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Consent for Psychotherapy Treatment

I give my voluntary consent to engage in psychotherapy with Joshua Coleman, Ph.D. I understand that psychotherapy is a joint effort and that results cannot be guaranteed. I understand that I may withdraw from treatment at any time.

Treatment is confidential, and unless I consent to release information, it will not be disclosed to anyone. The following circumstances, however, are exceptions. I have been informed that under California statutes: a) if a patient communicates to a therapist a serious threat to harm an identifiable person, the therapist must warn that person and the police; (b) if the therapist suspects child abuse or neglect, or abuse of a dependent adult or of a person over the age of 65, a report must be made to the appropriate agency; and (c) if a patient seems dangerous to self or other, or is unable to care for him or herself, hospitalization may be required.

Further, I understand that information and records otherwise confidential, and/or testimony concerning my family or me, must be provided in the event of a court order demanding it. Also, in litigation or official proceedings, information and records otherwise confidential and/or testimony concerning my family and me may have to be provided in limited circumstances without my specific consent in accordance with the law.

The fee per 50-minute session is $250 unless other arrangements have been made, due at the time of service or upon receipt of invoice. Clients are charged for all cancellations unless I am able to fill your time with another appointment, or you give me 48 hours notice and re-schedule within that week. In general, the more notice that I have, the greater the likelihood of being able to fill your time.

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