Treatment Consent

1. Purpose of this document

This Treatment Consent describes the nature of psychotherapy at Pasadena Clinical Group, a California professional psychology corporation ("PCG," "we," "us," or "our"); the risks and limits of treatment; the limits of confidentiality under federal and California law; the financial terms; and the dispute-resolution process for disagreements arising out of clinical care, including a binding arbitration agreement compliant with California Code of Civil Procedure §1295. This online version is provided for transparency and pre-intake review only; the binding consent is the version you sign at intake. If anything in this Treatment Consent is unclear, please ask before signing.

2. Information-only purpose of this website; no clinician-patient relationship from website use

The information posted on PCG's website is general and educational. It is not a substitute for, and may not be used as, evaluation, diagnosis, or treatment. Do not use the website to diagnose yourself or anyone else. Mere submission of an interest form, email, voicemail, or any other form of communication through the website does not establish a clinician-patient relationship. A clinician-patient relationship is established only when (i) PCG accepts you for care after intake screening, (ii) you sign this Treatment Consent and any other required forms, (iii) you provide all required identification and information, and (iv) you attend and pay for an initial clinical session.

3. Voluntary participation; right to decline or terminate

Psychotherapy at PCG is voluntary, except in the case of court-ordered programs (see Section 14). You may decline, pause, or terminate treatment at any time. We encourage you to discuss any decision to terminate with your clinician so a thoughtful close can be supported and appropriate referrals offered if helpful. PCG may also terminate services as described in our Office Policies, providing reasonable continuity-of-care assistance and referrals.

4. Nature, methods, risks, and benefits of psychotherapy

Psychotherapy is a collaborative process in which a licensed clinician and a patient work together to understand and change patterns of thinking, feeling, and behaving. Methods commonly used at PCG may include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT) skills, acceptance and commitment therapy (ACT), schema-focused therapy, motivational interviewing, exposure-based interventions, and relational/psychodynamic frameworks. Your clinician will discuss the rationale for the methods proposed for your care.

Possible benefits include reduction in symptoms; improved relationships, work, and self-understanding; better skills for managing emotions, anger, conflict, and stress; and improved decision-making.

Possible risks include the experience of uncomfortable feelings (sadness, anger, anxiety, shame, grief) as you discuss difficult material; recall of painful memories; temporary worsening of symptoms before improvement; difficulty in relationships as you change; misunderstandings between you and the clinician; and the possibility that treatment may not produce the changes you hoped for. No outcome of psychotherapy is guaranteed. Your clinician will work with you on goals, indicators of progress, and realistic expectations and will revisit the plan as needed.

5. Scope of practice; clinician credentials

Clinical services are provided by clinicians licensed under California law, including psychologists licensed by the California Board of Psychology, marriage and family therapists, professional clinical counselors, and licensed clinical social workers licensed by the California Board of Behavioral Sciences, each operating within the scope of their license. Some services are provided by registered associates or supervisees working under the supervision of a licensed clinician; you will be informed if this applies to you, including the name and license number of the supervisor. Names, titles, license numbers, and supervision arrangements are available on request.

6. Confidentiality and its limits

What you say in session is generally confidential. We will not disclose information about you without your written authorization, except as permitted or required by law. The following are the principal exceptions; the full scope is described in our Notice of Privacy Practices, which is incorporated by reference.

• Suspected child abuse or neglect. Mandated reporting under the Child Abuse and Neglect Reporting Act (Cal. Penal Code §11164 et seq.).
• Suspected elder or dependent-adult abuse. Mandated reporting under the Elder Abuse and Dependent Adult Civil Protection Act (Cal. Welf. & Inst. Code §15630).
• Imminent danger to self. If we believe you present a serious and imminent danger of suicide or self-harm, we may take steps to protect your safety, including contacting your emergency contact, contacting emergency services, or initiating a Welfare & Institutions Code §5150 evaluation.
• Imminent danger to others — Tarasoff. Under Cal. Civ. Code §43.92 and Tarasoff v. Regents of the University of California, if you communicate a serious threat of physical violence against a reasonably identifiable victim, we are required to make reasonable efforts to communicate the threat to the victim and to a law enforcement agency.
• Court orders and qualifying subpoenas. Where compelled by law.
• Public-health activities, certain government audits, and oversight by the California Board of Psychology, Board of Behavioral Sciences, or Medical Board of California.
• Limited consultation with other clinicians within PCG, with supervisors, and with attorneys or risk-management consultants where appropriate, with confidentiality safeguards.

Where lawful and clinically appropriate, we will discuss any reporting with you in advance. Special heightened protections apply to substance-use disorder records (42 C.F.R. Part 2), psychotherapy notes (45 C.F.R. §164.508), HIV/AIDS information (Cal. Health & Safety Code §120975 et seq.), genetic information (Cal. Civ. Code §56.17), and minors' records (Cal. Family Code §6924 and Health & Safety Code §123115).

7. Use of insurance; disclosure to payers

If you use insurance, your insurer typically receives, at minimum, a diagnosis, dates of service, and procedure codes; some plans may request authorization paperwork including additional clinical information. PCG will discuss this with you before sharing. You may choose to self-pay to limit insurer access (Cal. Civ. Code §56 et seq.; 45 C.F.R. §164.522(a)(1)(vi)). PCG cannot guarantee the privacy practices of insurers, employers (in self-funded plans), or third-party administrators.

8. Fees; billing; payment

Fees are disclosed at intake and reviewed annually. Current fees are explained in your Good Faith Estimate (under the No Surprises Act, when applicable) and in your engagement letter. Co-pays and patient responsibility are due at the time of service. Late cancellations and no-shows are billed at the full session rate (see Office Policies). Past-due balances over 90 days may be referred to a collection service after notice. Bounced checks are subject to a returned-payment fee permitted under California law. Court-related services (records review, court appearances, depositions, travel) are billed at our court rate; payment is required in advance.

9. Communications outside session

Routine communication (scheduling, billing, brief logistical questions) is handled by office staff during business hours. Clinical communication between sessions is generally limited to brief exchanges; matters requiring clinical attention are addressed in session. PCG does not provide crisis or emergency services and does not monitor messages 24/7. In an emergency, call or text 988 or call 911.

Email and text are not fully secure. By providing your email or mobile number, you consent to PCG communicating with you by those means for administrative purposes and accept the risks of unencrypted transmission. Substantive clinical content will be discussed in session or, when necessary, by phone or through our secure platform.

10. Telehealth

Telehealth is governed by California Business & Professions Code §2290.5 and our Telehealth Agreement, which is incorporated by reference. You must be physically located in California at the time of every telehealth session.

11. Records retention; access to records

California law (Health & Safety Code §123145 and applicable Board regulations) generally requires us to retain adult clinical records for at least seven (7) years from the date of last service; records for minor clients are retained until age 19 or seven (7) years from the date of last service, whichever is later. You have the right to inspect and obtain a copy of your records (Cal. Health & Safety Code §123100 et seq.; 45 C.F.R. §164.524), subject to limited exceptions. We may charge the reasonable, cost-based fees permitted by law.

12. Group, couple, and family therapy

In group therapy, members are expected to maintain the confidentiality of other members; PCG cannot, however, guarantee confidentiality among group members. In couple and family therapy, the "patient" is the relationship; PCG follows a "no-secrets" policy unless explicitly negotiated otherwise. Records reflect this format and information shared in joint sessions is generally accessible to all participating parties as permitted by law.

13. Recording prohibited; intellectual property

Sessions may not be recorded — by audio, video, screenshot, or otherwise — by either party without the express written consent of the other. Unauthorized recording violates Cal. Penal Code §632. Materials, worksheets, handouts, and content provided by PCG are licensed for personal use only and may not be reproduced, posted, or shared without permission.

14. Court-mandated treatment

If you are participating in a court-mandated program, you authorize PCG to communicate with the court, probation officer, attorney, batterer-intervention referring agency, or other authorized recipient regarding attendance, participation, compliance, and program completion. Clinical content remains confidential except as required by the court order, by mandated reporting, or by safety-of-others duties. You are responsible for ensuring that PCG receives all paperwork required by the referring agency.

15. Minors and dependent adults

Cal. Family Code §6924 governs minors' consent to outpatient mental-health services from age 12. PCG primarily serves adults; minor referrals are evaluated case-by-case. Special rules limiting parental access apply when access could harm the minor (Cal. Health & Safety Code §123115). For dependent adults, conservatorship documents will be reviewed.

16. Mandated supervision and case consultation

Clinicians may consult with PCG colleagues, supervisors, supervisees, and risk-management or legal advisors for the purpose of providing high-quality care. Such consultations are protected by confidentiality and privilege.

17. Boundaries; non-clinical interactions

To preserve clinical effectiveness, PCG clinicians do not enter into business, social, or personal relationships with current or former patients, do not accept friend or follow requests on personal social-media accounts, and do not exchange gifts of more than nominal value. Out-of-session encounters in public are handled discreetly to protect your privacy.

18. Termination of services by PCG

PCG may terminate services where (a) you have not paid for services after notice; (b) treatment is not productive or not in your best interest; (c) safety, fit, or fitness for service requires a higher level of care; (d) there has been a material breach of this Consent or our Office Policies; (e) a conflict of interest arises that cannot be cured; or (f) continued service is otherwise inappropriate. PCG will provide reasonable continuity-of-care assistance and referrals.

19. Limitation of liability for clinical care

To the maximum extent permitted by law, PCG, its officers, directors, shareholders, employees, contractors, supervisors, supervisees, interns, postdocs, volunteers, agents, and business associates shall not be liable for indirect, incidental, special, exemplary, punitive, or consequential damages arising from your use of clinical services, except where expressly prohibited by law or the rules of professional licensure. Nothing in this Treatment Consent waives any right or remedy that cannot be waived under California law, including statutory rights to a competent professional standard of care.

20. Indemnification — third-party reliance

If a third party (e.g., a court, employer, attorney, family member, or insurer) requests information or testimony that you have authorized PCG to provide, you agree to indemnify and hold PCG harmless from any claim, damage, or expense arising out of the reliance of that third party on the information provided, except for claims arising from PCG's negligence or willful misconduct.

21. Mandatory pre-suit notice; mediation

Before initiating any arbitration or court proceeding, the party intending to bring the claim must send a written Notice of Dispute to the other party (to PCG, addressed to: Pasadena Clinical Group, Attn: Risk Management/Compliance Officer, 301 N. Lake Ave, STE 600, Pasadena, CA 91101; copy by email to office@pasadenaclinicalgroup.com). The Notice must describe the claim, identify the relief sought, and attach supporting documents. The parties shall, within sixty (60) days after Notice, attempt in good faith to resolve the dispute through confidential mediation in Los Angeles County, California, before a single neutral mediator administered by JAMS (or, if unavailable, AAA or ADR Services, Inc.), with mediator fees split equally. Mediation is a mandatory condition precedent to arbitration, except for emergency injunctive relief.

22. CCP §1295 — binding arbitration of medical-malpractice claims

Article 1 — Arbitration of medical-malpractice and clinical claims

It is understood that any dispute as to medical malpractice — that is, as to whether any medical or psychological services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered — will be determined by submission to arbitration as provided by California law and not by a lawsuit or resort to court process, except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury and instead are accepting the use of arbitration.

Article 2 — All other claims subject to arbitration

It is further understood that any dispute that does not relate to medical malpractice — including disputes as to whether or not a dispute is subject to arbitration, as well as any other matter (such as billing disputes, breach of contract, alleged non-medical tort, statutory claims, or claims involving family members or dependents who are also patients) — will also be determined by submission to binding arbitration.

Article 3 — Procedure and applicable law

The arbitration shall be administered by JAMS under its Comprehensive Arbitration Rules and Procedures (or the JAMS Streamlined Rules if applicable), or, if JAMS is unavailable or declines to administer, by the American Arbitration Association under its Healthcare Arbitration Rules or Consumer Arbitration Rules, before a single, neutral arbitrator with experience in healthcare matters. The arbitration shall be seated in Los Angeles County, California. The arbitrator's award shall be final and binding and may be entered as a judgment in any court of competent jurisdiction. The arbitration is governed by the California Medical Injury Compensation Reform Act ("MICRA," Cal. Civ. Code §3333.2 and Cal. Code of Civ. Proc. §1295) and, where applicable, the Federal Arbitration Act. Punitive damages, if available at law, are subject to MICRA limits where applicable.

Article 4 — Class-action and representative-action waiver; jury-trial waiver

You and PCG agree that disputes shall be brought only in an individual capacity and not as a plaintiff or class member in any class, collective, or representative proceeding. You and PCG knowingly and voluntarily waive any right to a jury trial.

Article 5 — Statutory CCP §1295(b) and §1295(c) notices

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Pursuant to Cal. Code of Civ. Proc. §1295(c), this arbitration agreement may be rescinded by written notice to PCG within thirty (30) days of signature. After thirty (30) days, the agreement shall govern all professional services received by you and all other disputes between the parties.

Article 6 — Mass-arbitration protocol

If twenty-five (25) or more substantially similar arbitration demands are submitted by or with the assistance of the same or coordinated counsel within a 90-day period, the parties agree to follow JAMS Mass Arbitration Procedures or AAA Mass Arbitration Supplementary Rules and Mass Arbitration Fee Schedule, as applicable.

23. Choice of law; venue; severability

This Treatment Consent is governed by the laws of the State of California, without regard to conflict-of-law rules. Any judicial proceeding permitted by this Consent shall be brought exclusively in the state or federal courts located in Los Angeles County, California. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the unenforceable provision shall be reformed to the minimum extent necessary.

24. Acknowledgements and signature

By signing the intake version of this Consent at intake, you acknowledge that you have read it (or had it read to you), have had an opportunity to ask questions, understand its terms, and agree to be bound. You understand that the arbitration agreement in Section 22 is a material part of this Consent and that you may rescind it within thirty (30) days of signature.

25. Contact

Pasadena Clinical Group · 301 N. Lake Ave, STE 600, Pasadena, CA 91101 · (626) 354-6440 · office@pasadenaclinicalgroup.com