Definition
I understand that the term "telehealth" refers to mental health consultations, psychotherapy, or psychological education delivered via interactive audio, video, or data communications over the internet or phone.
Rights & Responsibilities
I understand that I have the following rights and responsibilities in receiving telehealth services:
- I am required to provide my full name, address, and phone number before the first telehealth session. I understand that I must be physically located in the State of California to receive telehealth services. I agree to confirm the address from which I receive telehealth services before the beginning of every session and to notify Psychotherapist in advance if I plan to be out of state for any scheduled session. I also agree to upload a copy of my picture ID as proof of identity.
- I understand that I have the right to access my psychotherapy records and that Psychotherapist has the right to determine how such access is provided.
- I have the right to ask questions and express concerns related to my treatment, as well as to receive information about alternative treatment options.
- I have the right to seek a second opinion. However, once a second opinion is obtained, I understand that I must commit to working with one mental health professional only. I may not work concurrently with another mental health provider while continuing therapy with Psychotherapist unless agreed upon by both professionals. I understand that engaging in concurrent therapy without such agreement may result in termination of services.
- I agree not to appear for psychotherapy sessions with any third party without prior discussion and agreement with Psychotherapist. I understand that if I appear with another individual without prior agreement, the session will be ended immediately and the full session fee will apply.
- I understand that telehealth psychotherapy is not appropriate for crisis or emergencies. If I am in crisis or a life-threatening or dangerous situation, I agree to immediately call 911, go to the nearest emergency room or crisis facility, or contact the National Suicide Hotline at 1-800-784-2433.
- I am responsible for securing my computer, internet connection, and access points, and for ensuring a private, secure location for each session. If I do not provide privacy, Psychotherapist will terminate the session and the session fee will apply.
- I agree not to consume alcohol or any mind-altering substances, including recreational drugs, during or within 12 hours before each session. I understand that failure to comply will result in termination of the session, and the session fee will not be reimbursed.
Confidentiality of Services
The laws that protect the confidentiality of medical and mental health information apply to telehealth psychotherapy services. I understand that information disclosed during therapy is generally confidential. However, there are mandatory and permissive exceptions to confidentiality, including but not limited to: reporting child, elder, or dependent adult abuse; expressed threats of violence toward an identifiable victim; and situations in which my mental or emotional condition is made an issue in a legal proceeding.
I understand that no recording or dissemination of any personally identifiable images or information from telehealth sessions will happen without written consent from both Psychotherapist and me.
The telehealth software used by Psychotherapist is HIPAA-compliant and uses encryption and other safeguards to protect confidentiality. However, I acknowledge that electronic transmission of information cannot be guaranteed to be completely secure.
Internet Service & Transmission of Information
I understand that despite reasonable efforts by Psychotherapist, telehealth services carry inherent risks, including possible disruptions, distortions, or unauthorized access due to technical failures.
In the event of a disruption during a session, Psychotherapist will attempt to contact me using the phone number I have provided to discuss appropriate next steps.
Medical Insurance
Psychotherapist is not an in-network provider for any insurance plans, including Medi-Cal or Medicare. However, Psychotherapist may provide services through third-party, insurance-affiliated platforms that allow clients to use insurance benefits.
If I choose to use insurance to pay for services, I understand that insurance coverage is a contract between myself and my insurance carrier, not between the insurance carrier and Psychotherapist. I understand that insurance coverage does not guarantee reimbursement for services rendered.
I understand and agree that I am fully financially responsible for all fees associated with therapy sessions if my insurance company denies coverage, delays payment, determines services are not medically necessary, or otherwise does not reimburse Psychotherapist for any reason.
When working through insurance-affiliated platforms, I agree to follow the billing, payment, and cancellation policies established by those platforms.
Session Frequency
If I choose to use insurance benefits to pay for services, I agree to commit to attending weekly appointments.
If I prefer more flexibility in scheduling frequency, I understand that I may do so under the private pay system.
Payments
The following applies only when I work directly with Psychotherapist and do not use insurance-affiliated platforms.
- The fee for telehealth psychotherapy is $175 per 50-minute session, unless otherwise negotiated.
- I understand that payment must be made online through the payment form on www.mtmft.com at least 24 hours prior to the scheduled session.
- A session is considered confirmed only after payment has been received.
- Payments are securely processed via Stripe (all major credit cards accepted).
- Session fees are subject to annual adjustment based on current market conditions. I understand that I will be notified in advance of any fee changes.
Canceling a Session
The following applies only when I work directly with Psychotherapist and do not use insurance-affiliated platforms:
- A minimum of 24-hour notice is required to reschedule or cancel a session.
- Sessions canceled with at least 24 hours' notice will have the prepaid amount credited toward a future session.
- Failure to provide timely notice will be considered a no-show, and the session fee will be forfeited.
Termination of Telehealth Services
I may terminate therapy at any time and for any reason.
Psychotherapist may terminate services for reasons including, but not limited to: lack of therapeutic benefit, scope-of-practice limitations, non-payment, threats or abusive behavior, completion of therapy goals, or circumstances in which continued treatment is inappropriate, contraindicated, or unnecessary.
If services are terminated by Psychotherapist, appropriate referrals will be provided when clinically indicated. If services are terminated by me, Psychotherapist is not obligated to provide referrals.
Risks and Benefits of Psychotherapy
I understand that psychotherapy:
- Does not guarantee favorable outcomes
- Can be unpredictable, with goals and focus evolving over time
- May involve emotional discomfort or temporary worsening of symptoms
- Has no predefined timeline for resolution
- Does not operate with the same predictability as other medical fields
Accordingly, no specific results can be guaranteed.
Scope of Competence & Limitations
I understand that Psychotherapist has training and experience in the assessment and treatment of conditions including depression, anxiety, stress, relational difficulties, life transitions, self-esteem issues, and symptoms of complex trauma (C-PTSD), among others.
I understand that Psychotherapist does not provide evaluations, reports, or documentation for legal proceedings, disability or workers' compensation claims, custody matters, employer accommodations, or Emotional Support Animal letters.
Involvement in Legal Proceedings
If I choose to involve Psychotherapist in any legal process, I agree to compensate Psychotherapist at a rate of $300 per hour for all time spent, including but not limited to testimony, record review, report writing, travel, and attorney communication.
