445 Burgess Drive, Ste: 150

Menlo Park, CA 94025

Telephone (650) 327-5915

www.couplesinstitute.com
Welcome to The Couples Institute!

We have prepared this sheet to give you some information about our office policies.

Fees: Fees stated are for a 50 minute session.

Payment: All balances are due and payable in full at each session. Checks should be written to The Couples Institute. Please discuss, in advance with your therapist, the need to make alternate arrangements for payment.

Insurance: We will mail you a monthly statement that you can use for insurance or tax purposes. You must negotiate with your insurance carrier. However, let us know if you have any problems with acceptance of a claim.*

Cancellation & Charges for Late or Broken Appointments:There is no charge for cancelled sessions when you provide 24 hours advanced notice. Otherwise, the full session fee will be charged for broken appointments or late cancellations.

Billing Questions: Please contact our office at (650) 327-5915 regarding questions about your monthly statement. Generally the office is staffed weekday mornings from 9 AM – 1 PM. Should you need to speak with the billing staff directly, please leave a message with your phone number and good times to reach you.

Confidentiality: All consultations and records are confidential. In order to protect your privacy, billings are mailed or you may arrange to pick your billing up at the office. We do not email, fax or transmit health information by any electronic mode. Further, no one will be advised of your participation in counseling unless you specifically request it, in writing. The law provides certain exclusions for confidentiality, including:

1. Child Abuse: When there is knowledge of or reasonably suspicion that a child has been the victim of abuse, neglect, mental suffering or a child’s emotional well-being is endangered.
2. Adult or Domestic Abuse: When there is knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult.
3. Health Oversight: When the California Board of Psychology or the Board of Behavioral Science Examiners subpoenas information relevant to a complaint.
4. Judicial or Administrative Proceeding: In court proceedings and when a request is received about the professional services that have been provided, health information may be disclosed with 1) written authorization or the authorization of the patient’s attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records) where the party seeking health information provides a showing that the patient or patient’s attorney have been served with a copy of the subpoena, affidavit and the appropriate notice. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered.
5. Threat to Health or Safety: When a serious threat of physical violence against an identifiable victim is known or reasonably suspected, efforts to communicate that information to the potential victim and the police must be issued.
6. Worker’s Compensation: When a worker's compensation claim is filed, a report must be provided to an employer, incorporating findings about the injury and treatment, within five working days from the date of the initial examination, and at subsequent intervals as may be required by the administrative director of the Worker’s Compensation Commission in order to determine eligibility for worker’s compensation.

If you request to communicate by email, you release the therapist from liability of lost and/or misplaced emails and emails that may be read by others. Please initial the appropriate line:

___ I do want to communicate with the therapist via email. ___ I do not want to communicate with the therapist via email.

I have read the above statements and agree to treatment under these conditions.

Signed __________________________________________ Date_________________________

Therapist ________________________________________ Date_________________________

*California law states that an insurance company which covers mental health services must pay for Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, as well as Psychologists. Some insurance companies may not cover these services by self-insuring or writing their policy out-of-state. Please check with your insurance policy, as every policy is different.