Disclosure Statement & Agreement for Services - Cardiff Counseling ...

In addition, a federal law known as The Patriot Act of 2001 ... Act (HIPAA, eff. date April 14, 2003) allow me to use or disclose Protected Health Information (PHI).
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Individual, Couples & Family Therapy

Bonnie J. Rumble, MFT • License #MFC 31229 Locations in Cardiff & San Diego 760-732-1539 – [email protected]

Disclosure Statement & Agreement for Services Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us. And as we begin, please note and understand that Bonnie J Rumble MFT/ Cardiff counseling Center is a sole-proprietor, which means that she is in business for herself, and that Bonnie J. Rumble MFT and Cardiff Counseling Center are not engaged in any partnerships, joint ventures, or professional corporations, or any other form of business organization with any of the other practitioners in this suite of offices. PSYCHOTHERAPY SERVICES Psychotherapy varies depending on the personalities of the therapist and client, 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 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. QUALIFICATIONS I am a Marriage and Family Therapist (License #MFC31229) and have a Master of Science degree in Counseling Education. My education, training and experience include providing counseling and psychotherapy to individuals, couples and families since 1993. I am also trained in Eye Movement Desensitization and Thought Field Therapy. MEETINGS Sessions are typically scheduled weekly and are 50 minutes long. Your therapist may suggest a different amount of therapy depending on the nature and severity of your concerns. During your first session, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours [1 day] advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. Located at 2047 D San Elijo Ave., Cardiff, CA 92007 & 3821 Front Street, San Diego, CA 92103 www.cardiffcounselingcenter.com

CONFIDENTIALITY – NOTICE OF PRIVACY PRACTICES All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in couple or family therapy, your therapist 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. However, it is important that you know that your therapist utilizes a “no-secrets” policy when conducting couple or family therapy. This means that if you participate in couple and/or family therapy, I am permitted to use information obtained in an individual session that we may have had, when working with other members of your family. Please feel free to ask me about my “no secrets” policy and how it may apply to you. There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder abuse. Therapists may be required or permitted to break confidentiality when they have determined that a client presents a