Office Policies, General Information Agreement, Informed Consent for Psychotherapy & Coaching Services
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 Dr. Eman Fallah 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 Dr. Fallah. 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. Dr. Fallah will use his clinical judgment when revealing such information. Dr. Fallah will not release records to any outside party unless 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.
If there is an emergency during therapy, or in the future after termination, where Dr. Fallah becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he will do whatever 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, he may also contact the person whose name you have provided on the biographical sheet.
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. Only the minimum necessary information will be communicated to the carrier. Dr. Fallah has no control over, or knowledge of, what insurance companies do with the information 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.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Dr. Fallah to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Dr. Fallah 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 important that you be aware that emails, faxes, and important texts are part of the medical records. Additionally, Dr. Fallah’s emails are secure and encrypted. Dr. Fallah’s computers are equipped with a firewall, a virus protection, and a password and he also backs up all confidential information from his computers on a regular basis. Please notify Dr. Fallah if you decide to avoid or limit in any way the use of any or all communication devices, such as email, cell phone, or faxes. Please do not use email or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM
Both the law and the standards of Dr. Fallah’s profession require that he keep treatment records for at least seven years. Unless otherwise agreed to be necessary, Dr. Fallah retains clinical records only as long as is mandated by California state law. If you have concerns regarding the treatment records, please discuss them with Dr. Fallah. 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 Dr. Fallah assesses that releasing such information might be harmful in any way. In such a case, Dr. Fallah 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, Dr. Fallah will release information to any agency/person you specify unless Dr. Fallah 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, Dr. Fallah 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
Although the preferred mode of communication with Dr. Fallah is through email, you may call him between sessions during emergencies or other exceptional circumstances, such as not having access to email or needing to cancel a session. Please leave a message at the answering service (650) 619-0113 and your call will be returned. Dr. Fallah checks his messages a few times during the daytime only, unless he is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call Psychiatric Emergency Services. San Mateo: (650) 573-2662, 24-hour crisis line: 1-800-SUICIDE, 911, or go to your nearest emergency room. Please do not use email or faxes for emergencies.
PAYMENTS & INSURANCE REIMBURSEMENT
Clients are expected to pay the agreed upon fee at the end of each 50 minute individual therapy or coaching session or at the end of the month unless other arrangements have been made. Group therapy is $30-40 per hour with the same collection policy as individual therapy. 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 Dr. Fallah 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. Dr. Fallah does not accept insurance but he can provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose depending on your policy. 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, Dr. Fallah can use legal or other means (courts, collection agencies, etc.) to obtain payment.
MEDIATION & ARBITRATION
All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. Fallah 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, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in San Mateo County, CA in accordance with the rules of the American Arbitration Association which will go into effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Fallah can use legal means (court, collection agency, etc.) to obtain payment. 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.
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. Dr. Fallah 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. Dr. Fallah 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, Dr. Fallah is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his 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. Dr. Fallah provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his scope of his practice.
Within a reasonable period of time after the initiation of treatment, Dr. Fallah will discuss with you his working understanding of the problem, treatment plan, therapeutic objectives, and his 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, Dr. Fallah’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.
As set forth above, after the first couple of meetings, Dr. Fallah will assess if he can be of benefit to you. If at any point during psychotherapy, Dr. Fallah assesses that he is not effective in helping you reach your therapeutic goals or that you are non-compliant, he is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, he would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Dr. Fallah 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, Dr. Fallah will assist you with referrals, and, if he has your written consent, he will provide her or him with the essential information needed. The termination stage of therapy is one of the most significant phases of treatment and it is most beneficial if not done abruptly. You have the right to terminate therapy at any time. However, it is expected that you will allow at least two additional sessions for properly processing the termination phase.
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 the therapist’s objectivity, clinical judgment or can be exploitative in nature. Dr. Fallah 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, military bases, university campus, etc., multiple relationships are either unavoidable or expected. Dr. Fallah will never acknowledge working with anyone without his written permission. Many clients have chosen Dr. Fallah as their therapist because they knew him before they entered therapy with him, and/or were personally aware of his professional work and achievements.
SOCIAL NETWORKING SITES
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 is likely to 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.
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. Most insurance companies do not reimburse for missed sessions. Cancellations may be done via telephone or email.
In order to request a copy of this form via docusign, please visit the appointment page here [LINK TO FORM].