Consent

All communication between client and counselor is confidential and will not be shared with anyone except for the following reasons:

Confidentiality/Limits to Confidentiality:
All information shared in sessions is strictly confidential! No information disclosed by you to me will be released outside of our sessions, except for consultation as needed with the following clearly defined exceptions mandated under California state law:
1) If you are abusing or allowing to be abused a person under the age of 18, a dependent adult or an elder;
2) Certain forms of sexual contact with a minor depending on respective ages;
3) If you intend to physically harm yourself (including by suicide) or cause physical harm to another person;
4) As mandated by court order if your mental health is questioned during legal proceedings

Counselors are able to give and receive confidential information to other parties upon your request and with a written consent form signed by you.

Schedule, Cancellation Policy and Fees:

Appointments will be for 50 minutes unless we determine another arrangement is warranted
72 hours (3 Business days) notice is required to cancel or reschedule a session; if you do not give me at least 72 hours, you will be asked to pay for the missed session in full
I charge for responding to emails other than for scheduling which will be pro-rated by my hourly fee
Conference calls with other therapists and/or attorneys will be charged $300
Written letters to court will be charged $300
I will pro-rate any documents, I need to read, over 5 pages
Payments are due at each session unless previous arrangements have been made
You will receive at least 30 days notice of any increases in my fee

Court Appearances and Depositions:
My fee is $400.00 per hour. Preparation for testimony is billed at the rate of $400.00 per hour. Court appearances are billed at a minimum of half-day rate of $2000.00. If I am asked to appear at court, I will ask that my fee be paid in full one week before my testimony. I will bill for additional charges (if asked to stay longer) and expect that any outstanding fees will be paid within 7 days. Please keep in mind I am canceling ongoing appointments with clients to make myself available and must receive notice of cancellation 72 hours in advance for my reserved time.

Thank you for your cooperation. Please discuss any questions or concerns you may have with me.

Jennifer Santos, LMFT, PC
license # 51058

I understand and agree to the above items:

Client Signature_____________________________________________
Printed Name_______________________________________________
Date_______________
Parent/Guardian Signature_____________________________________
Printed Name________________________________________________