Informed Consent for Couples Therapy

1. Voluntary participation

Therapy is voluntary. You have the right to refuse or end treatment at any time, for any reason. If you choose to end treatment, we encourage a final session to summarize the work, plan continuity if needed, and provide referrals. You will not be charged for ending care.

2. Risks and benefits of psychotherapy

Benefits may include improved relationship satisfaction, better communication and conflict-management skills, increased understanding of yourself and your partner, and resolution of specific concerns. Outcomes vary; we make no guarantees.

Risks include uncomfortable feelings (sadness, anger, frustration, loneliness, anxiety), recall of difficult memories, temporary increase in conflict as patterns surface, difficult realizations about the relationship, and — in some cases — the realization that the relationship may not continue. Couples therapy can be intense; we work to titrate the work to what you can use.

3. Confidentiality and its mandatory exceptions under California law

Information shared in therapy is confidential and protected under HIPAA and the California Confidentiality of Medical Information Act (CMIA, Civil Code §56 et seq.). However, California law requires us to disclose information in the following circumstances:

• Suspected child abuse or neglect. California Child Abuse and Neglect Reporting Act (CANRA), Penal Code §11164 et seq. We are mandated reporters and must report reasonable suspicion of physical, sexual, or emotional abuse or neglect of a child to the appropriate authorities.
• Elder or dependent adult abuse. Welfare and Institutions Code §15630. We must report reasonable suspicion of abuse, neglect, or financial exploitation of elders (65+) or dependent adults.
• Tarasoff duty to warn or protect. Civil Code §43.92. If a patient communicates a serious threat of physical violence against a reasonably identifiable victim, we must take reasonable steps including warning the intended victim and law enforcement.
• Imminent danger to self. When a patient is in imminent risk of suicide or serious self-harm, we may take protective action including notifying family, emergency services, or facilitating hospitalization.
• Court orders. We may be required to release records or testify pursuant to a valid court order.

4. Couples therapy — the "no secrets" policy

For couples therapy, the couple — not either individual partner — is generally the client. PCG follows a "no secrets" policy by default: we will not keep significant relational secrets between partners that compromise the work.

When we meet with one partner alone for an assessment session or briefly during couples work, we discuss in advance what we will and won't share with the other partner. Active ongoing affairs: if one partner discloses an ongoing affair only to the clinician, we will not collude in keeping it secret. We will work with the disclosing partner to bring the disclosure into the joint work in a contained way; if the partner refuses, we may need to pause or end the couples therapy.

Records release: couples therapy records typically require both partners' written authorization to be released. Court orders or subpoenas may compel release; we comply with applicable law and notify both partners.

5. Insurance authorization

If you choose to bill insurance, we will share information with your insurer as authorized by your insurance contract. This typically includes diagnosis codes, dates of service, CPT codes, and clinical justification for treatment. We provide superbills for out-of-network reimbursement on request. We will not bill insurance without your authorization.

For couples therapy specifically, insurance generally requires one partner to be the "identified patient" with a covered DSM diagnosis. We discuss the implications of this billing structure at intake before any insurance billing occurs.

6. Minors and California Family Code §6924

For adolescent patients (12 years of age or older), California Family Code §6924 permits a minor to consent to outpatient mental health treatment without parental consent if the treating professional believes the minor is mature enough to participate intelligently in treatment. The professional must document this judgment.

For minors under §6924, parental involvement is encouraged but not required for consent. Confidentiality between the minor and clinician is protected with the same mandatory exceptions described in Section 3, plus age-appropriate limits we discuss with the minor at intake. Billing under §6924 may be limited; we discuss this at intake.

For minors under 12, parental or guardian consent is required for treatment. For couples or family work involving minors, all parties with custodial rights must consent.

7. Emergency procedures

PCG is an outpatient practice. We do not provide emergency services or 24-hour crisis coverage. If you are experiencing a mental health emergency, call 988 (Suicide and Crisis Lifeline) or 911. If you are experiencing intimate partner violence, the National Domestic Violence Hotline is 1-800-799-7233. We provide crisis-line referrals at intake.

8. Communication outside of session

Email and text are useful for scheduling and brief admin questions but are not HIPAA-secure by default. Do not include sensitive personal health information (PHI) in email or text. We will keep email/text contact to administrative matters and direct clinical conversations to sessions.

Phone is appropriate for urgent admin issues and brief check-ins. We do not provide therapy by phone unless this has been specifically arranged.

Response times: same business day on weekdays for non-urgent admin questions. We do not respond to clinical or crisis communications by email or text — those channels are for scheduling only. For urgent clinical concerns, call us; for emergencies, 988 or 911.

9. Records retention

Clinical records are retained for at least seven (7) years from the last date of service for adult patients. For minors, records are retained until one (1) year past the age of majority or seven (7) years from the last date of service, whichever is later. These periods are consistent with California recordkeeping standards. Records release follows the procedures in our Notice of Privacy Practices.

10. Fees, billing, and the No Surprises Act

Our current fees are disclosed at intake. Fees may change with reasonable advance notice. Self-pay clients receive a Good Faith Estimate of expected charges per the federal No Surprises Act (45 CFR 149.610). See our Good Faith Estimate page. Cancellation, no-show, and late fees are described in our Office Policies.

11. Termination of services

You may end treatment at any time. We may end treatment when: clinical goals have been achieved; we no longer believe we can be helpful; you have not paid for services and have not made acceptable arrangements; or our scope of practice does not match your clinical needs. In all cases of termination, we provide referrals and bridge resources.

12. Court appearances and forensic services

PCG does not voluntarily participate in divorce litigation, child custody proceedings, or other forensic matters. If subpoenaed, we comply with applicable law. Time spent on subpoenas, depositions, or court appearances is billed at our forensic rate, separate from clinical fees, including preparation and travel time. Detail in Office Policies.

13. Social media and dual relationships

To protect your confidentiality, we do not connect with current or former patients on social media (Facebook, Instagram, LinkedIn, etc.). We do not Google patients except in genuine clinical safety situations. We recognize you may search for us; we do not respond to messages on social platforms beyond directing you to call the office.

14. Limitation of clinical liability and release of non-clinical claims

The Practice and its clinicians will deliver psychotherapy services in conformance with the standard of care of similarly-credentialed mental-health professionals practicing in California. Nothing in this consent limits the Practice's responsibility to provide care that meets the applicable professional standard of care, nor does it waive any right that you may not lawfully waive (including any non-waivable rights under California law).

To the maximum extent permitted by Applicable Law, you release the Released Parties (Pasadena Clinical Group; its current and former owners, members, partners, principals, officers, directors; current and former employees, independent contractors, supervisees, trainees, externs, interns, consultants, and HIPAA Business Associates; and the heirs, successors, and assigns of any of the foregoing) from non-clinical claims arising out of or relating to administrative, scheduling, billing, payment, recordkeeping, communications, or facility matters, whether known or unknown at the time of execution. This release does not extend to professional negligence (medical malpractice) claims, which are governed by Section 15 below, nor to claims that as a matter of Applicable Law cannot be released.

To the maximum extent permitted by Applicable Law, the Released Parties' aggregate liability for non-clinical claims is limited to the total fees paid by you to the Practice for services in the twelve (12) months preceding the event giving rise to the claim. The Released Parties will not be liable for indirect, incidental, special, consequential, exemplary, or punitive damages on non-clinical claims. Nothing in this Section limits liability for claims that cannot be limited under Applicable Law, including claims governed by Cal. Civ. Code §1668, the EFAA (9 U.S.C. §401 et seq.), CANRA (Penal Code §11164 et seq.), CMIA, HIPAA/HITECH, or the federal No Surprises Act.

Indemnification. You agree to indemnify and hold harmless the Released Parties from claims, demands, damages, costs, and expenses (including reasonable attorneys' fees) arising out of (a) your material breach of this consent or the Office Policies; (b) your knowing submission of false or misleading information at intake or in the course of care; (c) your unauthorized recording of a session or other violation of California Penal Code §632; (d) your violation of any third party's rights through your conduct in the course of care. The Practice retains the right to assume the defense at the Practice's own expense.

15. MANDATORY DISPUTE RESOLUTION FOR CLINICAL CARE — NEGOTIATION → MEDIATION → BINDING ARBITRATION

15.1 Article 1 — Agreement to arbitrate

It is the intention of the parties that this arbitration agreement bind all parties whose claims may arise out of or relate to professional services rendered by Pasadena Clinical Group, its clinicians, supervisees, employees, contractors, agents, and Released Parties (collectively, "Provider"). All claims for medical malpractice, professional negligence, breach of professional duty, lack of informed consent, intentional or negligent infliction of emotional distress arising out of clinical care, billing-and-coding disputes related to professional services, and any other claim arising out of or relating to the rendition of medical, mental-health, or psychotherapy services to the patient (including the death of a patient) shall be submitted to binding arbitration as set forth in this Section. This arbitration agreement applies to claims that arise during the course of, and after termination of, the clinician-patient relationship.

15.2 Step one — informal good-faith negotiation

Before initiating mediation or arbitration, the party raising a Dispute (defined as any claim arising out of or relating to clinical care, including those listed in §15.1) shall provide written notice describing the Dispute and the relief sought. Notice to the Practice goes to: Pasadena Clinical Group, Attn: Practice Manager, 301 N. Lake Ave, STE 600, Pasadena, CA 91101 (with copy to office@pasadenaclinicalgroup.com); notice to you goes to your last known address. The parties will negotiate in good faith for thirty (30) days. Compliance with this step is a condition precedent to mediation and to arbitration.

15.3 Step two — mandatory mediation

If the Dispute is not resolved within thirty (30) days of the negotiation notice, the parties shall mediate before a single neutral mediator administered by JAMS in Los Angeles County, California, under JAMS' then-current rules. Mediator and JAMS administrative fees are split equally. Each party bears its own attorneys' fees and costs. Mediation shall last at least one (1) full session of at least four (4) hours unless the mediator declares an earlier impasse. Completion of mediation (or the mediator's written declaration of impasse) is a condition precedent to arbitration.

15.4 Step three — final and binding arbitration

If the Dispute is not resolved at mediation, the parties shall submit the Dispute to final and binding arbitration administered by JAMS in Los Angeles County, California, under JAMS' then-current Healthcare Arbitration Rules and Procedures (or, if those rules are unavailable, the JAMS Comprehensive Arbitration Rules). The arbitration shall be conducted by a single neutral arbitrator who is a retired California state or federal judge or a California-licensed attorney with at least fifteen (15) years of healthcare or professional-negligence experience. The arbitrator's award shall be in writing, reasoned, and final and binding on the parties; judgment on the award may be entered in any court of competent jurisdiction. The arbitrator shall apply California substantive law. The arbitration is governed by the FAA (9 U.S.C. §§1–16) and Cal. Code Civ. Proc. §1295.

Confidentiality. The arbitration is confidential except as required to enforce the award or as required by Applicable Law (including required reporting under CANRA, elder-abuse reporting, mandated reporting to the California Board of Behavioral Sciences, or HIPAA disclosures).

Fees. Filing and arbitrator fees are allocated under JAMS' minimum-standards rules for healthcare and consumer arbitration; the Practice will advance fees as required so that the cost of arbitration is not greater than the cost of court litigation to you.

15.5 Class-action and representative-action waiver

To the maximum extent permitted by Applicable Law, all clinical-care Disputes shall be resolved on an individual basis. The arbitrator may not consolidate more than one person's claims, and may not preside over any form of class, representative, mass, or consolidated proceeding. If a court of competent jurisdiction determines that this waiver is unenforceable as to any particular claim, that claim shall be severed and proceed in court while all other claims remain in arbitration.

15.6 Carve-outs (claims that may proceed outside this Section)

• (a) Sexual assault or sexual harassment claims subject to the federal EFAA (9 U.S.C. §§401–402) — the patient may elect court at the patient's sole option;
• (b) Mandatory reporting by the Practice under CANRA (Cal. Penal Code §11164 et seq.), elder/dependent-adult abuse (Welf. & Inst. Code §15630), and Tarasoff (Cal. Civ. Code §43.92) — these are obligations imposed on the Practice and are not Disputes;
• (c) Government and licensing agency complaints, including the California Board of Behavioral Sciences, the California Attorney General, the California Department of Consumer Affairs, the Office for Civil Rights at HHS, and any analogous regulator — patients always retain the right to file regulatory complaints, and nothing in this consent waives any cause of action arising out of regulator findings;
• (d) Small claims within the jurisdictional limits of small-claims court in Los Angeles County, California, brought on an individual basis;
• (e) Equitable relief for trade-secret, copyright, or confidentiality matters in a court of competent jurisdiction in Los Angeles County, California;
• (f) Workers' compensation and similar non-arbitrable employment claims to the extent governed by Applicable Law.

15.7 Statute of limitations; survival

The applicable California statutes of limitations apply to claims brought under this Section as if the claims were filed in court. Filing a Notice of Dispute under §15.2 tolls the running of the statute of limitations as to the noticed Dispute. This Section 15 survives termination of the clinician-patient relationship and remains in effect for claims that accrue during or after that relationship.

15.8 Severability

If any provision of this Section 15 is held unenforceable as to any particular claim, that provision shall be reformed to the minimum extent necessary to be enforceable; if reformation is not possible, the unenforceable provision shall be severed and the remainder of this Section 15 shall remain in full force and effect for all other claims.

16. Acknowledgment

By signing the Treatment Consent form provided at intake, you acknowledge that you have read this consent (or had it explained to you), understood it, had the opportunity to ask questions, and agree to its terms. You specifically acknowledge that you have read the §1295 Notice of Arbitration Agreement above and understand your statutory thirty-day rescission right. Both partners (and any custodial parent, where applicable) sign before treatment begins. The signature page is provided separately at intake.

17. Contact us

For questions about this Treatment Consent or your care:

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