This form provides you, the client, with information that is
additional to that detailed in the Notice of Privacy Practices.
The following information is provided to you as required by law.
The notice is about 2 pages long and should take approximately 10
minutes to review and sign.
CONFIDENTIALITY:
All information disclosed within sessions and the written records
pertaining to those sessions are confidential and may NOT be
revealed to anyone without your written permission except where
disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED BY LAW:
Where there is a reasonable suspicion of child, dependent, or
elder abuse or neglect; where a client presents a danger to self,
to others, to property, or is gravely disabled; or when a
client's family members communicate to Alyson Giardini, LMFT that
the client presents a danger to others.
WHEN DISCLOSURE MAY BE REQUIRED BY LAW Disclosure may also be
required pursuant to a legal proceeding by or against you. If you
place your mental status at issue in litigation initiated by you,
the defendant may have the right to obtain the psychotherapy
records and/or testimony by Alyson Giardini, LMFT. In couple and
family therapy, or when different family members are seen
individually, even over a period of time, confidentiality and
privilege do not apply between the couple or among family
members, unless otherwise agreed upon. Alyson Giardini, LMFT will
use her clinical judgment when revealing such information. Alyson
Giardini, LMFT will not release records to any outside party
unless she is authorized to do so by all adult parties who were
part of the family therapy, couple therapy or other treatment
that involved more than one adult client.
CANCELLATION POLICY:
Since the scheduling of an appointment involves the reservation
of time specifically for you, a minimum of 24 hours notice is
required for re-scheduling or canceling an appointment. Unless we
reach a different agreement, a $40 fee will be charged for late
cancellations that are less than 24 hours from the appointment
time, but still arrive the day before your session time.
The full session fee will be charged for same day
cancellations or appointments missed with no notice given.
Insurance companies do not reimburse for missed sessions so
this will be an out-of-pocket charge.
EMERGENCY:
If there is an emergency during therapy, or in the future after
termination, where Alyson Giardini, LMFT becomes concerned about
your personal safety, the possibility of you injuring someone
else, or about you receiving proper psychiatric care, she will do
whatever she can within the limits of the law, to prevent you
from injuring yourself or others and to ensure that you receive
the proper medical care. For this purpose, she may also contact
the person whose name you have provided on the biographical
sheet.
CONSULTATION:
Alyson Giardini, LMFT consults regularly with other professionals
regarding her clients; however, each client's identity remains
completely anonymous and confidentiality is fully maintained.
TELEPHONE & EMERGENCY PROCEDURES:
If you need to contact Alyson Giardini, LMFT between sessions,
please leave a message at (510) 594-4066 or (530) 301-2376 and
your call will be returned as soon as possible. Alyson Giardini,
LMFT checks her messages a few times during the daytime only,
unless she is out of town. If an emergency situation arises,
indicate it clearly in your message and if you need to talk to
someone right away call Sutter Yuba Mental Health 24-hour crisis
line at (888) 923-3800, or the Alameda County 24-hour crisis
hotline at (800) 309-2131 or the Police by calling 911. Please
note, due to limited cell coverage in rural areas, messages do
not always reach Alyson Giardini, LMFT in a timely manner. In an
urgent situation it is best to leave a voicemail on both
510.594.4066 and 530.301.2376.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE:
Participation in therapy can result in a number of benefits to
you, including improving interpersonal relationships and
resolution of the specific concerns that led you to seek therapy.
Working toward these benefits, however, requires effort on your
part. Psychotherapy requires your active involvement, honesty,
and openness in order to change your thoughts, feelings, and/or
behavior. Alyson Giardini, LMFT will ask for your feedback and
views on your therapy, its progress, and other aspects of the
therapy and will expect you to respond openly and honestly.
Sometimes more than one approach can be helpful in dealing with a
certain situation. During evaluation or therapy, remembering or
talking about unpleasant events, feelings, or thoughts can result
in you experiencing considerable discomfort or strong feelings of
anger, sadness, worry, fear, etc., or experiencing anxiety,
depression, insomnia, etc. Alyson Giardini, LMFT may challenge
some of your assumptions or perceptions or propose different ways
of looking at, thinking about, or handling situations, which can
cause you to feel very upset, angry, depressed, challenged, or
disappointed. Attempting to resolve issues that brought you to
therapy in the first place, such as personal or interpersonal
relationships, may result in changes that were not originally
intended. Psychotherapy may result in decisions about changing
behaviors, employment, substance use, schooling, housing, or
relationships. Sometimes a decision that is positive for one
family member is viewed quite negatively by another family
member. Change will sometimes be easy and swift, but more often
it will be slow and even frustrating. There is no guarantee that
psychotherapy will yield positive or intended results. During the
course of therapy, Alyson Giardini, LMFT is likely to draw on
various psychological approaches according, in part, to the
problem that is being treated and her assessment of what will
best benefit you. These approaches include, but are not limited
to, behavioral, cognitive-behavioral, cognitive, psychodynamic,
existential, system/family, developmental (adult, child, family),
humanistic or psycho-educational. Alyson Giardini, LMFT provides
neither custody evaluations nor medication or prescription
recommendations nor legal advice, as these activities do not fall
within her scope of practice.
TREATMENT PLANS:
Within a reasonable period of time after the initiation of
treatment, Alyson Giardini, LMFT will discuss with you her
working understanding of the problem, treatment plan, therapeutic
objectives, and her view of the possible outcomes of treatment.
If you have any unanswered questions about any of the procedures
used in the course of your therapy, their possible risks, Alyson
Giardini, LMFT's expertise in employing them, or about the
treatment plan, please ask and you will be answered fully. You
also have the right to ask about other treatments for your
condition and their risks and benefits.
TERMINATION:
As set forth above, after the first couple of meetings, Alyson
Giardini, LMFT will assess if she can be of benefit to you.
Alyson Giardini, LMFT does not work with clients who, in her
opinion, she cannot help. In such a case, if appropriate, she
will give you referrals that you can contact. If at any point
during psychotherapy Alyson Giardini, LMFT either assesses that
she is not effective in helping you reach the therapeutic goals
or perceives you as non-compliant or non-responsive, and if you
are available and/or it is possible and appropriate to do, she
will discuss with you the termination of treatment and conduct
pre-termination counseling. In such a case, if appropriate and/or
necessary, she would give you a couple of referrals that may be
of help to you. If you request it and authorize it in writing,
Alyson Giardini, LMFT will talk to the psychotherapist of your
choice in order to help with the transition. If at any time you
want another professional's opinion or wish to consult with
another therapist, Alyson Giardini, LMFT will give you a couple
of referrals that you may want to contact, and if she has your
written consent, she will provide her or him with the essential
information needed. You have the right to terminate therapy and
communication at any time. If you choose to do so, upon your
request and if appropriate and possible, Alyson Giardini, LMFT
will provide you with names of other qualified professionals
whose services you might prefer.
PAYMENTS & INSURANCE REIMBURSEMENT:
Clients are expected to pay the prearranged fee per 45/50 minute
session at the time services are rendered unless other
arrangements have been made. Telephone conversations, writing and
reading of reports, consultation with other professionals, longer
sessions, etc. will be charged at the same rate, unless indicated
and agreed upon otherwise. Please notify Alyson Giardini, LMFT if
any problems arise during the course of therapy regarding your
ability to make timely payments. As a convenience, Alyson
Giardini, LMFT will bill your insurance provider directly on your
behalf if you have covered benefits. However, not all
issues/conditions/problems, which are dealt with in
psychotherapy, are reimbursed by insurance companies. It is your
responsibility to verify the specifics of your coverage.
You will be responsible for payment for all sessions held
when insurance reimbursement could not be secured. Note:
Insurers do not cover the costs of late cancellations or missed
sessions. See the section describing 'Cancellation Policy' for
details on out of pocket fees for late cancellations.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS:
Disclosure of confidential information may be required by your
health insurance carrier or HMO/PPO/MCO/EAP in order to process
the claims. When you agree to use your health insurance to access
benefits, you are consenting to this disclosure. Alyson Giardini,
LMFT, will disclose the minimum necessary information required to
process the claim. Alyson Giardini, LMFT has no control over, or
knowledge of, what specific insurance companies do with the
information she submits or who has access to this information.
Submitting a mental health invoice for reimbursement carries a
certain amount of risk to confidentiality and privacy in that
such details become part of your electronic medical record and as
such may be accessed under unknown future conditions (Patriot
Act, National Medical Database, unauthorized access via hackers).
Medical data has also been reported to have been legally accessed
by law enforcement and other agencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM:
Both the law and the standards of Alyson Giardini, LMFT's
profession require that she keep treatment records for at least 7
years. Please note that clinically relevant information from
emails, texts, and faxes are part of the clinical records. Unless
otherwise agreed to be necessary, Alyson Giardini, LMFT retains
clinical records only as long as is mandated by California law.
If you have concerns regarding the treatment records, please
discuss them with Alyson Giardini, LMFT. As a client, you have
the right to review or receive a summary of your records at any
time, except in limited legal or emergency circumstances or when
Alyson Giardini, LMFT assesses that releasing such information
might be harmful in any way. In such a case, Alyson Giardini,
LMFT will provide the records to an appropriate and legitimate
mental health professional of your choice. Considering all of the
above exclusions, if it is still appropriate, and upon your
request, Alyson Giardini, LMFT will release information to any
agency/person you specify unless Alyson Giardini, LMFT assesses
that releasing such information might be harmful in any way. When
more than one client is involved in treatment, such as in cases
of couple and family therapy, Alyson Giardini, LMFT will release
records only with signed authorizations from all the adults (or
all those who legally can authorize such a release) involved in
the treatment.
LITIGATION:
Due to the nature of the psychotherapeutic process and the fact
that it often involves making a full disclosure with regard to
many matters, clients' records are generally confidential and
private in nature. When clients become involved in litigation
while they are in therapy or after therapy has been completed,
they (or the opposing attorney, in a legal case) sometimes want
the records disclosed to the legal system. Clients should know
that very serious consequences can result from disclosing therapy
records to the legal system. Such disclosures may negatively
affect the outcome of custody disputes or other legal matters and
may negatively affect the therapeutic relationship. If you or the
opposing attorney are considering requesting Alyson Giardini,
LMFT's disclosure of the records, Alyson Giardini, LMFT will do
her best to discuss with you the risks and benefits of doing so.
As noted in this document, you have the right to review your own
psychotherapy records anytime. Alyson Giardini, LMFT will
not participate in court proceedings, write letters to the court,
or otherwise provide evaluations for the court on any matter. If
a subpoena is issued compelling her participation, you will be
charged for her time at a private rate of $150/hour. This
is not recoverable by insurance companies.
MEDIATION & ARBITRATION:
All disputes arising out of, or in relation to, this agreement to
provide psychotherapy services shall preferably first be referred
to mediation before the initiation of arbitration or litigation.
The mediator shall be a neutral third party chosen by agreement
of Alyson Giardini, LMFT and the client(s). The cost of such
mediation, if any, shall be split equally, unless otherwise
agreed upon. In the event that mediation is unsuccessful or not
an agreed-upon option, any unresolved controversy related to this
agreement should preferably be submitted to and settled by
binding arbitration, in accordance with the rules of the American
Arbitration Association which are in effect at the time the
request for arbitration is filed. Please note that neither
mediation nor arbitration is mandatory. In the event that your
account is overdue (unpaid) and there is no agreement on a
payment plan, Alyson Giardini, LMFT can use legal means (court,
collection agency, etc.) to seek payment. If there is
arbitration, the prevailing party in arbitration or collection
proceedings shall be entitled to recover a reasonable sum as and
for attorney's fees. In the case of arbitration, the arbitrator
will determine that sum. In the case of a court case, the court
will determine the sum.
DUAL RELATIONSHIPS:
Not all dual relationships are unethical or avoidable. Therapy
never involves sexual or any other dual relationship that impairs
Alyson Giardini, LMFT's objectivity, clinical judgment or can be
exploitative in nature. Alyson Giardini, LMFT will assess
carefully before entering into non-sexual and non-exploitative
dual relationships with clients. It is important to realize that
in some communities (i.e. small towns, military bases, university
campuses, spiritual and rehabilitation communities, etc.), dual
relationships are either unavoidable or expected. Alyson
Giardini, LMFT will never acknowledge working with anyone without
his or her written permission. Many clients have chosen Alyson
Giardini, LMFT as their therapist because they knew her before
they entered therapy with her, and/or are personally aware of her
professional work and qualifications. Nevertheless, Alyson
Giardini, LMFT will discuss with you the often-existing
complexities, potential benefits and difficulties that may be
involved in dual relationships. Dual relationships can enhance
trust and therapeutic effectiveness but can also detract from it
and often it is impossible to know which ahead of time. It is
your responsibility to advise Alyson Giardini, LMFT if the dual
relationship becomes uncomfortable for you in any way. Alyson
Giardini, LMFT will always listen carefully and respond to your
feedback and will discontinue the dual relationship if she finds
it interfering with the effectiveness of the therapy or your
welfare and, of course, you can do the same at any time.
PHONE, EMAIL OR OTHER WEB BASED THERAPY SESSIONS:
When requested, therapy sessions may be conducted via phone,
email or other web based communication tools. The same policies
and procedures laid out in this document apply. Alyson Giardini,
LMFT will discuss additional aspects of informed consent with you
as it relates to such modalities and send you the document,
"Telehealth Disclosures". Although many insurers are beginning to
cover telemedicine services, such services are not always a
covered benefit. You are responsible for determining if your plan
provides this service and are responsible for any session fees
not covered by your insurer.
SOCIAL NETWORKING AND OTHER ELECTRONIC COMMUNICATIONS:
As a general rule, Alyson Giardini, LMFT does not initiate or
accept friend requests from current or former clients on social
networking sites, such as Facebook, due to concerns that they can
compromise your privacy and confidentiality. However, if after
discussing the pros and cons, you have determined that this is a
form of connection and communication that is important to you,
Alyson Giardini, LMFT is open to allowing this connection. Should
such a connection be made, it is important to limit any
communications in that public medium that are related to your
work in therapy to protect your confidentiality. In the interest
of not compromising your therapy, any concerns that arise from
such a connection should be brought in for discussion as they
arise. Additionally, communication via text, unencrypted email,
or other messaging apps is not HIPPA compliant and is therefore
only allowable with your full informed consent to accept the
risks of such communication. Please complete the, "Electronic
Communications Consent" form to make your selections and opt in
to other forms of communication with Alyson Giardini, LMFT beyond
phone calls and secure encrypted email through the client portal.
AUDIO OR VIDEO RECORDING:
Unless otherwise agreed to by all parties beforehand, there shall
be no audio or video recording of therapy sessions, phone calls,
or any other services provided by Alyson Giardini, LMFT.
I have read the above Office Policies and Informed Consent for
Psychotherapy carefully.
NOTICE TO CLIENTS
The Board of Behavioral Sciences receives and responds to
complaints regarding services provided within the scope of
practice of (marriage and family therapists, licensed educational
psychologists, clinical social workers, or professional clinical
counselors). You may contact the board online at www.bbs.ca.gov,
or by calling (916) 574-7830.
