Informed Consent, Notice of Privacy Practices

Linda Rivadeneyra LMFT, #34416

www.LindaRivadeneyra.com, www.facebook.com/LindaRLMFT, (661) 857-5381

350 S. Lake Ave., Suite 201, Pasadena, CA 91101


Informed Consent to Treatment


Therapy is a unique partnership between therapist and client. Coming to therapy is often a big step and clients may have a lot of feelings related to beginning therapy, which is normal. Please feel free to share your feelings, thoughts and questions . I will try my best to understand you (will obtain a history about your issues, family, relationships, strengths), create a safe environment (building rapport as you get comfortable, be open minded/non judgmental), and support you (make recommendations, validate your experiences, empathize). I utilize various therapy approaches, and together we will find an approach that works for you. For example, if you want practical suggestions, you can let me know.  Or, if you want to explore your feelings, please let me know.  In general, I will want to utilize the most quickly effective approach such as implementing Cognitive strategies to reduce Anxiety and Depression (CBT is shown to be highly effective), or I will recommend EMDR for Trauma.  All the while, I will try to maintain an attuned, empathic approach with any interventions utilized.   At times I will make recommendations for reading materials and exercises for you, however, whether you follow up with these recommendations for resources is voluntary on your part. I would love to know if you did follow up on resources/recommendations.  


Length of sessions is between 45-50 minutes. Therapy sessions are usually held weekly.

Please provide a 24 hour notice for cancelations as much as is possible.

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.

Notice of Privacy Practices/Confidentiality:


It is my obligation to protect your health information, per HIPAA (HHS.gov) 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.


Linda Rivadeneyra, LMFT, #34416                                                                  ________________________________

Psychotherapist                                                                                                           Client Signature, Date