Disclosure Statement & Agreement for Services
This document is intended to provide important information to you regarding your therapy.
Please read the entire document carefully and be sure to ask any questions that you may have regarding its content.
Psychotherapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person in that relationship. This framework helps to create a safe and supportive place that allows one to take risks and feel empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about, and there are certain limitations to those rights you should be aware of.
With the exception of certain specific situations as described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior permission. You can authorize me to share information with whomever you choose, and you may change your mind and revoke that permission at anytime. The following are legal exceptions to your right to confidentiality. I will inform you of any time when I think I will have to put these into effect.
If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
If I have good reason to believe that you are abusing or neglecting or elder adult, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police. I am not obligated to do this, and will explore all other options with you before this step is taken.
If a third party such as an insurance company is paying for part of your bill, I am required to give a diagnosis to that third party. Diagnoses are technical terms that describe the symptoms of your issue(s).
The patriot Act of 2001 requires that therapists in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the client that the FBI sought or obtained the items under the act.
Family, Marital/Couples Therapy and Confidentiality
If you participate in marital or family therapy (where there is more than one client) I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide written authorization to release such information.
It is important that you know that I utilize a “no-secrets” policy when conducting Family or Marital/Couples Therapy. This means that what you say in individual sessions will be considered to be a part of the family or couples therapy, and may get discussed in our joint sessions. I will remind you of this policy before beginning such individual session.
Minors and Confidentiality
Communication between therapists and clients who are minors (under the age of 18) are confidential. However, parents/guardians who provide authorization for their child’s treatment are often involved in their child’s treatment. Consequently, I will exercise my professional judgment and may discuss my concerns and or the treatment progress of a minor client with parent/guardian. Clients who are minors and their parents are urged to discuss any questions or concerns that they have.
The service I provide include: Individual Therapy, Marital/Couples Counseling, Family Therapy, and child Therapy.
My Training and Approach to Therapy
I am a licensed Marriage and Family Therapist, MFCC #42395. I have a M.S. in Marriage and Family Counseling earned in 1998 at California State University Hayward. I have also earned a school counseling Credential and a B.A. in Personality Development and Clinical Processes. Because of the ever-changing nature of my field, I involve myself in ongoing training and continuous learning of new ways to help and support my clients as they achieve their life and relationship goals.
I have working knowledge and experience helping adults and children who have Mood swings, Anxiety, Depression and Anger Issues. I also work with people who are having a difficult time coping with life changes. This includes grief and loss, chronic and acute illness, separation, and divorce.
I have training in a variety of theoretical orientations which include: Cognitive Behavioral Therapy, Family Systems, Psychodynamic, Couples Counseling, Grief Therapy, Solution Focused Therapy, Dialectical Behavioral Therapy, and Crisis work.
It is my intention to provide services that will assist you in reaching your goals. My approach to therapy varies on the particular issues you are experiencing.
I believe that therapists and clients are partners in the therapeutic process, and you have the right to agree or disagree with any of my recommendations. Therapy calls for an active effort on your part.
Therapy also has potential emotional risks. Discussing unpleasant aspects of your life, or approaching feelings or thoughts that you have tried not to think about may be painful. Making changes in our beliefs and behaviors can be scary, and sometimes disruptive to the relationships you already have. It is important that you consider carefully whether these risks are worth the benefits to you. Most people who take these risks find that therapy is helpful. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feeling of distress, but there are no guarantees of what you will experience.
You are responsible for coming to your appointment on time and at the time we have scheduled. If you are late, we will end on time and not run over into the next person’s appointment. Appointments are generally 45-55 minutes in length, but can be as short as 25 minutes. Appointments are a scheduled as a standing appointment time once per week at a time you and I agree on, and will be reserved for you until your therapy has ended. If you cannot keep your scheduled appointment, it is your responsibility to call the office 24 hours in advance to cancel (510-657-7342). The answering machine has a time and date stamp which will keep track of the time of cancellations. If you do not cancel within 24 hours or fail to show for your appointment you will be responsible the session fee of $150.00.
My fee for a session is $150.00. I am an in network and out of network provider for many insurances. If you are using your insurance, it is your responsibility to understand your insurance coverage. It is your responsibility to be aware of your copayments and deductibles. You are responsible to pay the copayments and deductibles or for any services that are not covered by your insurance. Payments are due at the beginning of each session. I have a 24 hour cancellation policy, which means if you do not cancel within 24 hours of your appointment or fail to show, you will be charged a fee of $150.00. Currently I only accept cash or check as a form of payment.
Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. You may terminate therapy at any time; however it is a good idea to plan for your termination. I will discuss a plan for termination with you as you approach the completion of your treatment goals. If you or I (therapist) determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other things, referrals, changing your treatment plan or terminating your therapy.
If in my professional judgment I am not able to help you because of the kind of problem you have or because my training and skills are not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. If you do violence to, threaten, verbally or physically, or harass myself or the office, I reserve the right to terminate you immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources, but I cannot guarantee that they will accept you for therapy.
Minors and Therapy
Parents/ Guardians are responsible for bringing and picking up their children on time. Children may not be left unattended in the waiting room. Please notify the therapist if you notice any new, different, or worsening of symptoms. It is important to keep the therapist in the loop regarding life events or illnesses of the child. Check-in sessions between parent/guardian, therapist and possibly the child will be scheduled to review treatment plans and clients progress towards treatment. As stated earlier communication between therapists and clients who are minors (under the age of 18) are confidential and therapist will exercise professional judgment in discussing concerns and or the treatment of a minor client with the parent/guardian. The parent/ guardian who accepts treatment on behalf of the minor, also accepts full financial responsibility. The Parent/guardian is also responsible to bring up any concerns regarding therapy. If for any reason the parent/guardian is not happy or believes the child is not happy with the therapy and/ or therapist, or feels therapeutic goals are not being met, it is the parent’s/guardian’s responsibility to talk to their therapist about their concerns.
My Office Hours
Monday through Thursday 10:00am-8:00pm
I do not answer the phone while I am in session with clients, but you may leave a message at any time on my confidential voicemail. I you wish me to return your call, please be
Sure to leave your name and phone number along with a brief message concerning the nature of your call. I check my messages daily, and I will get back to you within 24 hours. I am not available to return calls after 8:00PM or on Saturdays or Sundays. If I plan to be out of the office for an extended period of time, I will tell you in advance.
In an Emergency
If you are experiencing a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance.
You should also be aware of the following resources that are available in the local community to assist individuals who are in crisis.
Alameda County 24 hour crisis line 1-800-309-2131
Suicide Hotline 1-800-SUICIDE
Domestic Violence/SAVE 510-794-6055
Fremont Police 510-790-6800
Client Consent to Psychotherapy
I understand that Nancy Outka, LMFT is a Licensed Marriage Family Therapist (MFC #42395). I have read and discussed with Nancy Outka, LMFT, my rights and responsibilities as a client. I understand a session can run from 25-55 minutes. I understand that the fee for a session is $150.00. I understand that it is my responsibility to come to session on time. I understand that if I am late, the session will end at the scheduled time. I understand that if I make an appointment it is my responsibility to cancel 24 hours in advance. If I do not cancel 24 hours in advance or fail to show for the appointment, I am responsible to pay $125.00 for that session. I understand it is my responsibility to understand my insurance coverage, and that I am responsible to pay the co-payments and deductibles or for any services that are not covered by my insurance. I understand that payments and co-payments for services are due at the beginning of each session. I understand confidentiality and the times my therapist may need to break confidentiality. My therapist has disclosed that therapy can have potential emotional risks. I understand that I will be working collaboratively with my therapist and I have the right to refuse any requests or suggestions made by the Therapist. If for any reason I am not happy with my therapy and/ or therapist, or I feel my therapeutic needs are being met, I am encouraged by my therapist and responsible to talk to her about this. I am also aware that I may end therapy at any time. If client is a minor, parents/guardians are responsibility to talk to the therapist if they have any concerns regarding the child and therapy.
I have read the disclosure statement and I have had sufficient time to ask any questions that I needed to. After reading the Disclosure Statement, I understand my responsibilities as a client. I understand that therapy can have potential emotional risks and after carefully considering the risks and benefits of therapy I agree to undertake therapy with Nancy Outka, LMFT. If client is a minor, parent signing understands they take full financially responsibility. I am 18 years of age.
Client’s Signature: ____________________________________________Date:__________
Parent’s signature if client is a minor
Client’s Signature: ____________________________________________Date:__________
Therapist’s Signature: ____________________________________________Date:_________