Information Sheet

I hereby consent to engaging in
telemedicine with Dr. Pat Allen as part of my
psychotherapy. I understand that “telemedicine” includes the practice of health care delivery, diagnosis,
consultation, treatment, transfer of medical data, and education using interactive audio, video, or data
communications. I understand that telemedicine also involves the communication of my medical/mental
information, both orally and visually, to health care practitioners located in California or outside of
California.
I understand that I have the following rights with respect to telemedicine:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care
or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be
entitled.
(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As
such, I understand that the information disclosed by me during the course of my therapy is generally
confidential. However, there are both mandatory and permissive exceptions to confidentiality, including,
but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards
an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I also understand that the dissemination of any personally identifiable images or information from the
telemedicine interaction to researchers or other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the
possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my
medical information could be disrupted or distorted by technical failures; the transmission of my medical
information could be interrupted by unauthorized persons; and/or the electronic storage of my medical
information could be accessed by unauthorized persons.
In addition, I understand that telemedicine based services and care may not be as complete as face-to-face
services. I also understand that if my psychotherapist believes I would be better served by another form of
psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can
provide such services in my area. Finally, I understand that there are potential risks and benefits
associated with any form of psychotherapy, and that despite my efforts and the efforts of my
psychotherapist, my condition may not be improve, and in some cases may even get worse.
(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
(5) I understand that I have a right to access my medical information and copies of medical records in
accordance with California law.
I have read and understand the information provided above. I have discussed it with my psychotherapist,
and all of my questions have been answered to my satisfaction.

"COUNSELING DISCLOSURE"
DEAR CLIENTS:
1. Counseling is confidential. By law no information of any nature may be given by therapist to a third party without the client's written consent. The exceptions to this guideline are (A) in the event you pose an imminent physical danger to yourself or to someone else. (B) In instances of suspected child. elder, or dependent adult abuse. In each case the therapist is mandated by law to report the exceptions to an appropriate authority. Additionally, if you participate in group therapy, you are required to hold confidential all communication made by participants and all information obtained from or about any participant while in a group session. By your signature you agree to this and accept responsibility for damages in the event you disclose confidential material.
2. Appointments for counseling are based on a therapy "hour" of fifty minutes. Half-hour appointments are twenty- five minutes. The hour given at your scheduled appointment time. A minimum twenty-four-hour notice is required to change or cancel an appointment. Broken appointments without the twenty-four notice will be subject to the established professional fee structure.
Telephone counseling conversations will be billed at the same fee schedule.
3. Professional fees are established according to the current schedule in effect at the initial counseling session. You will be given a thirty-day notice of any fee schedule changes. Fees for professional services are due and payable at the time the service is provided. Failure to pay may result in a termination of professional services. In addition, past-due accounts may be turned over to a collection agency. You will be given a receipt which may be used for possible third-party (Insurance) reimbursement.
4. Regular business hours are from 9A.M. to 5P.M. Monday thru Friday. If you have an emergency before, or after hour on weekends or holidays please call
(A) 911 (B) your medical doctor (C) go directly to the nearest emergency clinic or hospital.
5. Psychotherapy is an active, collaborative ventura between the therapist and client. You are encouraged to be an active participant. On occasion and tor various reasons, termination of the therapy process may be appropriate for a client’s benefit. Such termination will be given the form of a registered certified letter. Three professional referrals will be offered in the termination letter.
I have read and understand the disclosure and acknowledge receipt of a copy, of them and the professional fee schedule.