The following form outlines information about my policies and procedures. By reading and signing this form, you are giving your consent to receive therapy services with Prestige Therapy.

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BENEFITS AND RISKS OF TREATMENT

There are no guarantees that any or all of your problems will be resolved by participating in treatment. Therapy is a process and not an immediate cure. You may experience stress, strained relationships, and other difficulties as a result of working through issues in therapy. It is normal for individuals to feel worse before they start to feel better.  The benefits of therapy often outweigh the risks. When you have an open mind and are desiring true healing and problem resolutions, there is always some benefit you are able to gain, rather it be little or small. Those who get the most benefit from therapy are those who are ready for self-reflection, acceptance, and change.

 

 

EMERGENCY NEEDS

Emergency Phone Calls

Prestige Therapy does not offer emergency services.  Each therapist at Prestige Therapy has their own set of hours they are available outside of session for consultation and questions. Ask your therapist what their hours are.

 

For immediate emergencies, please call 911, go to your nearest emergency room, or call one of the hotlines provided below:

 

Mental Health Crisis Center: (916) 732-3637

Mental Health Crisis Intervention: (888) 881-4881

National Suicide Prevention Lifeline: 1 (800) 273-8255

 

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HOSPITALIZATIONS

If there is an interruption in services due to hospitalization, we will work to provide your psychiatrist and other hospital staff with any necessary information. This information will be limited to pertinent information only, we will not discuss detailed information about our sessions.

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CANCELLATION POLICY

We require a 24-hour advance notice for appointment cancellations. If you cancel an appointment less than 24 hours in advance, you will be charged the full fee for the appointment. You also will be charged if you no show for a scheduled appointment. We understand emergencies come up and will always take that into consideration.  Please reach out to your therapist if you need to cancel or change your appointment.

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FEE POLICIES

Payments are due at the beginning of each session. You are able to pre-pay for sessions so you do not have to worry about a payment the day of, and there is also an option to pay for a certain number of sessions at once so you will not have to worry about bringing payments into session.

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By reading and signing this form, you are agreeing to participate in psychotherapy services at the rate agreed upon by Prestige Therapy staff.

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Preferred methods of payment are cash, check, and Zelle.  We also accept credit card, Venmo, and PayPal upon request.

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PATIENT LITIGATION

I will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, or parties. I have a policy of not communicating with clients’ attorneys and will generally not write or sign letters, reports, declarations, or affidavits to be used in any client’s legal matter. I will generally not provide records or testimony unless compelled to do so. Should I be subpoenaed, or

ordered by a court of law, to appear as a witness in an action involving you, you agree to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my usual and customary hourly rate for such services of $150 per hour.

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TRAINEES AND INTERNS:

In order to provide access to as many clients as possible, and to provide excellent service, Prestige Therapy uses interns and trainees.  Interns have completed their Master’s Program and are gathering hours in order to become licensed. Trainees are currently in their Master’s Programs and are also collecting hours towards licensure.  Both trainees and interns are supervised by Patrick Yamamoto, Licensed MFT.  They meet at least twice weekly to consult and receive guidance.

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CONFIDENTIALITY

Information that you share within therapy is confidential and it is our responsibility to maintain all identifiable information about you in confidence and to not release any information without your permission. There are exceptions to this confidentiality. I am required by law to break confidentiality for the following reasons: If you threaten to harm yourself (suicidal threats with intent, plan, and means), if you threaten to harm someone else, if there is discussion that involves suspected child or elder abuse, if there is a court ordered subpoena for your records, if you are currently court referred to me.  Information is sometimes shared between Prestige Therapy staff for educational purposes and supervisory purposes.

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NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices describes how I may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

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USE AND DISCLOSURE OF INFORMATION

Treatment: I may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. In order to provide continuity of care, I may healthy information about you to doctors, nurses, psychiatrists, or other professions responsible for your care.

 

Payment: Your PHI may be used, as needed, to obtain payment for your health care services. For example, I may need to give your health information about a service you received so your insurance can pay me or reimburse you. I will only disclose the minimum amount of PHI necessary for purposes of collection.

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WITHOUT AUTHORIZATION

The following circumstances, by law, permits me to disclose information without your prior authorization:

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• Emergencies: I may use or disclose your PHI in an emergency treatment situation. It is my obligation to prevent or lessen a serious or imminent threat to yourself or other individuals.

• Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. This includes mandatory reporting of child or elder abuse; and to comply with a court order.