Informed Consent

PARENTS OR GUARDIANS

Parents may be asked to attend sessions. Both parents must consent if they share
legal custody. Children’s confidentiality is respected within legal limits.

NOTICE TO CLIENTS

The Board of Behavioral Sciences receives and responds to complaints regarding
licensed therapists. Visit www.bbs.ca.gov or call (916) 574-7830.

Signature

Signature(for shared custody Parent if applicable).

Date

PROFESSIONAL FEES:

General Child, Family & Adult Psychotherapy (50 minutes) $150.00
Court Ordered Child and Adult Psychotherapy (50 min) $175.00
Court Ordered Co-Parenting Counseling / Court Ordered Family/ Reconnection
Counseling / Other Services: $175 (50 minutes)
Professional Consultation (60 minutes) $175.00
Court Appearances, $250.00 an hour, 4 hour minimum
Written Reports (Hourly Rate) $175.00

PAYMENT OF FEES AND BILLING

The fees are payable at the beginning of each session unless we agree otherwise.
If the balance grows beyond $250.00 it may result in suspension of further sessions until the balance has been paid.

PAYMENT OPTIONS

Check, credit card, Venmo or Zelle (bank to bank transfers)
Credit Card payments are managed by Square, and it’s asked your credit card
is securely kept on file to use at the time of a session.