Informed Consent for Psychotherapy

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and note any questions you would like to discuss at our first session. When you sign this document, it will represent an agreement between us.

About Your Therapist

I am Amber Faille, a Licensed Clinical Social Worker (LCSW) in the State of California, License # 129737, licensed by the California Board of Behavioral Sciences. I provide psychotherapy to children, adolescents, and adults, in person and via telehealth, with a clinical specialty in substance use disorders. Telehealth is available only to clients physically located in California. Peaches Mindcare is a fictitious business name (DBA) of Moonstone Recovery, Inc.

The Psychotherapy Process

Psychotherapy is a collaborative process based on the relationship between you and your therapist. It varies depending on the personalities of both therapist and client and the particular concerns you bring. There are many different approaches I may use, including Cognitive Behavioral Therapy (CBT), Trauma-Focused CBT, mindfulness-based approaches, and psychodynamic techniques.

Benefits. Psychotherapy has been shown to have benefits for people who undertake it, including better relationships, solutions to specific problems, meaningful reduction in feelings of distress, and improved coping. There are no guarantees of what you will experience.

Risks. Because therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness, especially early in the process. These experiences are a normal part of therapy and usually temporary. Please share them with me so we can address them together.

Appointments and Cancellations

Sessions are typically 50 minutes, held weekly or at a frequency we agree upon. Your appointment time is reserved for you. If you must cancel or reschedule, please provide at least [24–48] hours’ notice; late cancellations and missed appointments are charged the full session fee, as described in the Financial Agreement & Fee Schedule.

Confidentiality

With limited exceptions described below, everything you share in therapy is confidential and will not be disclosed without your written authorization. Confidentiality is protected by federal law (HIPAA) and California law, including the Confidentiality of Medical Information Act (CMIA).

Limits of Confidentiality

California law requires or permits me to disclose confidential information without your authorization in certain situations, including:

• Suspected child abuse or neglect. As a mandated reporter under the California Child Abuse and Neglect Reporting Act, I must report known or reasonably suspected abuse or neglect of a child to the appropriate authorities.
• Suspected elder or dependent adult abuse. I must report known or reasonably suspected abuse, neglect, or financial exploitation of an elder (65+) or dependent adult.
• Serious threat of violence to an identifiable victim. If you communicate a serious threat of physical violence against a reasonably identifiable victim, I have a legal duty to take protective action, which may include notifying the potential victim and law enforcement (Cal. Civ. Code § 43.92, the “Tarasoff” duty).
• Danger to self. If I believe you are at imminent risk of seriously harming yourself, I may take steps to protect your safety, which can include contacting your emergency contact, crisis services, or law enforcement, or initiating hospitalization.
• Court orders and legal proceedings. I may be required to disclose information in response to a valid court order or where otherwise required by law.

If a disclosure is required, I will make every effort to discuss it with you first when possible, and to limit the disclosure to the minimum necessary. These limits apply to all clients, including minors and clients receiving care related to substance use.

Consent for Minor Clients & a Minor’s Right to Consent

Because this practice serves children and adolescents, in most cases a parent or legal guardian consents to and is involved in a minor’s treatment, and signs this agreement on the child’s behalf. Effective therapy for a child depends on trust, so I generally share themes, progress, and safety concerns with parents while protecting the details a child shares in confidence. We will discuss how information is shared at the start of care.

California law also gives some minors the right to consent to their own care:

• Outpatient mental health treatment (Cal. Family Code §6924). A minor 12 years of age or older may consent to outpatient mental health treatment or counseling when, in the treating professional’s judgment, the minor is mature enough to participate intelligently in it. The statute also addresses when involvement of the minor’s parent or guardian is required.
• Drug- or alcohol-related counseling (Cal. Family Code §6929). A minor 12 years of age or older may consent to medical care and counseling relating to the diagnosis or treatment of a drug- or alcohol-related problem, subject to the exceptions in the statute (for example, it does not include replacement narcotic abuse treatment).

Confidentiality when a minor consents on their own. When a minor lawfully consents to their own treatment under §6924 or §6929, the parent or guardian generally does not have an automatic right to that minor’s treatment information or records for those services, and information is released only as the law allows or the minor authorizes. The limits of confidentiality described above (mandated reporting, danger to self or others, and the duty to protect) still apply.

Substance Use & Additional Confidentiality Protections

Records of substance-use-disorder treatment receive additional federal confidentiality protection under 42 CFR Part 2, which strictly limits when such information may be disclosed or re-disclosed — protections that are generally stronger than those for other health information. If your or your child’s care involves substance use, we will discuss these protections, how they interact with a minor’s right to consent under §6929, and the Authorization to Release Information that would be required to share those records. The mandated-reporting and safety-related limits of confidentiality above still apply.

Emergencies

I do not provide 24-hour crisis services. If you are experiencing a mental health emergency, call or text 988 (Suicide & Crisis Lifeline), call 911, or go to your nearest emergency room. Please also review the emergency planning section of the Telehealth Informed Consent if we meet by video.

Your Records and Access to Them

I keep records of our work together as required by law and professional standards. Under HIPAA and California Health & Safety Code § 123100 et seq., you generally have the right to inspect or receive a copy of your records upon written request, subject to limited exceptions. In some circumstances I may offer a treatment summary instead. My Notice of Privacy Practices describes your rights in detail.

Professional Consultation

I may occasionally consult with other licensed professionals about cases to provide the best possible care. In these consultations, I do not reveal information that would identify you, and the consultant is also legally bound to keep information confidential.

Ending Therapy

You may end therapy at any time, for any reason. Ideally, we will discuss ending therapy together and have at least one closing session to review our work. If I believe I am not the right fit for your needs, I will discuss this with you and provide referrals to other qualified providers.

Acknowledgment and Consent

By signing below, I acknowledge that I have read and understood this Informed Consent for Psychotherapy, that my questions have been answered to my satisfaction, and that I voluntarily consent to treatment with Amber Faille, LCSW. I understand I may withdraw my consent at any time. For a minor client, the parent or legal guardian consents to treatment by signing below; a mature minor consenting to their own care under Cal. Family Code §6924 or §6929 may sign as the client.

Client (or minor client, where consenting on their own):

Parent / Legal Guardian (required if the client is a minor):