This form provides you, the client, with information that is in addition to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.

PRACTICE INFORMATION: The individual marital and family therapist who operates this practice is Shaliss Padilla, MA, LMFT. Her license number is #50593. This practice is a Licensed Marriage and Family Therapist Corporation: MINDBODYOLOGY FAMILY THERAPY INCORPORATED. This professional corporation operates under the fictitious business names of MINDBODYOLOGY - INTEGRATIVE MENTAL HEALTH & WELLNESS SERVICES, MINDBODYOLOGY INC., AND MINDBODYOLOGY.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. 

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to (Mindbodyology Inc./Shaliss Padilla, LMFT) that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by (Mindbodyology Inc./Shaliss Padilla, LMFT). In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. (Mindbodyology Inc./Shaliss Padilla, LMFT) will use his/her clinical judgment when revealing such information. (Mindbodyology Inc./Shaliss Padilla, LMFT)will not release records to any outside party unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct (Mindbodyology Inc./Shaliss Padilla, LMFT), only the minimum necessary information will be communicated to the carrier. Mindbodyology Inc./Shaliss Padilla, LMFT has no control over, or knowledge of, what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access.  Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

HIPAA - NOTICE OF PRIVACY PRACTICES:  I have read Mindbodyology Inc./Shaliss Padilla, LMFT's HIPAA/Notice of Privacy Practices which defines and discusses compilation and use of my Protected Health Information ("PHI") prepared pursuant to and consistent with the Health Insurance Portability Accountability Act ("HIPAA") and applicable California law.  I acknowledge that I have read and fully understand the Notice which describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations. I further acknowledged my understanding that the Notice of Privacy Practices describes my rights and the duties with respect to my PHI. I understand that a copy of the Notice is conspicuously posted in office waiting room and/or has been provided to me here on the Office Policies & Informed Consent for Psychotherapy form.

LITIGATION: Sometimes patients become involved in litigation while they are in therapy or after therapy has been completed. Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients' records are generally confidential and private in nature.  Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting (Mindbodyology Inc./Shaliss Padilla, LMFT)'s disclosure of the records, (Mindbodyology Inc./Shaliss Padilla, LMFT) will do his/her best to discuss with you the risks and benefits of doing so.  As noted in this document, you have the right to review your own psychotherapy records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW")

CONSULTATION: (Mindbodyology Inc./Shaliss Padilla, LMFT)consults regularly with other professionals regarding his clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

E-MAILS, CELL PHONES, COMPUTERS, AND FAXES:  It is very important to be aware that computers and unencrypted email, texts, and e-faxes communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication.  Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them.  While data of (Mindbodyology Inc./Shaliss Padilla, LMFT) 's computers are encrypted, emails, texts and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. (Mindbodyology Inc./Shaliss Padilla, LMFT)'s computers are equipped with a firewall, a virus protection and a password, and the company backs up all confidential information from computers on a regular basis onto an encrypted hard-drive.  Also, be aware that phone messages are transcribed and sent to (Mindbodyology Inc./Shaliss Padilla, LMFT) via unencrypted emails. Please notify (Mindbodyology Inc./Shaliss Padilla, LMFT)if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes.  If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, it will be assumed that you have made an informed decision, and will be viewed as your agreement to take the risk that such communication may be intercepted and (Mindbodyology Inc./Shaliss Padilla, LMFT) will honor your desire to communicate on such matters.   Please do not use texts, email, voice mail, or faxes for emergencies. 

SOCIAL NETWORKING AND INTERNET SEARCHES

If applicable, (Mindbodyology Inc./Shaliss Padilla, LMFT)  may conduct a web search on her clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with (Mindbodyology Inc./Shaliss Padilla, LMFT). (Mindbodyology Inc./Shaliss Padilla, LMFT) does not accept friend requests from current or former clients on social networking sites, such as Facebook due to the fact that these sites can compromise clients' confidentiality and privacy. For the same reason, (Mindbodyology Inc./Shaliss Padilla, LMFT) requests that clients do not communicate directly with her via any interactive or social networking websites.

RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of (Mindbodyology Inc./Shaliss Padilla, LMFT) profession require that treatment records are kept for at least 10 years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, (Mindbodyology Inc./Shaliss Padilla, LMFT)  retains clinical records only as long as is mandated by (California) law. If you have concerns regarding the treatment records, please discuss them with (Mindbodyology Inc./Shaliss Padilla, LMFT). As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when (Mindbodyology Inc./Shaliss Padilla, LMFT)  assesses that releasing such information might be harmful in any way. In such a case, (Mindbodyology Inc./Shaliss Padilla, LMFT)  will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, (Mindbodyology Inc./Shaliss Padilla, LMFT) will release information to any agency/person you specify unless (Mindbodyology Inc./Shaliss Padilla, LMFT) assesses that releasing such information might be harmful in any way.  When more than one client is involved in treatment, such as in cases of couple and family therapy, (Mindbodyology Inc./Shaliss Padilla, LMFT)   will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact (Mindbodyology Inc./Shaliss Padilla, LMFT)   between sessions, please leave a message at the answering service at 1-833-444-MIND and your call will be returned as soon as possible. (Mindbodyology Inc./Shaliss Padilla, LMFT) checks messages a few times during the daytime only, unless closed/traveling. If a emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away.  For Psychiatric Emergency Services call 911 or local Oceanside Police Department at 760-435-4900, or the local 24-hour crisis line (San Diego, CA): 1-888-724-7240 or the Police: 911. Please do not use email or faxes for emergencies. (Mindbodyology Inc./Shaliss Padilla, LMFT) does not always check email or faxes daily.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee per hour session at the end of each session or at the end of the month unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify (Mindbodyology Inc./Shaliss Padilla, LMFT) if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, (Mindbodyology Inc./Shaliss Padilla, LMFT)  client portal will provide you with your receipts, which you can print out and then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, (Mindbodyology Inc./Shaliss Padilla, LMFT) can use legal or other means (courts, collection agencies, etc.) to obtain payment.

ALL CLIENTS MUST LEAVE A CREDIT/DEBIT CARD ON FILE ON THIS SECURE CLIENT PORTAL (SECURED BY BLUE PAY) TO BE CHARGED 24 HOURS BEFORE OR ON THE DAY OF THE APPOINTMENT FOR CO-PAY/DEDUCTIBLES/FEES AND/OR TO PAY FOR MISSED APPOINTMENTS (NOT CANCELED WITH AT LEAST 48 HOURS OF NOTICE).

LATE APPOINTMENT CANCELLATION FEE IS $110.00. 

MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of (Mindbodyology Inc./Shaliss Padilla, LMFT) and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association which are in effect at the time the request for arbitration is filed.  Please, note that neither mediation nor arbitration is mandatory. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, (Mindbodyology Inc./Shaliss Padilla, LMFT) can use legal means (court, collection agency, etc.) to seek payment.  If there is arbitration, the prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT)  will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT)  may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT)  is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. (Mindbodyology Inc./Shaliss Padilla, LMFT)  provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his/her scope of practice.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT) becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the person whose name you have provided on the biographical sheet.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT)  will discuss with you his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your therapist's or (Mindbodyology Inc./Shaliss Padilla, LMFT)'s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: As set forth above, after the first couple of meetings, (Mindbodyology Inc./Shaliss Padilla, LMFT) will assess if he can be of benefit to you.  (Mindbodyology Inc./Shaliss Padilla, LMFT)  does not work with clients who, in his opinion, he cannot help.  In such a case, if appropriate, he will give you referrals that you can contact.  If at any point during psychotherapy (Mindbodyology Inc./Shaliss Padilla, LMFT)  either assesses that he is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, he will discuss with you the termination of treatment and conduct pre-termination counseling.  In such a case, if appropriate and/or necessary, he would give you a couple of referrals that may be of help to you.  If you request it and authorize it in writing, (Mindbodyology Inc./Shaliss Padilla, LMFT) will talk to the psychotherapist of your choice in order to help with the transition.  If at any time you want another professional's opinion or wish to consult with another therapist, (Mindbodyology Inc./Shaliss Padilla, LMFT) will give you a couple of referrals that you may want to contact, and if she has your written consent, he will provide her or him with the essential information needed.  You have the right to terminate therapy and communication at any time.  If you choose to do so, upon your request and if appropriate and possible, your therapist (Mindbodyology Inc./Shaliss Padilla, LMFT)  will provide you with names of other qualified professionals whose services you might prefer.

DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs your therapist's (Mindbodyology Inc./Shaliss Padilla, LMFT) 's objectivity, clinical judgment or can be exploitative in nature. Your assigned therapist (Mindbodyology Inc./Shaliss Padilla, LMFT) will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual and rehabilitation communities, etc., multiple relationships are either unavoidable or expected.  (Mindbodyology Inc./Shaliss Padilla, LMFT) will never acknowledge working with anyone without his/her written permission. Many clients have chosen (Mindbodyology Inc./Shaliss Padilla, LMFT)  as their therapist because they knew him/her before they entered therapy with him/her, and/or are personally aware of his/her professional work and achievements. Nevertheless, (Mindbodyology Inc./Shaliss Padilla, LMFT)   will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise (Mindbodyology Inc./Shaliss Padilla, LMFT) if the dual or multiple relationship becomes uncomfortable for you in any way. (Mindbodyology Inc./Shaliss Padilla, LMFT) will always listen carefully and respond to your feedback and will discontinue the dual relationship if s/he finds it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

TOUCH THERAPY (REIKI & OTHER ENERGY WORK): (Shaliss Padilla, LMFT, Reiki Master Teacher) may also incorporate non-sexual touch as part of psychotherapy (i.e. Reiki Treatments, Energy Psychology - EFT Tapping Techniques, Biofield Tuning and/or other types Energy Work).

Sexual touch of clients by therapists is unethical and illegal. Your therapist(Mindbodyology Inc./Shaliss Padilla, LMFT, Reiki Master Teacher) will ask your permission before touching you and you have the right to decline or refuse to be touched without any fear or concern of a negative response or reaction from your therapist. Touch therapy via working with energy can be very beneficial but can also unexpectedly evoke emotions, thoughts, physical reactions, or memories that may be upsetting, depressing, evoke anger, etc. Sharing and processing such feelings with the therapist, if they arise, may be a helpful part of therapy. You may request not to be touched at any time during therapy without needing to explain it, if you choose not to, and without fear of a negative response or reaction from your therapist.

PHONE, TEXT OR EMAIL THERAPY: Consulting with clients exclusively over the phone or via text or email rather than in person (face-to-face) in the therapist's office brings additional complexities and potential disadvantages to the therapeutic process. When appropriate, (Mindbodyology Inc./Shaliss Padilla, LMFT) may recommend that the client/s first choice is to find a local therapist with whom the client/s can meet face to face. If (Mindbodyology Inc./Shaliss Padilla, LMFT) is not aware of a local referral, one way to find such a therapist is to call the local Psychological Association chapter/ local NASW chapter / local Counseling chapter, etc. Treating clients exclusively via phone consultations or emails may put therapists at a disadvantage because they cannot detect nonverbal cues, may not be able to accurately diagnose, may not always be aware of the resources available locally, and may not be able to intervene as effectively as necessary in emergency situations. Acute crises and severe psychological disturbances, such as schizophrenia, dissociation, bipolar or some types of personality disorders may not be effectively handled exclusively via phone, email or other web based communications. As was noted in the Termination section, above, if (Mindbodyology Inc./Shaliss Padilla, LMFT)  assesses, at any point, that s/he is not effective in helping you reach the therapeutic goals via the telephone sessions, s/he is obligated to discuss it with you and, if appropriate, to terminate treatment. For more information on the topic you can go to: http://psychcentral.com/best.

SOCIAL NETWORKING AND INTERNET SEARCHES: At times, (Mindbodyology Inc./Shaliss Padilla, LMFT)  may conduct a web search on my clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss them with me. I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.

AUDIO OR VIDEO RECORDING:  Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, online video counseling or any other services provided by (Mindbodyology Inc./Shaliss Padilla, LMFT).

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.  The full fee is $110.00. Most insurance companies do not reimburse for missed sessions therefore you will be responsible for full fee.

CANCELLATIONS MUST BE MADE BY EMAIL OR BY PHONE AT LEAST 48 HOURS BEFORE YOUR APPOINTMENT TIME/DATE.  CALL 1-833-444-MIND OR EMAIL:  INFO@MINDBODYOLOGY.ORG.

I have read the above Office Policies, General Information and Informed Consent for Psychotherapy, Notice of Privacy Practices - HIPAA carefully; I understand them and agree to comply with them.