Psych Lab Consent for Psychological Services

Below is the text of our consent form, provided for reference. To sign the form, you must be logged into our system and complete a New Patient Registration.

This agreement establishes a healthcare relationship between the signer (“you”) and Psych Lab Psychology, Inc. (Psych Lab, “us”). By signing this document, you’re requesting psychological services from Psych Lab and its staff, and agreeing to all the terms described below.

Your providers at Psych Lab will recommend the services they deem most appropriate for your needs, such as psychological assessment & diagnosis, psychotherapy, counseling, biofeedback, education, or other services that we may be qualified to offer. The nature and purpose of any recommended services will be explained to you beforehand, and subject to your agreement.

Collaborative Care

Staff at Psych Lab collaborate to provide high-quality, comprehensive mental health services. Your provider may share your information, discuss details of your case, and receive supervision or consultation from other members of our team. We regularly review cases as a team, so that each of our patients can benefit from the combined training and experience of our diverse clinicians.

If you have been referred to us by another healthcare provider or organization, such as the VA healthcare system or a military clinic, you agree that we may share your private health information with them for purposes of coordinating care.

Each clinician at Psych Lab is independently credentialed by the state licensing boards of their profession. Some clinicians may have provisional licenses or registrations that allow them to provide services under the supervision of a fully licensed professional.

Format of Therapy

Therapy sessions typically last 50-55 minutes, and are scheduled one to three times weekly depending on the severity of presentation and the therapist’s clinical judgement. Less frequent therapy sessions have not been shown effective and are not offered except in rare cases. Whenever possible, a standing weekly appointment time will be arranged at the outset of therapy, and held for you each week until therapy is ended. If you miss a session, reschedule, or cancel your appointment less than one day in advance, you will be charged for the price of the missed session. 

The length of treatment can vary widely depending on the presenting issues and biopsychosocial factors affecting the client's condition. Our clients control the length of their own treatment, with advice from the therapist and treatment team. On average, our patients decide that they have accomplished their goals for therapy and are ready to discontinue within 8-12 months.

In couples therapy, the relationship itself is considered the client rather than any of the individuals involved in it. For this reason, except in rare cases, both partners must be present for each session and the therapist will not agree to hold any secrets for either partner from the other. Similar rules apply to family therapy, although the therapist may choose to work separately with various family members in the service of strengthening the family unit.

If in-office appointments are not possible due to distance or other factors, therapy sessions can be provided online via secure, HIPAA-compliant video. In rare cases, online therapy may prevent the therapist from taking steps to ensure your safety that would otherwise be available to them. Therefore, in certain cases you may be advised that online therapy sessions are not indicated for your needs.

If a client misses two scheduled appointments without notice, or is out of contact with their therapist for a period of 30 days or more, they may be automatically discharged from our care. In that case your file would be closed and any regular appointment times would be offered to other clients.

Privacy & Confidentiality

All members of our team are committed to protecting your confidentiality. We will not share your information with anyone outside of Psych Lab without your permission, except where we are required to do so by law or by court order. You are encouraged to read the "Notice of Privacy Practices" which details how mental health information may be used and disclosed for treatment, payment, or health care operations, as well as your right to request restrictions on how this information is used.

Under California Law, there are some situations in which we may disclose confidential information:

1. If we believe you are an immediate danger to yourself or someone else, we are required to take reasonable steps to protect those in danger – such as by referring for hospitalization, alerting police, or warning potential victims.
2. If there is reasonable suspicion that a child, or an elderly or disabled person, is or has been abused or neglected, we are required to notify the California Department of Social Services.
3. If a client files a lawsuit or complaint against their treatment provider, the provider may break confidentiality in order to defend themselves.
4. If a client is a minor or otherwise under the care of a legal guardian, then the guardian has the right to access information regarding their treatment.

We are not required to disclose past crimes committed by our clients, unless the client sought therapy to aid in planning or committing the crime, or to escape detection or apprehension after committing the crime.

If you die or become incapacitated, you agree to waive your right to confidentiality in situations where we, at our sole discretion, determine that sharing your health information may be beneficial.

In some cases – such as family therapy, group therapy, or educational events –individuals who are not Psych Lab employees may be exposed to your personal information. All therapy and workshop participants are strongly encouraged to keep each other’s information private, but we cannot guarantee that they will do so. By participating in these services, you indicate that you understand this risk and agree to hold us blameless in the event that your confidentiality is compromised.

Electronic Communications & Recordings

Our office uses a variety of electronic means of communication, including phone, fax, text messaging, and email. Terms and conditions of SMS service are available at: https://psychlab.us/faq/sms/

At times, we may record phone calls or therapy sessions to assist in training or quality assurance, or to help ensure patient and clinician safety. Any communications between us may become a part of your medical record.

While we are careful to ensure that all of our own information systems are compliant with healthcare privacy regulations, we cannot guarantee the security of transmissions outside of our own systems. Therefore, messages that you send to us or receive from us electronically may not be entirely secure. If you are uncomfortable with the privacy risks associated with one or more types of electronic communications, please let us know so that we can arrange an alternate means of communication.

Telehealth

When services are provided via telehealth, additional risks of privacy breach are introduced. We take precautions to ensure the privacy of your telehealth communications, including using a fully-encrypted and privacy-compliant video and audio platform to communicate with you.

Telehealth services also present the risk of service disruption due to poor connection or other technological failure. In the event that the telehealth connection is lost or cannot be established at the appointed time, your therapist will attempt to continue providing service by phone.

Additionally, telehealth services limit the clinician's ability to respond to certain client crises, such as safety risks. Please ensure that your therapist is updated on your current location at the start of any telehealth service, so that they are able to respond appropriately to safety concerns.

Lastly, while we can implement security and privacy measures on our end, we cannot control the security of the environment in which you are connecting for telehealth services, or the equipment you use to connect.

Limitations of Service

Psychological services are provided without guarantee. Diagnostic procedures are sometimes inconclusive, and psychological treatment is not helpful in all cases. Additionally, psychological services can at times be uncomfortable, and can in some cases provoke uncomfortable reactions.

Emergencies & Crises

We do our best to return phone calls and electronic messages within one day. However, our office is not equipped to handle emergency situations. In the event that you are experiencing a clinical emergency requiring immediate attention, you are directed to call 911 immediately.

Financial Terms

All patients who are paying for services privately, or whose insurance coverage requires copays or deductibles, are required to have an active credit card on file to reserve an appointment time. You are welcome to arrange another method of payment for regular charges. Full payment for therapy service charges and/or applicable copays is due at the time of service.

Payment for the estimated total cost of any psychological assessment or diagnostic services is due at the outset unless covered by an insurance plan we accept. If additional costs are incurred beyond the original estimate, then additional charges will be invoiced as they arise. You agree to pay any invoiced charges within 5 days.

If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, or in the event of a chargeback or canceled payment, additional legal means of payment collection may be used, including the use of an outside collection agency. If such collection activities become necessary, you hereby agree to waive the confidentiality of personal and health information to the extent necessary to facilitate this action, and accept responsibility for any additional costs of collection activity.

Accepted Insurance Programs

We are in-network providers for Medicare, TriCare, Aetna, and VA Community Care Network (CCN). For patients eligible for benefits under those programs, we will bill and collect payment for all services directly from the insurance payer. You remain responsible for the cost of any copays, deductibles, or services which your insurance does not cover or denies payment for.

• Medicare: We accept only straight federal Medicare, and do not accept patients covered by Medicare Advantage plans unless they are provided by an insurance company we are in-network with. If you have a Medicare Part B supplemental plan, it will cover your 20% part B copay but not the annual deductible. 
• Medi-Cal / Medicaid: We do not accept Medicaid or Medi-Cal insurance, and are not allowed to accept Medicare patients who receive or qualify for Medi-Cal / Medicaid / QMB coverage. By signing this agreement you certify that you are not covered by Medi-Cal.

If you have insurance that we are not in-network with, but which offers out-of-network mental health benefits, we can submit electronic claims to your insurance company to help you get reimbursed for any portion of the charges that they may cover. We do not bill out-of-network insurance companies directly or guarantee reimbursement from insurance.

If you choose to engage our services using an external payer — whether one of the above-listed insurance companies or any other contracted entity, you agree to allow that payer access to your records.

Estimated total costs of psychotherapy

Most therapy clients choose to continue services at a rate of one 55-minute session per week for 6 to 12 months, for an estimated total of approximately 25 to 50 sessions. If you are not covered by one of the insurances we accept, then the total out-of-pocket cost of psychotherapy would range from $5000 to $10000.

Cancellation policy

You agree to pay the full session fee for any psychotherapy appointments not canceled more than one business day before the scheduled visit. For scheduled psychological assessment appointments canceled within one business day of the scheduled time, you agree to pay 25% of the total cost of the scheduled appointment, with a one-hour minimum charge. Exceptions can be made for sickness or emergencies at our sole discretion. 

Clients covered under VA CCN are exempt from no-show and late cancelation charges. However, missed appointments may result in discharge from therapy and loss of eligibility to receive services from us.

Fees for court appearances and legal involvement

Clients are strongly discouraged from having clinicians subpoenaed. In the event that any Psych Lab employee’s provision of services to you results in their becoming involved in a legal matter in any capacity, you agree to pay a rate equal to 150% the current session fee for all time spent preparing for or participating in legal proceedings, including but not limited to: submission of records, phone calls, depositions, time required in giving testimony, and time away from office due to depositions or testimony. Should any attorney fees or costs be incurred by Psych Lab or its clinicians in the course of such legal involvements, you agree to pay 100% of these costs. The minimum charge for a court appearance is $2400, and a retainer in that amount is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 72 business hours notice there will be an additional $300 “express” charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $600 (in addition to the above retainer). Even though you are responsible for the testimony fee, there is no suggestion that testimony provided will be solely in your favor. Our clinicians can only testify to the facts of the case and to their professional opinion.

Additional Legal Provisions

This document contains all the terms of your agreement with us regarding your assessment and treatment. You are not relying on any promises or representations other than what is contained in this document. This agreement cannot be changed or waived by oral agreement; it can only be changed or waived in writing with our signature. Any waiver of this agreement in one circumstance will not apply to any other circumstance. Our refraining from exercising a right under this agreement will not be considered a waiver.

This agreement and any dispute related to this agreement or our provision of services to you will be governed by California law. In the unlikely event of a lawsuit between us that in any way relates to your relationship with us as a healthcare provider, you waive the right to a jury trial, and agree that the state or federal courts (as applicable) in Los Angeles County, California will have exclusive jurisdiction. If a court finds any part of this agreement invalid or unenforceable, that part will be reformed to the minimal extent necessary to make it valid and enforceable, and the rest of this agreement is severable and remains binding and enforceable.