of your intake appointment will be spent completing necessary paperwork included in this packet. If you would like assistance to complete this paperwork, please ask the receptionist to call your counselor, or you may wait until your appointment starts, and we can answer your questions then. </p><p>Attached is the “General Information and Counseling Agreement.” Please read this agreement carefully and sign. If you would like a copy of this agreement, please ask your counselor, and they will make a copy for you. </p><p>In addition, please fill out the “Personal Information” form and the “Fee Acknowledgement and Agreement” form, which are attached. </p><p>Fees for subsequent therapy sessions will be determined at the end of your appointment. If you need assistance with your weekly fees, please ask for a “Fee Reduction Request Form.” Reduced fees are based on monthly income and the number of dependents. </p><p>After you have completed the intake paperwork, you will be meeting with a counselor to discuss your specific concerns. Counselors at the ACFC are licensed mental health professionals, interns or trainees (students). All interns or trainees are under the supervision of licensed mental health professionals. </p><p>If you have any questions about this informed consent or our program, please ask your counselor.</p><p>Thank you, ACFC</p><p>General Information and Counseling Agreement ACFC ACFC is owned and operated by Alliant International University. Our policies and procedures comply with applicable State regulations. Our staff is comprised of licensed and registered mental health professionals, interns and trainees affiliated with Alliant International University. All interns and trainees are supervised by a licensed mental health professional. Confidentiality General Information and Counseling Agreement Under the law, what you reveal to your counselor is legally “privileged communication.” You must sign a written release before any information about you or your treatment can be disclosed. The following are exceptions to the general rules regarding your confidentiality:</p><p>1. State laws mandate that psychotherapists report all incidents of actual or suspected child abuse or neglect, elder abuse, and dependent adult abuse. The law also requires that incidents of threatened harm to self or others be reported. </p><p>2. If you are a minor, we are required to answer questions your parents or guardians might have about your progress. We do not have to reveal the details of what is said during your sessions unless we have a concern about someone’s safety. If you are the guardian of a minor or are a minor, please read the following: Minors By signing below, I give my consent for the therapist to conduct therapy sessions with the minor listed below. I have also been informed of the limitations to confidentiality in terms of certain topics such as substance use and sexual activity. I accept the therapists’ judgment in regards to releasing information related to the treatment of this minor. In addition, I understand that at anytime if the therapist believes this minor is in danger of hurting himself or herself, I will be notified immediately. </p><p>Name of minor: ______Parent/Guardian Printed Name: ______Signature: ______</p><p>Recording of As licensed mental health professionals and counselors in training, our ethics require Sessions that we consult other professionals when necessary to provide appropriate treatment. All training mental health staff review their sessions with their clinical supervisors, treatment team members, and Alliant MFT Faculty and are required to videotape their client's sessions. Cameras in session are recording at all times so that supervisors will be able to review the quality of your session with your counselor. Your counselor is able to provide more effective treatment for you and your family with the recorded clinical session and supervision. All recorded sessions are retained long enough for a supervisor to review them and then deleted immediately, unless you have been told otherwise. All supervisors and clinical staff are bound by the same rules of </p><p>Page 2 confidentiality as your primary counselor. Your counselor may make a diagnosis that documents the medical necessity of your treatment. Your counselor may also make periodic treatment plans which document that treatment is being provided according to medical necessity. This information may be requested by other health professionals or by insurance companies. This information is confidential unless you give written permission to allow us to release this information. Our phone number is (858) 547-9803 for the Front Desk or email ACFC at [email protected]. If you have an emergency outside of clinic hours, please call the San Diego County Crisis Line at 1-888-724-7240 Cancellation Sessions are 50 minutes long at the ACFC, unless otherwise specified by your counselor. Policy You must arrive on time in order to have a full 50 minute session. When appointments are scheduled, that time is reserved for you. If you need to change or cancel an appointment you must give 24-hour notice, or you will be charged the full cost of the session. The credit card number provided in this agreement will be charged the appropriate fee on the day of the missed session.</p><p>Couples/Family This written policy is intended to inform you, the participants in therapy, that when your Limitations to ACFC counselor agrees to treat a couple or a family, they consider that couple or family Confidentiality (the treatment unit) to be the patient. For instance, if there is a request for the treatment records of the couple or the family, your counselor will seek the authorization of all members of the treatment unit before they release confidential information to third parties. Also, if your counselor’s records are subpoenaed, they will assert the psychotherapist-patient privilege on behalf of the patient (treatment unit).</p><p>During the course of an ACFC counselor’s work with a couple or a family, they may see a smaller part of the treatment unit (e.g., an individual or two siblings) for one or more sessions. These sessions should be seen by you as a part of the work that your counselor is doing with the family or the couple, unless otherwise indicated. If you are involved in one or more of such sessions with your counselor, please understand that generally these sessions are confidential in the sense that your counselor will not release any confidential information to a third party unless required by law to do so, or unless your counselor has your written authorization. In fact, since those sessions can and should be considered a part of the treatment of the couple or family, your counselor would also seek the authorization of the other individuals in the treatment unit before releasing confidential information to a third party.</p><p>However, your counselor may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with other or all members of the treatment unit – that is, the family or the couple, if your counselor is to effectively serve the unit being treated. Your counselor will use their best judgment as to whether, when, and to what extent they will make disclosures to the treatment unit, and will also, if appropriate, first give the individual or the smaller part of the treatment unit being seen the opportunity to make the disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one , you might want to consult with an individual therapist who can treat you individually.</p><p>This “no secrets” policy is intended to allow your counselor to continue to treat the </p><p>Page 3 couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or the family. If your counselor is not free to exercise their clinical judgment regarding the need to bring this information to the family or the couple during their therapy, your counselor might be placed in a situation where they will have to terminate treatment of the couple or the family. This policy is intended to prevent the need for such a termination.</p><p>We, the members of the ______(couple/family or other unit) being seen, acknowledge by our individual signatures on this informed consent that each of us has read this policy, that we understand it, that we have had an opportunity to discuss its contents with ______(the therapist), and that we enter couple/family therapy in agreement with this policy.</p><p>Email, Text, and Please do not communicate with your therapist by text messaging or email, other than Social media for scheduling sessions. Your therapist will not respond to other texts or emails. Also, Policy therapists do not schedule via email. Please call for all scheduling. So much of our work depends on clear, connected communication. Our therapists have found that phone and in-person communication works best. Please do not text or email your therapist content related to your therapy sessions as text and email are not completely secure or confidential. Please review this policy with your therapist. Your therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.) Our therapists believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of your therapeutic relationship. If you have any questions about this, please bring them up when you and your therapist meet and you can talk more about it.</p><p>Fee Acknowledgement and Agreement The undersigned, by providing his/her signature in the space below agrees to accept the therapy services provided by the Alliant Couple and Family Clinic in accordance with and pursuant to the terms and conditions set forth herein.</p><p>The fee for your initial evaluation has been set at: ______. Subsequent treatment provided by the above mentioned names, will be billed at a rate of: ______per 50 minute session. If your session goes longer than an hour, or if you are participating in intensive therapy, your fee for this service will be negotiated with your therapist, and the amount agreed will be charged to you card at the end of each therapy session. </p><p>All fees are expected to be paid at the end of your therapy session. </p><p>All outstanding balances remaining unpaid more than 30 days will be charged directly to your credit card. If the credit card does not authorize payment, you are subject to interest accrued at a rate equal to 10% per annum of such outstanding balance. </p><p>The undersigned hereby authorizes the Alliant Couple and Family Clinic to charge my credit card (provided below) for the amount of any balance remaining at the end of each therapy session or after a balance has been unpaid for 30 days. </p><p>Page 4 I am also authorizing the Alliant Couple and Family Clinic to charge my card when I do not show up for my scheduled appointment, or if I cancel in less than 24 hours notice. The charge for a “no show or late cancellation” is the same as a full session fee. </p><p>If payment by check is the preferred method agreed upon, the following card will only be charged if there is an outstanding balance more than 30 days after issuance of an invoice, if you have a returned check, or if you have a late cancellation or a “no show”. All clients must have a credit card on file, even if paying by check or cash. </p><p>Alliant Couple and Family Clinic reserves the right to refuse service to any patient on the account of any delinquent or unpaid fees for services performed without any liability or further obligation to the undersigned. </p><p>Alliant Couple and Family Clinic does not participate in any insurance, and therefore you are entirely responsible for the payment of your therapy.</p><p>Credit Card The credit card to remain on file is: Information Please Circle: MasterCard Visa Card No.: ______Exp. Date: ______CVC:______Name as it appears on the card: ______Street address: ______City, State, Zip: ______Signature of card holder: ______Date: ______Preferred method of payment for your therapy sessions (please circle one): credit card check cash</p><p>The undersigned understands and agrees to be bound to such agreements as outlined in this document. Please provide your signature below. If there is more than one adult participating in treatment, both must sign below. </p><p>PRINTED NAME(S): ______DATE: ______SIGNATURE(S): ______DATE: ______</p><p>PRINTED NAME(S): ______DATE: ______SIGNATURE(S): ______DATE: ______</p><p>Page 5 Confidential Family Information</p><p>Please fill in each item as completely as possible </p><p>Please enter the first name, age, and DOB of those attending sessions: (1) First: ______Age ______DOB: ______(2) First: ______Age ______DOB: ______(3) First: ______Age ______DOB: ______(4) First: ______Age ______DOB: ______(5) First: ______Age ______DOB: ______Family Last Name: ______Home Address: ______Primary Contact Family Name Phone: ( _____ ) ______Email Address: ______</p><p>Family Ethnicity: ❑ Asian/Pacific Islander ❑ African American ❑ Native American ❑ Latino ❑ Caucasian ❑ Middle Eastern Status of Parental Relationship: ❑ Not Applicable ❑ Single ❑ Married/Partnership ❑ Cohabitating ❑ Separated ❑ Divorced ❑ Widowed Highest Education Level in the Family: ❑ Elementary ❑ Junior High ❑ High School/GED ❑ Technical/Trade School ❑ Some College ❑ Associates Degree ❑ Bachelors Degree ❑ Graduate Degree</p><p>Occupations of Legal Guardians: ______</p><p>Active Military Family Member? ❑ Yes ❑ No Is this person a Military Veteran? ❑ Yes ❑ No Who is in the Military? And what Branch: ______(How many years have you been in the military: ______)</p><p>Is there anyone specific that you want us to have contact with as you participate in counseling at the clinic? Please list name and contact information: ______</p><p>IN CASE OF EMERGENCY, I give you Permission to contact this person: Name: ______Phone: ______Relationship to the client: ______Client signature acknowledging permission to contact in the event of an emergency: ______</p><p>Referral Source: How did you hear about the Alliant Couple and Family Clinic: ❑ A specific person* ❑ Internet/Website outreach ❑ Friend of Family Member ❑ My child’s school ❑ Other: ______*Please list name and number of a specific person if you would like us to thank them for the referral on your behalf: (Name) ______(Phone) ______. </p><p>Page 6</p>