Welcome to FamilyCounselingSanDiego.com


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Welcome to our practice and Thanks for choosing Our Practice

This document contains important information about our professional services and business policies and how they may affect you. Please read it carefully and make note of any questions you want to discuss with us. Once you sign this document, it will become a binding agreement between us and also provide your consent for us to begin therapy.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. 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. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. We are all professionally licensed, insured and vetted to work per Board of Behavioral Sciences requirements Under the Board of Consumer Affairs of California.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, 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 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, we will be happy to help you set up a meeting with another mental health professional for a second opinion. However, there is no guarantee that therapy will yield positive or intended results. Because feelings will be explored, you may feel a range of emotions that can be intense and uncomfortable at times. During the course of therapy, some of your assumptions, perceptions, or behaviors may be challenged, which can cause you to feel very upset, angry, depressed, uncomfortable, confused, or disappointed. We encourage you to explore those feelings during our sessions, as they are part of the therapeutic process. In the attempt to resolve issues that originally brought you to therapy, unintended changes in your personal and interpersonal relationships may result.

Our therapeutic relationship is strictly voluntary. At any time during our work together, you have the right to decide to end treatment. If you are thinking about ending therapy, I encourage you to discuss it with me/us, and if you wish, we will be glad to provide you with the names of other mental health providers or a different provider within our group. During the course of therapy, if we assess that I am either unable or not effective in helping you reach your therapeutic goals, I will discuss this with you, and if appropriate, terminate treatment. We will provide you with appropriate referrals and assist you in the transition to a new therapist if you so desire. It is unhealthy for you to terminate treatment without closure session such that we can create a support plan (safety net) within the community or family in such case you become emotionally overwhelmed and need a quick guide towards that support.

Following The Notice of Privacy Practices is our Services Agreement, Clinic Policies and Procedures. Please read each of them and if you have any questions please direct them to your therapist during your first session so you can have all of your concerns addressed at the beginning of treatment. =

We are REQUIRED to give this notice to you under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how psychological / medical information about you may be used and disclosed, and how you can get access to this information and the limits of said access. Please review it carefully. It contains, Use and Disclosure for Treatment, Payment, and Health Care Operations. Your Protected Health Information (PHI) is any information about your past, present, or future physical or mental health conditions and/or treatment, or any other information that could identify you.

Appointment Reminders
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment. We currently use TherapyNotes.com automatic reminder service which may text you, email you or call you with a robotic voice. This is standard in the dental/medical community. If you reject our ability to provide you this reminder and you do not show-up for any reason you are charge 100% of standard visit fee.

Treatment Alternatives
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services
We may use and disclose medical information to tell you about our health-related products or services that may be of interest to you.

As Required By Law
We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Health Oversight Activities, We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement
We may release medical information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the hospital; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others
We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Multidisciplinary Personnel Teams
We may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.

Special Categories of Information
In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information – e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program.

You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy - You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to FamilyCounselingSanDiego.Com, Inc., 2003 El Camino Real STE 106, Oceanside, CA 92054, ATTN: Health Information Manager. Please allow 7 to 10 business days for processing from date of receipt of the completed authorization. California law permits up to 15 days to respond to requests (IN WRITING) for medical records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the clinic will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the clinic. To request an amendment, your request must be made in writing and submitted to the Health Information Management Department. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
•Was not created by FamilyCounselingSanDiego.COM, Inc., unless the person or entity that created the information is no longer available to make the amendment;
•Is not part of the medical information kept by or for the clinic;
•Is not part of the information which you would be permitted to inspect and copy; or
•Is accurate and complete in the record.
Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment and health care operations, (as those functions are described above) and with other exceptions pursuant to the law. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact the Health Information Management Department at 760-498-1053 or go online to www.familycounselingsandiego.com.

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the clinic. The notice will contain the effective date on the first page, in the top right-hand corner. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with the administration hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the clinic, contact the Privacy Officer at call 760-498-1053 or directly to Janet Phillips LCSW 858-883-8624. You will not be penalized for filing a complaint. If you have agreed to LENS treatment this treatment is a package and there is no refunds if you do not complete the treatment recommended and results are not guaranteed as with any treatment provided. You are welcome to request a mediation from another therapist within the group or administration to help in your disagreement or complaint.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. This disclosure statement is intended to inform you of our background, experience, theoretical orientation, and approach to therapeutic services. This document is meant to help you be an informed consumer about these aspects of the clinical practice and your rights as a client. Please don’t hesitate to ask questions or bring up any concerns you might have now or anytime in the future. We look forward to working with you and invite you to bring any questions you have via phone or during session. This document contains important information about this Behavioral Healthcare Organization known as FamilyCounselingSanDiego.Com, Inc. At which all clinicians are Independent Contractors working within our group practice as such. This Behavioral Healthcare Organization is operated by Janet P. Phillips, MSW, LCSW, V.P. and Walter Patrick Martin, MA, LMFT, President which is providing professional services to the community such as educational coaching, counseling, psychotherapy, psych testing, and many more, thus within this document all statements of "I" refers to anyone within the group of professionals whom are independently responsible for their own practice, license renewal and private practice liability. When you sign this document, it will represent a legally binding agreement between you and The Group Practice AKA FamilyCounselingSanDiego.com, Inc. (FCSD).

MEETINGS/APPOINTMENTS: Walter Martin normally conduct an evaluation that will last from 2 to 4 sessions and ask for you to agree to 8 sessions prior to judging the possible success of meeting your goals as he works hard to find you a "An Life worth living" improving your outlook with DBT, CBT and EMDR protocols. During this period of an average of 6 weeks, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals need. If psychotherapy is begun, Mr. Martin will usually schedule one therapy session (one appointment hour of 45-60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours [2 days] advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. All missed appointments are a $80 charge to your credit card on file.

CONFIDENTIALITY: All communications between you and your Counselor will be held in strict confidence unless you provide written permission to release information about your treatment. There are exceptions to confidentiality as we utilize Practice Fusion Software and OfficeAlly.com and Availity.com insurance approved clearinghouse. All are HIPPA compliant systems. We pay for a BSA agreement of HIPPA complaint systems with Google so we can utilize Google Apps, Email and Video Communication. EXAMPLE OF LIMITS TO HIPPA, therapists are required to report instances of suspected child, elder or dependent adult abuse. Therapists may be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. PMI (Protected Medical Information) is taken very seriously. This practice in known for it extreme private needs of active duty military and if requested no information is records for our free hour for active duty Military or DOD contractors to all freedom without concerns of loss of a security clearance. Also all active duty families also afforded only the highest level of privacy as we take privacy very seriously.

COUPLES: 1) Walter Martin, LMFT, President, Founder of FamilyCounselingSanDiego.com, Inc. is a Licensed Marriage and Family Therapist and Relationship Coach. He is the author of Heart and Soul Toward Intimacy and has been coaching couples through relationship struggles for 17 years.

FAMILY THERAPY: If you participate in marital or family therapy, your Counselor will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. Children benefit when they have relationships with both parents WITHOUT NEGATIVITY TOWARD EACH OTHER. This provides a safe place to get to the root of the issues that brought you into treatment. A summary/verification of dates/time of attendance, diagnosis of primary patient is all that will be provided for court purposes. AT THIS LEVEL OF TREATMENT RECORDS ARE NOT RELEASED WITHOUT COURT ORDER EVEN IF ALL PARTIES AGREE if therapist or group legal team feels it would harm the patient.

CO-PARENTING, PARENTING, HIGH CONFLICT PARENTING, ANGER MANAGEMENT: (San Diego Superior Court Approved) Be flexible and fair. Sometimes, unexpected situations arise that may require some flexibility in how shared parenting is carried out day to day. Be willing to trade some responsibilities or time with the other parent when needed. CO-PARENTING requires commitment of 10 – 90 minute sessions (15 hours total if change to hourly classes) and will sign a contract at office. In addition, it is cash or credit only. You can only miss 1 appointment via 48 hour notice during the program to adhere to Superior Court guidelines. If you miss appointment or cancel appointment prior to 48 hours you pay $50 and discouraged to change your appointment after it is made. On website is current groups that are open to new patients.

MINORS and Confidentiality: Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, your Counselor, in the exercise of his professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker. Patients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their Counselor. Your Counselor generally requires the consent of both parents prior to providing any services to a minor child. Your Counselor might require that you provide legal documentation, such as a custody order, prior to the commencement of services, if such an order applies.

BILLING AND PAYMENTS: You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.]

If your account has not been paid for more than 60 days by your insurance and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. In addition your credit card on file will be charged all co-payments and the amount for services rendered that is contracted by your insurance. If you wish to utilize EAP insurance payments you will need to pay for any sessions not paid or payments we have not received by your EAP insurance company. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs will be included in the claim.] In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. We do not welcome court appearances and charge $500 per hour including travel if you insist on a therapist going to court. As proposed model legislation drafted by DOJ provides, “A victim has a privilege to refuse to disclose and to prevent any other person from disclosing confidential communications between a victim and a victim counselor, in any criminal, civil, legislative, administrative, or other proceeding. Confidential communications may be disclosed by a person other than the victim only with the prior written consent of the victim.” In addition to preventing counselors from testifying or being compelled to testify in court, many privilege laws directly extend protection to a counselor’s written records, such as reports, memorandum, and working papers produced during the course of the counseling. DOJ’s proposed model legislation defines “confidential communications” as any information, whether written or spoken, which is transmitted between a victim . . . and a victim counselor in the course of the counseling relationship and in private, or in the presence of a third party who is present to facilitate communication or further the counseling process.

Even in the absence of specific statutory language, courts have interpreted the privilege to apply to records and materials developed throughout a counseling relationship. As the Pennsylvania Supreme Court reasoned, “the statutory privilege considered here must extend to the subpoena of records and other documents developed throughout the counseling relationship, any other interpretation of the statute would render the entire privilege meaningless. . . . Insulating the counselor from giving testimony would be inconsequential, as most information the counselor might give would be available in the records themselves.” The U.S. Supreme Court observed that effective psychotherapy . . . depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories, and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment.

MINIMUM RECORD KEEPING AGREEMENT (Intended to Protects Military Personnel such that they feel safe in treatment)
I do not believe that keeping detailed records of what happens in each session is either clinically or practically useful. Therefore, I will only keep written records of session content when it is legally or ethically appropriate. Such circumstances will include documentation of at-risk behaviors (either to self or others); documentation of information related to suspected child/vulnerable adult abuse or neglect; when required by legal authorities due to the client being in court mandated treatment (under state or federal laws); or if documentation of certain issues or events is deemed clinically useful as a way to track crucial details of the therapeutic process (as in for use in consultation/supervision in order to provide the best service to the client). I will abide by all other state requirements for record keeping which requires me to keep, at the very least: the client name; fee arrangement and record of payment; dates of services received, signed disclosure form, and this record of an agreement to not keep other session records.

INSURANCE: WE HONOR AND THANK OUR MILITARY so there is no cost for any active duty service and retired military on first session (Walter Pat Martin LMFT only) as I am a proud member of "GIVE AN HOUR" program. I am also a STAR CIVILIAN PROVIDER, Tri-Care West and TriWest Choose Program for VA. Our clinic is a contracted provider with many insurance companies. If however we can not take your insurance, we will work with you, provide a monthly statement (Superbill) which can be provided for you to submit to your insurance company for reimbursement of what you have paid. If you are on Medi-Cal the plastic card is required to be on file to be seen at our office and a valid credit card on file as well. We accommodate all active duty to maintain clearance to protect the one whom protect and service this country. Mr. Martin hold level one security clearance with Riverside County Sheriff and understand needs and requirements to remain top level clearance.

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 will usually 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 our fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course 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 will be willing to call the company on your behalf.

Due to the rising costs of health care, 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 patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.]

You should also be aware that most insurance companies require you to allow me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. 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. I will provide you with a copy of any report I submit, if you request it. I understand that by using your insurance I am aware that such information may be provided to them. I will try to keep that information limited to the minimum necessary.

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 walkout before you feel ready to end our sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above [unless prohibited by contract].

If you have a deductible with your insurance you are responsible to report that to therapist on your first session. Otherwise, you may receive a large bill from our company when we find that the payments have not been received. You will be responsible for what we agreed to get paid by insurance company only not our uninsurance rate which is often more than the insurance rate. Neurofeedback, LENS, is not covered by insurance companies and is paid via cash/cc/check or can be financed with our business partner to allow you to get treatment for only the average payment of $500 per month until it is paid off.

CANCELLATION POLICY: ALL scheduling in ONLINE through secure online portal a PHI protected portal. We send reminder message via email and text prior to session asking if you can make your appointment please press Y or N to answer the system. Sessions are typically scheduled one time per week at the same time each week and day. Your Counselor may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify your Counselor at least 24 hrs. in advance of your appointment, by phone. If you do not provide your Counselor with at least 24 hours notice in advance, you are responsible for $70.00 missed session fee. If you arrive for co-parenting/couples session and your partner walks out of treatment, your insurance may get billed and/or a $70.00 will be charged no exceptions. WE NO LONGER TAKE MEDI-CAL OR ANY MEDI-CAL PLAN AT THIS TIME. SO PLEASE DO NOT COMPLETE THIS FORM UNLESS PLAN TO PAY CASH if you have Medi-Cal.

EMERGENCY ISSUE: If your Counselor is unable you can leave a message or if needed we provide on-call therapist for therapeutic emergency not life threatening which you need to call 911. When you call 858-217-5770 to reach our office and on call therapist or Janet Phillips LCSW 858-883-8624 will answer the call and connect you to on-call therapist. In the event that you are feeling unsafe or require immediate medical or psychiatric assistance, you should call 911 or go to emergency room. If your safe at home but need some help now call National Hopeline Network (800) 784-2433. Our Counselors are unfortunately unable to use emails except for non-clinical uses and if you do use email you accept that email is not confidential. If an email correspondence is particularly important to your therapy, please be sure to print out and bring a copy of the email to your next session so Counselor can read at that time.

TERMINATION OF TREATMENT: 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. It is a good idea to plan for your termination, in collaboration with your Counselor. Your Counselor will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or your Counselor determines that you are not benefiting from treatment, either of you may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.

NEUROFEEDBACK (BRAIN RETAINING): (“EEG-biofeedback”) is a comparatively new and emerging treatment modality that is currently applied to a wide variety of disorders. Neurofeedback for attention deficit/hyperactivity disorder (ADHD), substance addiction, depression, anxiety, and post-traumatic stress disorder (PTSD) have a reasonably good research basis for clinical application. However, neurofeedback for these disorders and many others may be considered “experimental” by some insurance providers, health care practitioners, or others. Other psychological, neurological, and behavioral disorders, including tinnitus and tremors, have limited published neurofeedback research available, and neurofeedback treatment of these conditions is currently considered to be “experimental.” Our office also utilize FDA approved CES technology AlphaStim and/or CES ultra this is the only FDA approved medically prescribed device approved to treat anxiety, sleep and depressive disorders. This is not considered in any way "Experimental" as it has FDA approval which many drugs can not get for anxiety, sleep and depressive disorders. It has over 35 years of valid research backing up the treatment as being effective. Every CES Ultra unit comes with a one-year warranty for all parts and labor. It also comes with a 60 day money back guarantee. If you are dissatisfied for any reason with your CES Ultra, we will return the full amount of your purchase price (less shipping) – every penny, no extra restocking charges, no hidden fees. You are a valued customer. We value your trust and your business. We stand fully behind our product. We want to ensure your full satisfaction. If you do pass your 60 days we have the right to refuse returning the unit. But we always will provide you a new unit if you unit is not functional within the one-year warranty. We are not responsible if you do not use the unit as recommended and if you do not use the unit as recommended we take no responsibility for that fact and if we are willing to take a unit back after guarantee time period it will fee charged. All AphaStim has a 30 day money back guarantee. Return Policy is such hat while the Alpha-Stim is significantly effective when it is used correctly for 9 out of 10 people who use it, it will not work for everyone. If the Alpha-Stim is not working well for you, please first contact your healthcare practitioner, your local authorized Alpha-Stim distributor, or EPI for technical and/or clinical support. If for any reason you wish to return your Alpha-Stim, you may return it within 30 days of purchase and get a full refund, less a 10% restocking fee. Product must be in good, working, resalable condition and returned with all accessories, packed in the original case. Valid only for your first product purchase. 30 day money-back guarantee excludes devices not purchased directly through EPI. The Alpha-Stim is not user serviceable. To obtain service, first contact your authorized distributor or EPI for advice or a Return Material Authorization number (RMA). If necessary, send the entire device, with all accessories, packed in the original case, if available. Send it insured, freight prepaid, and include a copy of your invoice and a note describing the problem. Please do not forget to include your return address, including country, and your phone number, along with fax and email if you have them. This is standard business practices. We also hold a Resale License with San Diego County and hold a City of San Diego Business Permit.

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize billing my insurance company or other third party payers for any covered services received and authorize my insurance company to make direct payment for said services. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment. I further understand that portions of my clinical record may be disclosed to my insurance company or other third party payers for reimbursement purposes. You are responsible for co-payment at time of visit.

ACKNOWLEDGEMENT: I acknowledge that I have read the Agreement give Informed Consent to treatment as well as agree to the policies set forth in the Agreement. I acknowledge that I have the opportunity to read the separate Privacy Practices/HIPAA disclosure (On website - FamilyCounselingSanDiego.com, Inc.). (If a minor child), I as parent/guardian give consent, has been offered and agreement to services for my child as set forth in this Agreement.

BINDING AGREEMENT AND RELEASE OF LIABILITY and/or CONFIDENTIALITY - CLIENT and CLIENT’s parent or guardian, (if CLIENT is a minor) agree that this agreement as it is written and releases liability related to "having an accident such as slip/fall around the office/property, interacting with animals which by there nature are unpredictable, such as "horse's and/or dog's" is a choice of accepting the risk, contract that when signed by the parties involved will be legally binding to all parties, subject to the above terms and conditions and shall be enforced and interpreted under the laws of the state of California. I have not been coerced, fully understand what I have read above, and understand without question, this agreement and release of liability contract before having clicking SUBMIT as that is considered your signature. If you utilize Skype you release your independent contractor therapist and the group AKA FamilyCounselingSanDiego.com, Inc. from all liability for violations of Protected Medical Information (PMI) or HIPPA as Skype does not have a Business Association Agreement but is 256 bit encrypted so required by law we do not recommend use of Skype. We utilize free Doxy.me,Therapynotes.com and other communication protocols which are HIPPA compliant but again unless we pay for an agreement contract we are not able to use ZOOM as HIPPA compliant so again you waive that or do not use it. You accept this limitation of privacy by agreeing to utilize medium such as Skype, Google Video or any other video conferencing software that is not fully HIPPA compliant due to BSA requirement. You waive confidentiality around use of Skype or emailing if you so choose to use it. We suggest limited messages around appointments being set and no more if you choose that method to communicate which we do not recommend. You the user and customer take 100% responsibility of utilizing anything that is not HIPPA compliant which you have been warned not to use such.

We do utilize best practices and security protocols. We have a Business Association Agreement with Google such that our use of all Google Business products are used in agreement with HIPPA compliant needs. Please be aware that emails and texting communication can be intercepted in transmission or misdirected if not encrypted. There is a risk associated with your use of email and text messaging to communicate protected health information utilized by your cellphone or internet provider. Please consider communicating any sensitive information by telephone, fax or in person. Please let me know if you prefer not to use email or text message communication for scheduling reminders. Please let me know if you would like to discuss these options. Finally, please be aware of the risks associated with using your work email or phone to communicate sensitive information. It may be possible for your employer to have access to information exchanged through your work email or phone.

By signing document below "I am agreeing that I Consent and I have received FamilyCounselingSanDiego.com Use of Emails, Line2 PBX Phone System, Google Business emails/docs, EMR (AKA, TherapyNotes.com) and Texting protocols. Such that we can respond to you or to this Informed Consent and you have an opportunity to ask questions. I am aware of my right to choose whether I want to communicate with FamilyCounselingSanDiego.com by email or text message. If you utilize email or utilize my cellphone or internet provider for texting that is not HIPPA compliant then you waive your right to that level of encryption. We will utilize password, secondary verification and other privacy protection provided by the equipment being utilized.

You are aware of the right to request "IN WRITING" the use of encrypted email/phone system and we will set this optional security protocol. By signing this I agree that I have been provided with a copy of this form, offered a discussion related to the risks associated with using a work email or personal phone and I indicated the preferred email address and phone number for communication with a clinician within FamilyCounselingSanDiego.com, INC.

Highlights Of The Privacy Rule, The Security Rule, and the HITECH Act
The Privacy Rule, applies to protected health information (PHI) in any form whether paper, oral, electronic, etc. While it requires covered entities to put in place "administrative, physical, and technical safeguards" for protecting PHI, it differs from the Security Rule in that it discusses the cases in which PHI can be used, when authorization is required and what are patients' rights with respect to their health information. (Page 8335 of the final Security Rule)

Summary of Privacy Rule
The Security Rule applies only to protected health information in electronic form (E-PHI) and builds on the Privacy Rule requirements of "administrative, physical, and technical safeguards." Unlike the Privacy Rule which is more concerned about patients' rights and how health information is used and released, the Security Rule sets standards on the processes and technical security measures that should be taken to keep PHI private. It discusses acceptable ways to "implement basic safeguards to protect E-PHI from unauthorized access, alteration, deletion, and transmission." (Page 8335 of the final Security Rule) * Under the Security Rule, paper to-paper faxes, person-to-person telephone calls, video teleconferencing, or messages left on voice-mail do not count as E-PHI because they did not exist in electronic form before the transmission. Thus those activities are not covered by [the Security Rule]" (Page 8342 of the final Security Rule). In contrast, the Privacy Rule applies to all forms of PHI. Security Rule Guidance Material - The US Department of Health & Human Services (HHS) now also offers a Security Risk Assessment (SRA) tool to help organizations ensure they are compliant with HIPAA’s administrative, technical, and physical safeguards and to expose areas where their PHI may be at risk. The figure below gives you an idea of the security measures covered by the Security Rule. (from paper "Reassessing Your Security Practices in a Health IT Environment: A Guide for Small Health Care Practices") The HITECH Act essentially added teeth to the HIPAA Privacy and Security Rules by specifying levels of violations and penalties for violations. It also requires periodic audits to ensure that covered entities and business associates are complying with the HIPAA Privacy and Security Rules and Breach Notification. HITECH modifications to privacy and security Who Is Required To Comply With HIPAA? Not all operations that handle health-related information must follow HIPAA law (such as many schools, state agencies, law enforcement agencies, or municipal offices). Under HIPAA the 2 groups that must follow HIPAA rules are covered entities - health care providers, health plans, and health clearinghouses, business associates - a person or group providing certain functions or services for a covered entity which require access to identifiable health information, such as a CPA firm, an attorney, or an independent medical transcriptionist; More business associate FAQs here, Doxy.me, Therapynotes.com, VSee would be considered the business associate of a covered entity that uses said companies to communicating private health information with a client. My Disclaimer contains important information I need to share with you and for you to understand. Please be advised of the following. The information contained on this website, and accompanying blog, including ideas, suggestions, techniques, and other materials, is educational in nature and is provided only as general information and is not medical or psychological advice. Transmission of the information presented on this website is not intended to create and receipt does not constitute any professional relationship between Janet Phillips, LCSW, CEO or any FamilyCounselingSandiego.com clinician and the visitor and should not be relied upon as medical, psychological, coaching, or other professional advice of any kind or nature.

If you are having co-therapy as a family and/or couple please provide name of person or persons whom you are releasing confidentiality in box indicated below.

When This Medical Practice May Not Use or Disclose Your Health Information. Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by California and federal law. We may deny your request under limited circumstances. If we deny your request to access your child’s records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional. If your written request clearly, conspicuously and specifically asks us to send you or some other person or entity an electronic copy of your medical record, and we do not deny the request as discussed above, we will send a copy of the electronic health record as you requested, and will charge you no more than what it cost us to respond to your request.

Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice’s denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 16 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.6.You have a right to a paper copy of this Notice of Privacy Practices. We do not use e-mail to distribute the Notice of Privacy Practices.

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Region IX, Office for Civil Rights, U.S. Department of Health & Human Services, 90 7th Street, Suite 4-100 San Francisco, CA 94103(415) 437-8310; (415) 437-8311 (TDD)(415) 437-8329 FAX OCRMail@hhs.gov. The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized for filing a complaint.

HIPPA - Privacy of Information Policies
This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.

Legal Duties
State and Federal laws require that I keep your medical records private. Such laws require that I provide you with this notice informing you of my privacy of information policies, your rights, and my duties. I am required to abide these policies until replaced or revised. I have the right to revise my privacy policies for all medical records, including records kept before policy changes are made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to me in an evaluation, intake, or counseling session are covered by the law as private information. I respect the privacy of the information you provide me and I abide by ethical and legal requirements of confidentiality and privacy of records.

Use of Information
Information about you may be used by me for diagnosis, treatment planning, treatment, and continuity of care. I may disclose it to health care providers who provide you with treatment with your permission and business associates affiliated with this clinic for billing. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian or personal representative. It is my policy of this not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.

Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Public Safety
Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker's compensation laws.

If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, I may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.

Prenatal Exposure to Controlled Substances
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

In the Event of a Client's Death
In the event of a client's death, the spouse or parents of a deceased client have a right to access their child's or spouse's records.

Professional Misconduct
Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional's actions, related records may be released in order to substantiate disciplinary concerns.

Judicial or Administrative Proceedings
Health care professionals are required to release records of clients when a court order has been placed.

If you need to check in, discuss, bring up, or clarify any issues over the phone between sessions, please feel free to do so. You can call main phone system or speak to Walter Martin LMFT 760-498-1053 or speak to Janet Phillips LCSW 858-883-8624 confidential cell phone and/or leave a message. We normally return phone calls within 48 working hours. For phone consultations that is 15 minutes or more, you will be responsible for a fee of $150.00 and another $150.00 for each 15-minute increment used. If you need additional support beyond a phone conversation, please schedule a face-to-face discussion meeting with me. In addition, should an urgent matter arise between your scheduled appointments, please do not hesitate to call me. In the case of an emergency, Help is available! If you or someone you care about is in crisis and needs immediate help, call the Access and Crisis Line at (888) 724-7240.

Other Provisions
When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client's credit report may state the amount owed, the time-frame, and the name of the clinic or collection agency. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.

Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment i.e. psychiatrists prescribing medications. In such cases your permission to talk with the other professional will be requested. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify me in writing where I may· reach you by phone and how you would like me to identify myself. For example, you might request that when I phone you at home or work, I do not say my name or the nature of the call, but rather the mental health professional's first name only. If this information is not provided to me (below), I will adhere to the following procedure when making phone calls: First I will ask to speak to the client (or guardian) without identifying my name. If the person answering the phone asks for more identifying information I will say that it is a personal call. If! reach an answering machine or voice mail I will follow the same guidelines.

Your Rights
You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. The charge for this service is $ 0.25per page, plus postage. You have the right to cancel a release of information by providing me a written notice. If you desire to have your information sent to a location different than my address on file, you must provide this information in writing. You have the right to restrict which information might be disclosed to others. However, if I do not agree with these restrictions, I are not bound to abide by them. You have the right to request that information about you be communicated by other means or to another location. This request must be made to me in writing. You have the right to disagree with the medical records in my files. You may request that this information be changed. Although I might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file. You have the right to know what information in your record has been provided to whom. If you desire a written copy of this notice you may obtain it by requesting it from me at any time.

If you have any complaints or questions regarding these procedures, please contact Walter or Janet directly. You understand the limits of confidentiality, privacy policies, your rights, and their meanings and ramifications. You are responsible for a non-refundable deposit upon completion of this form. There is a CC fee for this transaction which is removed from your payment. You will be given a credit for your deposit within the course of your treatment. Remember you can call and reschedule no less than 48 hours to prevent loss of deposit.

You understand by viewing this website you will be introduced to an integrative approach to psychotherapy/counseling/coaching which includes using several techniques within the field of complementary and alternative medicine (CAM Methods). Although the CAM Methods appear to have promising mental, spiritual, and physical health benefits, and there is a growing amount of scientific research indicating that they are effective evidence supported group of methods, they have yet to be fully researched by the Western academic, medical, and psychological communities and therefore, may be considered experimental. Any information, stories, examples, or testimonials presented on this website do not constitute a warranty, guarantee, or prediction regarding the outcome of an individual using such material contained herein for any particular purpose or issue. While all materials and links and other resources are posted in good faith, the accuracy, validity, effectiveness, completeness, or usefulness of any information herein, as with any publication, cannot be guaranteed. Any FamilyCounselingSandiego.com, Inc. contractor or clinician accepts no responsibility or liability whatsoever for the use or misuse of the information contained on this website, including links to other resources.
  • All information request to assist us in not billiing you. IF CHILD MAKE SURE CURRENT DATE OF BIRTH ABOVE IS CORRECT NOT INSURED DOB - NOT REQUIRED
  • WE DO NOT TAKE MEDI-CAL or Blue Shield of California or MAGELLAN
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    Please provide us your cell phone.
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    If you are the parent of a child being seen please put parents cellphone here.

  • Very Important. Can email it to yourself and use your camera on phone so you can attach the photo here. PLEASE PROVIDE THIS TO HELP US PRE-AUTH INSURANCE.
  • Only Use Insurance ID
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    Primary on Insurance Card
  • PPO, POS, HMO Front of Insurance Card
  • If does not apply please put NA in all boxes.
  • X0001004...... Front of Insurance Card
  • 123456789......Please Provide SSN of Primary Person on Insurance NEVER REQUIRED
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    Please look on the back of your card for MENTAL HEALTH Phone Number !!! You may want to call and find out if you have a deductible of $1000 or more as most seem to have.
  • If does not apply put NA.
  • Are you native, born in another county or first generation from another county?
  • Relationship Status
  • Relationship to you and how many people in your family.
  • Please tell us in detailed why you are seeking treatment currently. AGAIN PLEASE BE DETAILED AS THIS REALLY HELPS DURING INTAKE PROCESS.
  • NAME. AGE, SEX, In Custody Y/N
  • Helps with treatment planning. Best guess is fine. (Enter None if None apply.)
  • Helps with treatment planning. Best guess is fine. (Enter None if None apply.)
  • Anxiety Hopelessness Panic Sadness Energy Socializing utilize scale 0 no pain to 10 severe pain how much emotional pain are you in..
  • Estimated date is fine. Best guess please. If you on medications please list for what you are taking medication for and dosage of the medication you currently take..
  • 12=HS, 16=BS, 18=MA, 20=PHD
  • Please answer best estimate. 1 Drink is equal to 1 shot or 8-10 oz of beer or wine.
  • If you do not utilized the LENS technology within your treatment providing permission does not mean you are required to utilize this treatment at anytime and no cost is involved.
  • Remember to complete form you will be automatically directed to following completion of this form. This form is Oshslabs.com so we can start treatment right away when you arrive for appointment.
  • This is Secured E-Signature https://www.geotrust.com/resources/repository/legal
  • Please provide us who is signing this form
  • We never give out your email to anyone so please provide. We can use to send you reminder if you would like but only with your permission.
  • All medical providers require Emergency Contract Name and Number.
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