Informed Consent, Notice of Privacy Practices

Linda Rivadeneyra LMFT, #34416,, (661) 857-5381

Informed Consent to Treatment


Length of sessions is normally about 55 minutes. Therapy sessions are usually held weekly.

Please provide a 24 hour notice for cancelations so that I can offer the time slot to someone else. 

Co-payments or payments are due at the beginning of each session.

A signed written Release of Information, from you, is required to share information with any person or entity.

Regular appointment times can be offered however if there are regular cancelations the same slot cannot be gauranteed.

Notice of Privacy Practices/Confidentiality:

It is my obligation to protect your health information, per HIPAA ( standards for privacy.

As your therapist, I am legally prohibited from revealing to another person that you are in therapy with me, nor can I reveal what you have said to me in any way that identifies you without your written permission. However, in the following instances, your right to confidentiality

must be set aside as required by law and/or professional guidelines; see exceptions below:

A. Instances of actual or suspected physical or sexual abuse, emotional cruelty, or neglect

of a child or an elder or dependent adult must be reported to the appropriate

protective services.

B. If I have a reason to believe that a client poses an unavoidable and imminent danger of

violence to another person (or to another’s property), I must warn whoever may be in

danger, and I must notify the appropriate authorities.

C. If a court has ordered your treatment with me, or if I am served with a subpoena.

D. Finally, if you as a client reveal a serious intent to harm yourself, I am ethically bound

to do what I can to help you keep safe, which may involve notifying others who may be

of help.

Insurance Audits:  Insurance companies sometimes ask for medical records.  My understanding is that they look for medical necessity of treatment and treatment effectiveness and outcomes, since they are paying for my services.  At that time I offer a treatment summary.  The summary does not include personal information.  The summary outlines symptoms, interventions and progress in a relatively generic manner to protect your confidentiality.

Linda Rivadeneyra, LMFT, #34416                                                                  ________________________________

Psychotherapist                                                                                                           Client Signature, Date