Informed Consent for Psychotherapy

This document outlines the terms of our relationship and what we can expect from each other, whether services occur in-person or virtually. If telehealth services are applicable, additional informed consent specific to those services is provided below.

Please feel free to discuss any aspect of this document with your VEBA therapist. You have the right to accept or refuse the proposed treatment. If you consent, you retain the right to revoke your consent for any reason at any time.

By signing this document, you acknowledge that you have reviewed and agreed to these terms, including the use of telehealth as an acceptable mode of delivering health care services when applicable.

California Schools Voluntary Employee Benefits Association (VEBA) has verified the licensure status of your therapist, Kalena Riffenburgh, PhD. Should you have questions, you may ask your therapist or contact the VEBA Resource Center at (619) 398-4220.

Your therapist is a:

[X] Psychological Associate*

* If your therapist is a Marriage and Family Therapist Registered Intern, Marriage and Family Therapist Trainee, Associate Clinical Social Worker, Psychological Assistant, Registered Psychologist or Professional Clinical Counselor Intern, his/her practice is conducted under the supervision of a licensed mental health professional. The clinical supervisor’s name, license type and license number are listed below:

Name of Clinical Supervisor: Lawrence Woodburn, PhD
License Number: PSY5312

Therapy is a voluntary process, and you have the right to discontinue at any time. While therapy does not guarantee immediate solutions, your therapist will provide support and assist in clarifying personal goals. Additionally, you should be aware that psychotherapy is not the only option for treatment. Alternative treatments may include medication or different forms of counseling. Your therapist can discuss these options with you and help you determine the best course of action based on your needs and preferences.

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor, whether for in-person or telehealth services. Contact information of the consenting parent or guardian is also required prior to treatment.

If the parents of a minor are divorced or separated, treatment is provided to the minor only with the written consent of both parents, unless a legal document such as a custody agreement or court order, designates one parent as the sole decision-maker for medical and mental health treatment. If any question exists regarding the authority of Parent/Caregiver to give consent for psychotherapy, the therapist will require that Parent/Caregiver submit supporting legal documentation, such as a custody order, prior to the commencement of services.

All therapy session content and related treatment materials are confidential and will not be disclosed without your written consent, except in the following circumstances required by law:

• Threats of self-harm or suicide
• Threats of harm or death to others
• Suspected abuse or neglect of children, elderly, or dependent adults
• Legal subpoenas or court orders
• Court-ordered therapy or treatment
• Evaluations for legal purposes

Additionally, your therapist may consult with other professionals to enhance your care. These consultations will not include any identifying information about you.

Communication with the minor during counseling sessions is confidential. However, if parents and/or legal guardians who have authorized the minor’s treatment are involved in the treatment plan, the therapist may discuss the treatment progress of a minor with them at the therapist’s professional discretion.

If you encounter your therapist outside of the therapy setting, the therapist will not acknowledge you unless you initiate the interaction first. This is to ensure and protect your privacy.

Kindly arrive 10 minutes before your scheduled appointment and please be mindful of the following:

Cancellation/Rescheduling – if you need to cancel or reschedule your therapy appointment, please contact the VEBA Resource Center by calling (619)398-4220 or emailing [email protected] within 24 hours of the scheduled date/time of your session. Canceling and/or rescheduling of three sessions will result in losing your preferred appointment time/date.

No Show – you will be considered a “No Show” if you do not arrive within 10 minutes of your session start time. VEBA Care Coordinator will attempt to reach you and reschedule however you will lose your preferred time/date. Two missed appointments without notice will result in losing your preferred appointment time/date.

If you need Child Care during your in-person appointment at the VRC, please register: Child Care Registration.

If you are experiencing an immediate, life-threatening emergency, call 911 or go to the nearest emergency room.

In the event of a medical or psychiatric emergency or an emergency involving a threat to your safety or the safety of others, please call or text 988 to connect with the 988 Suicide and Crisis Lifeline.

Short-term therapy services are considered a wrap-around benefit, included in your VEBA membership. There is no fee for accessing in-person or virtual therapy services through the VEBA Resource Center.

If you have a question about your VEBA benefits or are interested in finding a therapist in your health plan benefit network, please contact Advocacy by calling (888) 276 – 0250, Monday-Friday, 8 am – 5 pm.

The below explains how information shared with the therapist may be used or disclosed, including legal rights and responsibilities.

Health information may be used without written consent for purposes related to treatment, payment, or health care operations. Disclosure may also be required by law in certain circumstances, including exceptions to confidentiality as noted above, or public health reporting.

However, there are certain uses and disclosures of health information that do require written consent, including:

• Psychotherapy Notes, as defined in 45 CFR § 164.501, written consent is required for the disclosure of psychotherapy notes, including sharing them with another healthcare provider for treatment purposes, except in cases where disclosure is required by law, such as mandatory reporting of abuse or in mandatory “duty to warn” situations where there is a threat of serious and imminent harm.
• HIV Information: Disclosure of HIV status or related information requires written consent.
• Alcohol and Drug Use Information: Any information related to substance use treatment requires written consent before it can be disclosed.

As a client, you have the following rights regarding your health information:

• Request Limits: you may request restrictions on how your information is used or disclosed. However, the therapist may not agree to the restriction if it impacts your care.
• Request Privacy: You can ask to be contacted in a specific way (e.g., at home or work), and the therapist will accommodate reasonable requests.
• Access to Records: Except for “psychotherapy notes,” you can request a copy of your health information, and the therapist will provide it within 30 days.
• List of Disclosures: You can request a list of how your information has been disclosed (excluding uses related to treatment or payment) for the past six years.
• Request Corrections: If you believe there is an error or missing information in your records, you may request corrections. The therapist will review your request and respond within 60 days.
• Receive a Copy of This Notice: You may request a paper or electronic copy of this notice at any time.

Telehealth allows you and the therapist to meet for therapy outside of a physical office through secure, live, two-way audio and video. By consenting, you understand that telehealth sessions are voluntary, and you may withdraw consent at any time.

All telehealth services are delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The primary benefit of telehealth is the ability to access psychotherapy from the convenience of your home or other location. However, there are potential risks, including:

• The therapist will not be physically present in the same room, which may create a different experience compared to in-person sessions. Immediate care may not always be available.
• Technical problems, such as unclear video, loss of sound, or connection interruption may require a session to be rescheduled.
• Although rare, security measures could fail causing a potential breach of Personal Health Information (PHI).

Telehealth sessions will not be recorded by the therapist, and it is requested that you also refrain from making any recordings. Although telehealth uses secure systems, no internet communication guarantees 100% security. By participating, you agree not to hold VEBA responsible for potential unauthorized access by third parties.

A licensee or registrant of the State of California may provide telehealth services to clients located in another jurisdiction only if the California licensee or registrant meets the requirements to lawfully provide services in that jurisdiction, and delivery of services via telehealth is allowed by that jurisdiction.

If technical issues arise during a session, we will attempt to reconnect by phone or an alternative method. In case of an emergency during a telehealth session, the therapist may contact emergency services or your designated emergency contact to ensure your safety.

By signing this form, you acknowledge receipt of this privacy notice and provide informed consent to participate in psychotherapy services, including telehealth treatment if applicable.

The information provided in this form contains protected health information (PHI), which is safeguarded under federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically using encryption and access controls to safeguard it during transmission and storage.

The contents of this informed consent have been explained verbally, and you confirm that you fully understand and agree to the terms outlined in this consent form, including the collection and use of your PHI as outlined above.