This document contains important information about our professional services and policies. Please read it carefully. When you click “I Agree”, it will represent your agreement to the policies, procedures and informed consent contained in this document.



  • Become actively involved in the treatment goals by having scheduled sessions with your provider and keeping your provider informed as to your progress, in order to assure each other of productivity toward desired outcomes.
  • Notify the provider no less than 48 hours in advance of any non­ emergency cancellations. Emergency cancellations are at the discretion of the provider, but do NOT include transportation issues, minor illnesses, vacations, ineffective appointment tracking, etc.
  • Take medication as prescribed, do not exceed the maximum prescribed dose, and do not make changes to your dose unless it has been authorized by your physician. Repeated failure to take medications as prescribed/changing dosages will be grounds for termination and referral of treatment. In the event of going against medical advice and exceeding the prescribed dose, no substitute medication will be provided.


Psychiatry is not easily described in general statements. It varies depending on the particular problems you bring forward. There are many different methods that may be used to deal with the problems that you hope to address. Psychiatry calls for a very active effort on your part. In order for it to be most successful, you will have to work on things both during your sessions and at home, including taking your prescribed medication as directed.
Psychiatry can have benefits and risks. Since psychiatry often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, anxiety, depression and helplessness. On the other hand, psychiatry has also been shown to have benefits for people who go through it. Psychiatry often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress and anxiety. Working toward these benefits requires effort on your part.

During your first session, your psychiatrist will assess whether he/she can be of benefit to you. If your psychiatrist does not think he/she can help you, he/she will let you know and try to refer you to others who work well with your particular issues. Please note that your psychiatrist, in his/her sole discretion, may decide not to start a doctor­patient relationship with you after reviewing your case during the initial intake process or following your first session; similarly your psychiatrist reserves the right to discontinue services at any time. If you and your psychiatrist decide to continue, within a reasonable period of time after starting treatment, your psychiatrist will discuss his/her working understanding of your issues, a proposed treatment plan, and therapeutic objectives and possible outcomes of the therapy. If you have questions about any of the procedures used in the course of your treatment, their possible risks, your psychiatrist’s expertise, or about the treatment plan in general, please ask your psychiatrist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your psychiatrist does not provide, your psychiatrist will provide assistance or referral information for obtaining those treatments. During the time it takes for your psychiatrist to evaluate you, you or your psychiatrist can decide if the assigned psychiatrist is the best person to provide the services you need in order to meet your treatment goals. If the two of you decide to continue, your psychiatrist will usually schedule one session per week at an agreed time, although some sessions may be longer or more or less frequent. Once an appointment is scheduled, you will be expected to pay for it unless you provide 4 8 hours advance notice of cancellation, unless your psychiatrist agrees that you were unable to attend due to circumstances beyond your control.

Psychiatry involves a commitment of time, money, and energy, so you should be careful about the psychiatrist you see. If you have questions about the procedures, you should discuss them whenever they arise. If your doubts persist, you can see another mental health professional.

Deciding when to stop your work with your psychiatrist is meant to be a mutual process. Before it is stopped, you and your psychiatrist will discuss how you will know if or when to come back or whether a regularly scheduled "checki n" might work best for you.

Noncompliance with treatment recommendations may necessitate early termination of services. Your psychiatrist will look at your issues with you and exercise his/her educated judgment about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved.

If at some point your psychiatrist assesses that he/she is not effective in helping you reach your goals, your psychiatrist is obliged to discuss this with you and, if appropriate, terminate treatment and try to give you referrals that may be of help to you. If you request it and authorize it in writing, your psychiatrist may talk to the psychotherapist or psychiatrist 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 psychiatrist, your psychiatrist will assist you in finding someone qualified. You have the right to terminate treatment at any time. If you choose to do so, your psychiatrist may offer to provide you with names of other qualified professionals whose services you might prefer.

If you commit violence to, verbally or physically threaten or harass your psychiatrist or the psychiatrist’s colleagues or family, your psychiatrist reserves the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. Please contact your psychiatrist or health coach to discuss arrangements any time your financial situation changes.

Unless we have made other arrangements, should you not schedule an appointment for a period of 60 days and make no other arrangement with your provider, you agree that you will no longer be considered to be an active patient of our psychiatry services, and therefore have terminated psychiatric treatment. A lso, if you “no show”/ “late cancel” for two consecutive appointments or “no show”/ “late cancel” for one appointment and do not reschedule within sixty days, you will be considered to have terminated your treatment relationship. 



Medication management sessions typically last 15­30 minutes, are more frequent in the beginning, or after any changes are made, and then typically occur every 4­8 weeks. Duration of treatment varies depending on the nature of the treatment and individual client needs. When medications are used in psychiatry, please be advised that they are frequently used “off­label” meaning that they are used to control symptoms other than what the FDA originally approved the medication to treat.



Your psychiatrist is often not immediately available by telephone. If you need to reach your psychiatrist, please contact your health coach, who will address your concerns or contact your psychiatrist on your behalf. Your psychiatrist will make every effort to return to respond within 24 hours of your message, with the exception of weekends and holidays. If you are difficult to reach, please inform your psychiatrist or health coach of some times when you will be available. If you are unable to reach your psychiatrist and feel that you can’t wait for your psychiatrist to return your call, contact your family physician or the nearest emergency room. Your provider will do his/her best to return all telephone calls within 24 hours. Also please note that cellular, computer, and voicemail technology is not infallible. It may be more than 24 hours before your provider returns your call to set up an appointment with you. If you need faster assistance, please let your health coach know. Emergency phone consultations of 5 minutes or less are normally free. However, if you and your psychiatrist spend more than 5 minutes in a week on the phone, if your psychiatrist spends more than five minutes reading and responding to messages from you during a given week, or if your psychiatrist spends more than five minutes involved in case management or coordination of care, you may be billed on a prorated basis for that time. If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. If your psychiatrist will be unavailable for an extended time, your psychiatrist will provide you with the name of a colleague to contact, if necessary; or, otherwise please contact your health coach. Please note that email systems are not entirely secure, and you acknowledge this and consent to use of email when you correspond with your psychiatrist by email.

If an emergency situation arises, please indicate it clearly in your message to your psychiatrist or your health coach. If your situation is an acute emergency and you need to talk to someone right away, contact the closest 24h our emergency psychiatric service: Dial 911 or Go to your nearest Emergency Room.

Sometimes patients have questions about their medications, side effects, pharmacy problems, or their diagnosis that come up in between appointments. Please do not hesitate to contact your provider to inform him/her of your questions. Your provider will try his/her best to answer you promptly. However, certain important clinical decisions may not be able to be made in­between appointments. For example, you may need an appointment in order to start a new medication. If your situation is severe enough that it cannot be handled until the next in­person appointment, we recommend that you go to the nearest health care facility/ emergency room for attention.

Urgent situations are conditions that might have severe consequences if not addressed for over a few days and include (but are not limited to) acute, severe depression, mania, or extremely severe anxiety. In an urgent situation, please contact your health coach. Your health coach will work to get a hold of your provider.

Emergencies include any situations where there is a question of danger to your own life or anyone else, or conditions like psychosis, where patients may be incapable of making rational decisions. In emergency situations, you should go directly to the emergency room. In addition, your provider may require you to go to the nearest emergency room. If your provider has any concern of imminent danger to yourself or someone else, your provider will also be required to involve the police or medical authorities to transport you to the nearest medical facility for evaluation, sometimes for an extended time (>24 hours).
If your provider is away for an extended time period, your health coach will direct you as to who is providing coverage. In the event of a crisis, you may contact the following or go to the nearest emergency medical facility:

  • Emergency (police, fire, ambulance)
  • 911 Nearest Emergency Room
  • National Suicide Prevention Hotline


If medication is prescribed, you agree to abide by your psychiatrist’s directions regarding your medication. Please discuss with your psychiatrist the effects, including any side effects, of your medication.

If your provider has prescribed medication, please contact your pharmacy and ask to have your pharmacy FAX us refill requests.


Refills of medication are not usually written at the time of your scheduled appointment. Instead they should be handled through your pharmacy. Prescription refills are not normally considered urgencies or emergencies, and must therefore be handled during regular business hours. Refill request submitted on Fridays or weekends will be turned around the following week. Any controlled or scheduled substances (benzodiazepines, sleep medications, stimulants) will NOT be prescribed by your provider. 

Medications will not be replaced if they are lost, damaged, or stolen without a scheduled appointment. Requests for early refill secondary to lost, damaged or stolen prescriptions will be handled on a case by case basis and an occurrence more than once within a year may be grounds for discharge from the practice.

Failure to respond to a trial of medication does not guarantee further medication trials.



If you late cancel (cancel with under 48 hour notice) or no show for an appointment, we will contact you to set up another appointment. Repeated missed appointments or no shows may be grounds for termination of treatment. Missed appointment or late cancel will be charged by the length of the scheduled appointment at the then current rate.



Your psychiatrist’s primary role is to provide diagnosis and treatment for your medical condition. Disability is a legal or occupation definition, not a medical one; therefore we are unable to provide an opinion on as to whether you are disabled or not. Your provider is able to offer a detailed opinion as to your diagnosis, history, type of treatment, response to treatment, typical prognosis and your appearance at examination. This is called a “Narrative Summary of Treatment,” and we can provide this in disability information requests. Occasionally lawyers will submit to us detailed questionnaires about your ability to perform certain functions. Regrettably, we do not have the information or training to make these kinds of assessments. We are happy to substitute a “Narrative Summary of Treatment” in response. Your attorney may want to consult an expert in the area of psychiatric disability assessment for further information.



The laws and psychiatry standards require that your psychiatrist keep treatment records.You are entitled to inspect a copy of certain professional records regarding your treatment unless your psychiatrist believes that seeing them would be harmful, in which case your psychiatrist will be happy to send them to a mental health professional of your choice, or your psychiatrist can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them in your psychiatrist’s presence so that the contents can be discussed. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

Medical records requests from other agencies need to come in writing.

We can furnish letters of diagnosis or a narrative summary directly to you; typically the request will need to come in writing. Please note that these information requests require a substantial amount of time to compose, and thus we ask for at least 30 days notice. It is our policy not to release chart notes directly, nor can we reissue parts of your treatment chart that were submitted by other agencies. You will need to request your records separately from those agencies.



Psychiatry never involves sexual, business, or any other dual relationships that could impair the objectivity, clinical judgment or therapeutic effectiveness of your psychiatrist or could be exploitative in nature. Please discuss this with your psychiatrist if you have questions or concerns.



In addition to scheduled appointments, your psychiatrist charges fees for other professional services you may need, though your psychiatrist will break down the hourly cost if he/she work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of your psychiatrist. If you become involved in legal proceedings that require your psychiatrist’s participation, you will be expected to pay for your psychiatrist’s professional time even if your psychiatrist is called to testify by another party. Because of the difficulty of legal involvement, your psychiatrist may charge more per hour for preparation and attendance at any legal proceeding.



You will be expected to pay for each session at the time it is held or prior thereto. Payment schedules for other professional services will be agreed to when they are requested. Un less otherwise required by your p sychiatrist, billing will be provided after each session, although you may be required to pay for the service prior to your scheduled session(s). Fees may be periodically raised, and you will be provided at least 30 days notice. If your psychiatrist is a provider of your insurance panel, this consent authorizes your p sychiatrist to send treatment records to your insurance company in order to receive reimbursement. It is your responsibility to determine that your sessions will be covered by your insurance if your p sychiatrist is a member of your insurance panel. Regardless of whether your p sychiatrist is a member of your insurance panel or not, you will be responsible for the fees not paid by insurance.

If services have not been paid within 30 days, you will be notified in writing that payment has not been made and that the patient make payment or contact the insurance carrier in order to get them to pay for the services in a timely manner. I f your account has not been paid for more than 30 days, a 3% per month fee may be added to the bill or the maximum amount allowed by law (whichever is less). I f your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, your p sychiatrist has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

An Important Note About Credit Card PreA uthorization:
This consent gives permission to charge the patient’s credit card for any services. This consent allows for credit card processing and the charge will appear on the patient’s statement. This consent is valid unless the patient cancels the authorization in writing. The patient’s agreement to this consent constitutes prea uthorization to provide payment in this manner.



You are responsible for the fees for your psychiatry services – not your insurance company. You will be provided with a billing form that you may use to claim insurance reimbursement for treatment costs, but any dealings with the insurance company will be through you and solely your responsibility.



If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records.



In general, the privacy of all communications between a patient and a psychiatrist is protected by law, and a psychiatrist can only release information about his/her work with a patient with the patient’s written permission. But there are a few exceptions.
In most legal proceedings, you have the right to prevent your psychiatrist from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your psychiatrist to testify if the judge determines that the issues demand it.

There are some situations in which a psychiatrist is legally obligated to take action to protect others from harm, even if he/she has to reveal some information about a patient’s treatment. For example, if a psychiatrist believes that a child, an elderly person or disabled person has been abused or neglected, the psychiatrist must file a report with the appropriate agency.
If a psychiatrist believes that a patient is threatening serious bodily harm to another, the psychiatrist is required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, the psychiatrist may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

Your psychiatrist may occasionally find it helpful to consult other professionals – either as individuals or in a consultation group  about a case. The consultant(s) is/are also legally bound to keep the information confidential. If you don’t object, your psychiatrist will not tell you about these consultations unless your psychiatrist feels that it is important to your treatment. This consent allows your psychiatrist to share information and/or records regarding your treatment with others in compliance with state and federal laws (such as HIPAA) and the Notice of Privacy Practices. Please refer to the Notice of Privacy Practices.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you raise with your psychiatrist any questions or concerns that you may have.


This consent verifies that you release your psychiatrist to provide someone with your records and your contact information due to your psychiatrist’s death or disability or other discontinuance, unless you otherwise advise your psychiatrist in writing that you do not wish to provide such information.


Service Animal Requests: We recognize the importance of animals and pets for many people. That said, we are unable to complete service animal designations for psychiatric conditions because of the lack of research and co­ordination of policy guidelines for this indication.

Medical Marijuana: Due to the lack of controlled research on inhaled marijuana for psychiatric conditions and possible harms, we are unable to endorse its use from a medical perspective. However, some people report that the use of marijuana helps with certain psychiatric conditions. Regrettably, we cannot assist in obtaining a medical marijuana card due to conflicts between the state of California’s policy of medical marijuana’s legalization and our prescribing authority, which comes from Federal law.


To facilitate consumers in receiving appropriate psychological services, all licensees and registrants are required to post the Notice below in a conspicuous location in their principal psychiatry business office. Since your psychiatrist works in multiple locations, that Notice is in this Contract:


The Department of Consumer Affairs receives questions and complaints regarding the practice of psychiatry. If you have any questions or complaints, you may contact this department by calling (916) 263­ 2382, or by writing to the following address: