Lani Chin, Psy.D. Licensed Clinical Psychologist, PSY Informed Consent

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1 Page 1 of 12 Lani Chin, Psy.D. Licensed Clinical Psychologist, PSY Informed Consent Welcome! Psychotherapy is a process of growth and healing through self-awareness, self-discovery, and selfacceptance. It is at times painful, frightening, reassuring, sad, and exciting. When successful it leaves one feeling more whole, more at peace, more one with humanity, and more one with one s own humanity. All psychologists are required to provide information to clients in order to obtain what is known as informed consent prior to beginning treatment. Informed consent simply means you have been given sufficient information to make an informed decision before entering therapy or treatment. This document contains important information about my professional services and business policies. In it you will find everything you need to know regarding the policies, procedures, rules, regulations, ethics codes, etc. that guide how my practice operates. Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. You are encouraged to review the material in this informed consent document prior to our first meeting. Please read it carefully and initial each section where indicated to acknowledge that you have read and understood the information. In addition, jot down any questions you might have so that we can discuss them at our next meeting. When you sign and initial this document, it will represent an agreement between us. QUALIFICATIONS I am a Licensed Clinical Psychologist, registered with the California Board of Psychology (PSY 24971). I received my doctorate in clinical psychology in 2010 from the California School of Professional Psychology in Alhambra. I continued my training as a pre- and post-doctoral fellow at The Saturday Center in Santa Monica. I draw from several therapeutic approaches (psychodynamic, existential, cognitive, mindfulness-based therapy, etc.) according to the person being treated. My overall approach is holistic and mind/body/spirit oriented. You and I will work together to build a trusting and non-judgmental relationship where you can feel safe to talk about yourself openly. The strength of our relationship is a crucial foundation for our work together. You know your life better than anyone else. Therefore, we will hold great respect for your wisdom about yourself. I will offer my professional knowledge and wisdom as well, and together, we will work to help you discover how to live the life that is best and most fitting for you. THE FIRST FEW SESSIONS /EVALUATION & CHOOSING A TYPE OF THERAPY Our first few sessions will involve an evaluation of your needs. By the end of the evaluation I will be able to offer you some first impressions of what our work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and

2 Page 2 of 12 energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to make a referral to another mental health professional for a second opinion. The problems that bring you here might be the result of some current events or circumstances. As we discover and examine them in detail we might bring about a favorable change in your life. However, it is useful to consider that the problems might be due to characteristics that in one form or another have been a part of you for much of your life and now have become attached to certain contemporary events or relationships. Although a briefer therapy might allow you to feel better for a while, the problems probably, as in the past, will come back. If the longer history of problems were the case, psychodynamic psychotherapy is the treatment of choice because, to bring about more lasting change, you will have to come to understand how and why your mind fails to serve your best interests. If it is clear that your problems do have a long history, that they become aggravated from time to time, and that they repeat themselves, then psychodynamic psychotherapy is the treatment of choice. BENEFITS & RISKS OF PSYCHOTHERAPY Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships, significant reductions in feelings of distress, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I will ask for your feedback and views on your therapy and its progress. Sometimes more than one approach can be helpful. During the initial evaluation or the course of therapy, remembering unpleasant events, feelings, or thoughts may result in your experiencing considerable discomfort, strong feelings, anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of thinking about or handling situations that may cause you to feel upset, angry, or disappointed. You may feel worse before feeling better. Sometimes you will feel badly when you leave a session, and mistakenly feel things are worse; however, it might be that you are feeling aspects of yourself from which you were previously disconnected. Attempting to resolve issues that brought you into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions to change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick and easy, but more often it can be gradual and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. HOW PSYCHOTHERAPY WORKS Psychotherapy is sometimes a long journey. The more you put into it - the more vulnerable you are willing to be, the deeper you are willing to delve - the more you will get out of it. But it is important to remember that you are not in this process alone. Psychotherapy is a process focusing on one person, but engaged in by two. Psychotherapy is the process of working together (client

3 Page 3 of 12 and therapist) in an effort to gain insight and clarity into the challenges and conflicts that we all face. Thus, the more you can feel engaged with me, the more you can count on me as a coequal partner, the easier and more productive the process will be. In order to reach the things in your mind that contribute to your problems (things that are not otherwise accessible), we go about it in a rather simple, though not necessarily easy, way. The aim is to understand the ways you have been able to keep these parts of yourself out of awareness, and why that has been necessary. As a result, you ll come to have better access to them and, if you wish, may choose some different solutions than the involuntary ones that trouble you now. The problems that brought you here are repetitive experiences over which you haven t had much control or choice. Basically they re solutions to conflicts you were up against as a child. There was a time when they were the best solutions you could work out, and they may have been successful for what you needed then. As you have learned, now the solutions don t always fit in with what you want in your life today. How will it help to study all of your thoughts and feelings, as you gradually make them available here? Because, in the process of working to reveal these things here, you ll encounter versions (close-ups) of the very problems you ve described in your life outside of the therapy room. Once these problems are in the room, we can think about them and work through them together in real time. WHAT IS EXPECTED OF YOU IN SESSION Psychotherapy calls for a very active effort on your part. There are many different methods I may use to deal with the issues that you hope to address. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Part of your task will be to try to let thoughts spontaneously come to mind, observe what is there, and put all of those things into words so that we may gradually study them. It will sometimes be difficult to show me your mind in that way. My listening and commenting on what I observe is intended to help you understand the obstacles that get in the way. It is extremely important to be as open and honest with me as possible. This is especially true about issues within the client/therapist relationship itself. Any feelings you have toward me anger, disappointment, betrayal, longing are important for the two of us to discuss. I encourage you to push yourself to bring them up; I will help to discern next steps from there. Reasonably you know (or will come to know) that it is safe here to undertake this task of showing me - in words and feeling all of the things that enter your mind. But many of your past life experiences will automatically caution you to oppose undertaking the job. Our primary task is to study these involuntary, inhibiting reactions based on repeated versions of previously conflicted and obstructing experiences. As we work at this, you will gradually make available for us for yourself in particular the part of your mind that has remained largely out of your reach and has thereby robbed you of being whole. Your familiarity with this manner of observing the conflicts and the involuntary, symptomatic ways that your mind has used to deal with them is not only

4 Page 4 of 12 essential in allowing you to gain control over these involuntary solutions (held onto from childhood), but will give you knowledge and skill you make take with you and use by yourself to keep these restored mental activities available. In our work you will learn to use several different kinds of observing. The first has to do with observing what is on your mind so you can put it into words. On the other hand, when I interrupt to tell you about something I noticed taking place within what you have been saying or feeling, your task is to suspend telling me the spontaneous flow of your thoughts so that you may reflect back over what I noticed while listening to you. In other words, we ll do a sort of instant replay. That is probably a more reasoning kind of observation than you were using just moments before. It s intended to familiarize us with what your mind, without your awareness, might have been doing in a self-protective way. As you learn about these self-protective measures that your mind has been taking right in the midst of what you were saying, you have an opportunity to return to that place in your thoughts where that protective diversion automatically took place, and by being there again, you re able to sense more clearly the form of discomfort which was arising as you began to get into that particular thought or feeling. When you can do that, it will allow us to learn more about the anticipated risk (possibly in the background) that caused you to interrupt speaking what you had in mind and draw away. We can also notice the way you went about moving away from the threatening material. By actively using this insight you can gradually gain useful access to parts of yourself which your problems are keeping from you. WHAT IS EXPECTED OF YOU BETWEEN SESSIONS This way of observing the activity within your thinking may be entirely new to you. Basically, it involves being able to shift from regarding your expressed ideas and feelings only in the familiar contexts of the past (recent or distant) or future, so that you can learn how you experience and influence those same thoughts and feelings as you reveal them aloud in therapy. Oftentimes this takes some practice. Working on your observational skills between sessions is not required. However, if you are eager to dig into the process and would like a task between sessions, meditation is an excellent platform from which you can build strength in your ability to observe without judgement while also resisting impulsive actions and reactions. If you would like guidance on starting a meditation practice, please ask and I will facilitate this process. DUAL RELATIONSHIPS Therapy never involves sexual, business, or any other dual relationships that could impair my objectivity, clinical judgment, or therapeutic effectiveness, or could be exploitative in nature. Please discuss this with me if you have questions or concerns.

5 Page 5 of 12 APPOINTMENTS I normally schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a day and time we agree on. At certain points in treatment I might recommend that you come in two or three sessions per week. The length of treatment depends upon the particular concerns you bring to the sessions and our progress in addressing them. I will only conduct psychotherapy in person, at my office, at a day and time mutually agreeable to us. Under very specific circumstances (i.e. illness, birth of a child, moving from one city to another) I will offer sessions by phone and/or Skype/Facetime. However, this is the exception made only during extraordinary circumstances; it is important to note that your confidentiality will not be as secure via electronic means as it is during appointments at my office. Please see the below Electronic Communication Policy for more information about ways your confidentiality is less secure via electronic communication. CANCELLATIONS When you enter into therapy, a specific treatment hour is set aside for you, and you only. This is your hour whether you use it or not. Therefore, I ask that, by-and-large, you pay for that hour whether you use it or not. You may cancel up to four sessions in any year, provided you give 24 hours advance notice. (Eight sessions when seen twice a week.) My full fee will be charged for sessions missed without such notification. (In the event of a sudden illness or an emergency, exceptions can be made.) You are also responsible for payment when you have cancelled more than 4 sessions with the 24-hour notice. In the latter case, you and I can try to re-schedule the appointment within the week at no charge. Special arrangements may be made for persons whose work requires them to be out of town for extended periods of time. If you are requesting a Superbill from me to send to your insurance company, be aware that most insurance companies do not reimburse for missed sessions, so you will be responsible for full payment of all missed sessions. Please let me know as soon as you know that you will not be able to keep your scheduled appointment. PAYMENT & FINANCIAL ARRANGEMENTS My hourly fee (50 minute session) is $180 unless otherwise arranged. The fee is to be paid at the beginning of each session by cash or personal check unless other arrangements have been made. Personal checks can be made payable to Lani Chin, Psy.D. Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments. If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, a late fee of $100 will be added to your balance. If your account has not been paid for more than 60 days, and additional $100 late fee will be added to the balance, and I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. (If such legal action is necessary, the cost of doing so

6 Page 6 of 12 will also be included in the claim.) In most collection situations, the only information I release regarding a client s treatment is his/her name, the nature of services provided, and the amount due. An annual increase will occur every year on the date you began treatment. I have several reduced fee slots, and I can sometimes negotiate a lower fee based upon need. I will be happy to let you know if I have openings for lower fee appointments if your financial situation qualifies for a sliding fee scale. In addition to weekly appointments, I charge the same hourly rate for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, preparation of records or treatment summaries, and time spent performing any other service you may request of me. If you request, I will provide you with a statement at the beginning of each month containing a record of therapy appointments from the previous month, fees we agreed upon, and the payments you made during the month. This monthly statement is your receipt for tax or insurance purposes. An annual increase will occur every year on the date you began treatment. I have several reduced fee slots, and I can sometimes negotiate a lower fee based upon need. I will be happy to let you know if I have openings for lower fee appointments if your financial situation qualifies for a sliding fee scale. If a personal check is returned for insufficient funds there will be an additional $50 fee to cover the cost. If you have insurance, I will submit claims on your behalf at no additional fee. I require full payment for sessions, and you will be reimbursed by your insurance company. HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it may provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of all fees incurred for services rendered. Likewise, you are responsible for identifying, understanding, and verifying the details of your mental health coverage. You should carefully read the section in your insurance coverage booklet that describes out-of-network outpatient mental health services. If you have questions about the coverage, call your plan administrator. I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I am willing to call the company on your behalf.

7 Page 7 of 12 Insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Submitting a mental health invoice for reimbursement carries a certain amount of risk to the confidentiality of your treatment. Most insurance companies require you to authorize me to provide them with a clinical diagnosis. Only the minimum necessary information will be communicated to your insurance carrier, including diagnosis, the date and length of our appointments, and what services were provided. Often the billing statement and your company's claim form are sufficient. I will release as little information as possible as your confidentiality is my primary concern. However, sometimes treatment summaries or progress toward goals are also required. Unless explicitly authorized by you, Psychotherapy Notes will not be disclosed to your insurance carrier. This information will become part of the insurance company files and will probably be stored in a computer and reported to the National Medical Data Bank (NMDB). Medical data has been reported to be legally accessed by government and enforcement agencies, so please carefully consider this. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Upon request, I will provide you with a copy of any report I submit. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Please remember that my services are provided and charged to you, not your insurance company, so you are responsible for payment. Fees you pay for therapy services that are not reimbursed by insurance may be deductible as medical expenses if you itemize deductions on your tax return. CONTACTING ME I can be reached at (310) When I am unavailable, my telephone is answered by voic . Due to my work schedule, I am often not immediately available by phone. I will not answer the phone when I am with a client, but I do check my messages very frequently during the business day, Monday- Friday. With the exception of vacations, I will make every effort to return your call within 24 hours. On weekends, I monitor my voic less frequently, although usually twice a day. I do not return calls on weekends that can wait until Monday morning. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can t wait for me to return your call, contact your family

8 Page 8 of 12 physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide the name of a colleague to contact, if necessary. Phone consultations of 10 minutes or less will not be charged. If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. If you are unable to reach me and feel that you can t wait for me to return your call, contact your family physician, 911, or the nearest emergency room and ask for the psychologist/psychiatrist on call. I can also be reached by at for scheduling and administrative issues (billing, insurance, invoices, etc). I do not conduct therapy by , text, or phone. ELECTRONIC COMMUNICATION POLICY In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others whether their relationships are social or professional. However, many of these common modes of communication put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with me. Communications I use communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not me about clinical matters because is not a secure way to contact me. If you need to discuss a clinical matter with me, please wait so we can discuss it during your therapy session, or, if you feel it cannot wait until your next session, call me so we can discuss it on the phone. The telephone or face-to-face context simply is much more secure as a mode of communication. Text Messaging Because text messaging is an unconfidential and impersonal mode of communication, I will only respond to text messages about scheduling issues. However, I do want to emphasize that this is the least confidential way to communicate outside of your weekly session. Social Media I do not communicate with, or contact, any of my clients through social media platforms like Twitter, LinkedIn, Facebook, Google+, etc. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these

9 Page 9 of 12 types of casual social contacts can create significant security risks for you and can adversely affect the therapeutic relationship. I participate on various social networks in my professional capacity on Facebook and LinkedIn to provide information to others about me and my practice. You are welcome to access and review the information on these platforms. I also participate on various social networks in my private life (i.e. not in my professional capacity). If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental. Websites I have a website that you are free to access (www.drlanichin.com). I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions. Web Searches I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together. Skype & Phone Sessions Phone, Skype, and Facetime sessions are not HIPAA compliant. Therefore, choosing to have a session within these forums is done at your own risk and understanding that the exchange may not be completely confidential. Summary All forms of electronic communications (phone, , voice mail, text messaging, fax, etc) can be easily accessed by unauthorized people, compromising the privacy and confidentiality of such communication. Please notify me at the beginning of treatment if you would like to avoid or limit in any way the use of any or all of these communication devices.

10 Page 10 of 12 Please don t contact me via , phone, or text. (Initial if applicable) PROFESSIONAL CONSULTATION & YOUR CONFIDENTIALITY I consult regularly with other professionals regarding my clients in order to provide you with the best possible service. Names or other identifying information are never mentioned; client identity remains completely anonymous and your confidentiality will be fully maintained. RELEASE OF INFORMATION Considering all of the above exclusions, upon your request and with your written consent, I may release limited information to any person/agency you specify, unless I conclude that releasing such information might be harmful to you. If I reach that conclusion, I will explain the reason for denying your request. COMPLAINTS If you have a concern or complaint about your treatment, please talk with me about it. If we cannot resolve your concern, you can contact the California Board of Psychology (CA BOP) to request that someone from the BOP review the services I have provided: Board Of Psychology 2005 Evergreen Street, Suite 1400 Sacramento CA PROFESSIONAL WILL In the event that something prevents me from continuing your care, I have made arrangements with Erin Kuntze, Psy.D. Dr. Kuntze is a local psychologist with the professionalism and competence to take responsibility for my practice in the event that I am unable to continue. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the

11 Page 11 of 12 contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. PATIENT S RIGHTS You have the right to end therapy at any time, for whatever reason. In addition, you have a right to question any aspect of treatment, and to expect that I will provide you with a referral to another qualified therapist for adjunctive treatment, or alternative treatment if requested. Furthermore, you have the right to know your diagnosis. CONFIDENTIALITY In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But, there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. In addition, please be aware that I am required to comply with the Patriot Act, which may result in the mandated release of any and all records to government officials. TERMINATION Termination of therapy is inevitable. Either of us may terminate our work together if we do not think it is in your best interest, or we can make that decision together if your work is complete. However decided, termination can and ought to be made a valuable part of the psychotherapy experience. I typically will ask that we meet for one or two sessions after an agreement to

12 Page 12 of 12 terminate. Such sessions will help us to review your goals and accomplishments, outline any further work to be done, and examine your options for the future. It is also important to discuss if you would like to take a break from therapy. We often can arrange for such time to be maximally productive if discussed in advance. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Your Printed Name Your Signature Date

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