Consent for Treatment

Consent for Treatment

Notice Of Business Policies And Privacy Practices

This document contains important information related to professional services and business policies. Please read it carefully. Questions related to this agreement can be discussed at any time. When you sign this document, it will represent an agreement between you and your therapist.

The information provided herein regarding the policies for protecting the privacy of confidential medical information is provided as required by law.


As your therapist, this document contains important information about services and business policies. It also contains information about privacy protections and patient rights with regard to the use and disclosure of your personally identifiable information used for the purpose of treatment and payment. Although this document is long and sometimes complex, it is very important that you read it carefully before beginning your first session. I can discuss any questions you have about the procedures explained in this document. When you sign this document, it will also represent an agreement between us.

The therapists and supervisors at Triquetra are committed to offering high-quality therapeutic services to the community. We are dedicated to helping meet the mental health and relationship care needs of individuals. All of our therapists have at least a master’s degree and some have not yet been licensed. Those who have not yet received their license are receiving post-master’s supervision by a licensed clinical psychologist on a weekly basis.

There are several types of pre-licensed therapists at Triquetra who are practicing therapy under the supervision and earning training hours that are being applied to becoming licensed professionals. Our therapists are under the ongoing supervision of Dr. Di Toro and are working to become licensed Marriage and Family therapists, Licensed Social Workers, and Licensed Clinical Psychologists according to the requirements of both The Board of Behavioral Sciences and the CA Board of Psychology accordingly. All of our therapists are at the training stage similar to when medical doctors graduate and spend several years in a residency program. The pre-licensed therapists have taken this step in their careers and are currently earning the post-graduate experience required for independent licensure. This places the pre-licensed therapists at Triquetra under the mentoring of clinicians who have earned the highest supervision designation in the mental health field. The current clinical supervisor is Dr. Bernadette Di Toro (PSY29800) and her contact information is 619-436-1622, email:

Therapy experiences vary depending on the personalities of the therapist and patient(s) and the particular problems being addressed. There are many different methods that may be used to deal with the problems that you hope to focus on. Seeing a therapist is not like a visit to a medical doctor. Rather, it calls for a very active effort on the part of the Patient(s). In order for therapy to be most successful, you will have to work on things at home that are talked about during your sessions. Therapy has both risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, helplessness, and other difficult emotions. We believe that therapy has stronger benefits than risks. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees, however, regarding your experiences in therapy or the outcome of your therapy. During your first session, you will have the opportunity to ask your therapist some questions you may have and he or she will tell you what you can expect as a patient at Triquetra. Your therapist will also ask you questions about your life, health, and relationship history, substance abuse history, and legal history and will give you the opportunity to describe your reasons for coming to therapy. Throughout therapy, you should evaluate your progress along with your opinions of whether you feel comfortable working with your therapist. Therapy involves a large commitment of time, money, and energy, so you should be careful about the therapist with whom you select to work. If you have questions about procedures at Triquetra, you should discuss them with your therapist whenever they arise. If your doubts persist, your therapist will be happy to help you set up a meeting with another mental health professional for a second opinion. Your decision to enter therapy with a therapist at Triquetra is voluntary. You can stop therapy at any time and discontinuing treatment will not result in any penalty.


Teletherapy or Teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, transfer of medical data, emails, telephone conversations, and/or education using interactive audio, video, or data communications. It is necessary to secure a private and quiet space for you to engage in your therapy sessions with your therapist. If this is not currently available to you, you will not be eligible to participate in teletherapy. Teletherapy involves the communication of my medical/mental health information, both orally and/or visually. Teletherapy has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted in person. However, due to the nature of the technology used, teletherapy may be experienced somewhat differently than face-to-face treatment sessions. Every effort should be made to secure a private and quiet space prior to entering your call with your designated therapist. If you fail to meet these criteria at the time of your session meeting, and you do not request to reschedule prior to 24 hours before your time slot, you will be charged the $150.00 cancellation fee which will not be billed to insurance.

You must be a resident of California and you have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment. The laws that protect the confidentiality of your medical information also apply to teletherapy. As such, you understand that the information disclosed by during the course of your therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are described later herein.

Additionally, you understand that there are risks and consequences of participating in teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of your therapist, that: the transmission of your information could be disrupted or distorted by technical failures; the transmission of your information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. There is a risk that services could be disrupted or distorted by unforeseen technical problems.

Teletherapy-based services and care may not be as complete as face-to-face services. If your therapist believes you would be better served by another form of therapeutic services (e.g. face-to-face services) You will be referred to a professional who can provide such services in your area.

You may benefit from teletherapy, but results cannot be guaranteed or assured. There are potential risks and benefits associated with any form of psychotherapy, and that despite best efforts by both you and your therapist your condition may not improve, and in some cases may even get worse.

Teletherapy does not provide emergency services. If you are experiencing an emergency situation, call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24-hour hotline support. Patients who are actively at risk of harm to themselves or others are not suitable for teletherapy services. If this is the case or becomes the case in the future, your therapist will recommend more appropriate services.

There is a risk of being overheard by anyone near you if you are not in a private room while participating in teletherapy. You are responsible for (1) providing the necessary computer, telecommunications equipment, and internet access for your teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions of teletherapy sessions. It is the responsibility of the psychological treatment provider to do the same on their end.

Dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent and a signed Release of Information form.


Once an appointment day and time is scheduled, you will be expected to pay for it unless you provide 24-hours advance notice of cancellation. This fee will not be billed through your insurance and you will be solely responsible for paying for those missed appointments. The cancellation fee is $150 per missed session canceled within 24-hours no matter the reason for cancellation. If your billing information is on file you will be charged automatically for the cancellation fee. If there is a time available on the same day as your scheduled appointment, however, and I can coordinate a time on that day that works, then you may have that new time on the same day or do a phone session instead of an in-person session. If you need to book an appointment for another day, however, you will be charged the cancellation fee.



Unless otherwise agreed upon, payment is expected at the time of service. Based upon your needs, and if mutually agreed upon, we may be willing to negotiate a reduced fee or billing agreement. Payment schedules for other professional services will be determined at the time they are requested and a retainer may be requested upfront for services to include but not limited to.


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a PPO health insurance policy, it will usually provide some coverage for mental health treatment. We have verified your benefits coverage and explained to you any co-pays, deductibles, or co-insurance expenses that you will be responsible for directly.

You authorize Triquetra Center to bill your insurance for services rendered. You also authorize your insurance provider to pay Triquetra Center directly. You agree that if the insurance company sends you reimbursements directly, you will sign the payment over to Triquetra Center within 24 hours of receipt. You agree that you are ultimately responsible for the financial obligation to Triquetra Center for services provided.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. We will provide your insurance company with only the information required in order to meet their administrative needs.



The laws of California and the standards of my profession require that we keep treatment records for minor patients 7 years after the age of 18 (until age 25), or for those over 18 years old, for 7 years from the date treatment was completed.


We use electronic record-keeping which entails an offsite backup storage system. Your record is only alterable by me, your provider. No one else has access to your records or can make changes to them. We often take handwritten notes during our meetings. These do not include any personally identifying information and are for my use only to protect patient confidentiality.


The information in your medical record is utilized in a number of ways. We use it to plan your treatment and keep a record of the significant issues that we address in treatment. We also use the information to coordinate your treatment with other professionals or to provide information to significant others or family members; information is only provided to those that you have given me permission in writing to communicate with regarding your treatment. If you choose to communicate with me via email, or if you have provided me with permission to contact you via email (typically regarding appointments or billing issues), We use a HIPPA compliant encrypted email address.

Information in your medical record may also be required by your insurance company or health plan so that the treatment you receive from me can be paid
for by the insurance company or health plan. For example, we may need to provide information about a service you received, or we may be required to provide information prior to treatment so that your plan will cover the treatment. In these cases, the only information required for payment is provided to the insurance company or health plan. By signing this Consent, you authorize me to provide information to your insurance company as needed for payment for services.

In general, the privacy of all communications between a patient and a psychologist is protected by law, and we can only release information about our work to others with your written permission.


There are some exceptions to your protections, and in general, we will provide information from your record when required to do so by local, state, or federal law. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he or she determines that the issues demand it.

Therapists, supervisors, and staff at Triquetra have a responsibility to protect information received from you during treatment. In order for any information about you to be shared, usually, you must first sign a Release of Information that allows us to communicate only with the person identified on the release and only regarding specific information identified by you. Because of our commitment to evidence-based practice, and the team treatment approach at Triquetra we regularly discuss our clinical work with supervisors and other treatment team members, and at times administrators of Triquetra to make sure that we are providing our patients with the best care possible. During these meetings, trainings, and consultations, we most often do not share our patients’ personally identifiable information. When circumstances do require identifiable information to be shared, all Triquetra staff, supervisors, consulting clinicians, and related staff are legally and ethically bound to keep your information confidential. Under certain conditions, the laws of the State of California allow exceptions to patient confidentiality.

These exceptions occur under the following circumstances:

1. We are required to report suspected child abuse or neglect and to report suspected abuse of the disabled or elderly. This information is required to be shared with Child Protective Service, and local officials where the suspected victim resides, or a judge having jurisdiction.

2. We may give information to law enforcement or medical personnel in order to protect patients and others when there is a probability of imminent physical danger, including the potential for suicide, homicide, or serious injury on the part of the patient. We may also disclose information to law enforcement or medical personnel in order to protect you from immediate mental or emotional injury. We may be required to disclose information to the courts regarding treatment information in proceedings affecting the parent-child relationship.

3. Confidentiality is not protected in connection with criminal proceedings, except communication by a person voluntarily involved in a substance abuse treatment program.

4. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by patient-therapist confidentiality. We cannot provide any information without your written authorization or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss with your therapist any questions or concerns you may have now or in the future.

If a situation occurs that requires that I share information without your written permission, I will make every effort to fully discuss it with you before taking any action. In order to release any information to another party, I will ask that you sign an Authorization to Release Information. You may revoke your Authorization(s) at any time.


If any aspect of our communication occurs outside of regular sessions, it is important to know that the privacy of those communications cannot be guaranteed. Note that any electronic communications are potentially not as private as one might wish. Communication for any purpose that occurs via email, text message, fax, Ring Central, voicemail, or any other electronic means may be compromised. Your entering into any of those modes of communication implies your acknowledgment of the risk associated with that means of communication, and your consent to making use of that means of communication for our professional relationship



You are entitled to receive a copy of your medical record unless I believe that receiving that information would have adverse consequences. Records would only be lawfully withheld when life or physical safety are endangered.

Professional records can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records or receive a copy of your records, we require written notice to that effect and I would expect to discuss your request with you in person. After receipt of your written request, you have a right to inspect your records within 5 working days.

Please allow for 15 working days (after our receipt of your written request) to obtain a written copy of your records. If we deny you access to your records, you can request to speak with an independent colleague of mine about your request. Your request for an independent review of your request should also be made in writing. If you are provided with a copy of your medical record information, we may charge a fee for any costs associated with that request (no more than $0.25 per page).

Should you prefer a treatment summary, please request this too in writing and after our receipt of your request, you will receive the requested summary in 10 working days unless extenuating circumstances exist (for example extraordinary length of treatment record) which could take up to 30 days to deliver the summary in this case of which you will be notified.


If you believe that the information I have about you is incorrect or incomplete, you may ask me to amend that information. It is my practice to accept this sort of
request in writing, and that any information you may wish to add to your record also be provided to me in written form.


You have the right to request an “Accounting Of Disclosures.” This is a list of the disclosures I have made of medical record information. That information is listed on the Authorization To Release Information and will be provided to you at your written request.


You have the right to privacy, and to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. As noted above, I will not release your confidential information without your written permission. Any restrictions to your Authorization To Release Information should be specified on the Authorization.


You have the right to request that I communicate with you only in certain ways. For example, you can ask that I do not leave a telephone message for you, or that I only contact you at work or by mail. These options will be available for you to select on the demographic sheet you will complete along with this form and any changes to such requested are to be communicated in writing.


If you believe your privacy rights have been violated, you may file a written complaint with me, or with an independent colleague of mine, or with the U.S. Department of Health and Human Services, 50 United Nations Plaza, Room 322, San Francisco, CA, 94102. You will not be penalized for filing a complaint.


It is understood that any dispute as to psychological malpractice, that is as to whether any psychological services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the psychologist and the psychologist’s partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them, must be arbitrated including claims for loss of consortium, emotional distress or punitive damages. A demand for arbitration must be communicated in writing to all parties. Each party to the arbitration shall pay such party’s pro-rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the
absolute right to arbitrate separately the issues of liability and damages upon written request.


I am often not immediately available by telephone or other electronic means. Due to my schedule with patients, I will not answer the phone or any other communications while with other patients. When I am unavailable, my telephone will roll over to a voicemail system that I monitor frequently. I will make every effort to return your call as soon as possible. In emergencies, you can attempt to reach me at my office number and leave an appropriate message. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. If you feel that you can’t wait for a return call, you can contact the San Diego Access and Crisis Line (1-800-479-3339) or go to the nearest emergency room and ask for the psychologist or therapist on call. If you are in a medical emergency, call 911.

Filling the form below indicates that we have reviewed the information contained in this Consent For Treatment & Notice Of Business Policies And Privacy Practices document and that you agree to abide by its terms during our professional relationship. You will receive a copy of this document for your records. By filling this form, you are providing me with permission to provide you with my professional services as a psychologist.

Triquetra Consent for Treatment

This document contains important information related to professional services and business policies. Please read it carefully. Questions related to this agreement can be discussed at any time. When you sign this document, it will represent an agreement between you and your therapist.
By submitting this, you acknowledge that you've read the service agreement terms explained above.
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