Steven Monroe, LMFT #92746

                                       Individual, Couples, Child, and Family Therapy

                                                                           323-327-2399

 

Welcome! I am a Licensed Marriage and Family Therapist (Lic. #92746). The following information is provided to inform parents of child and adolescent clients of the right to confidential consultation with a psychotherapist. We would also like to inform you of the means of contacting your therapist outside the therapy time and of billing and insurance procedures. I hope this information is helpful. Please discuss any questions and concerns directly with your therapist during the initial consultation. 

Confidentiality: Therapy with your child is strictly confidential. Information about your child will not be revealed to anyone without your written permission. As parents, you have the legal right to your child’s records as well as information about the therapy sessions. However, therapy is most effective when there is respect for your child’s privacy. Your therapist, Steven Monroe, will discuss this balance between your legal rights as parents and the therapeutic benefits of confidentiality for your child with you and your child. If you request that your therapist consult with your child’s physician, school counselor, or teachers, any information shared will be discussed and agreed upon in advance. Again, no information will be shared without a discussion of the content and your written permission. 

Exceptions to Confidentiality: The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, your therapist can only release information about treatment to others, if you as a parent sign a written authorization form that meets certain legal requirements imposed by state law and/or HIPPA (Health Insurance Portability and Accountability Act). Disclosure of session information is permitted and required by law in the following exceptions to confidentiality:

        a.) when there is reasonable suspicion of child abuse (physical or sexual) or neglect

        b.) when there is reasonable suspicion of elder or dependent adult abuse (physical, sexual, or financial) or neglect

        c.) when the client presents a serious danger of violence to others or to the property of others

        d.) when the client presents a serious danger of harm to him/herself

        e.) when the court of law issues a legitimate subpoena

Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultation, your therapist makes every effort to avoid revealing any identifying information. Consulting professionals are also legally bound to keep all information confidential. Please let your therapist know if you have any concerns regarding professional consultation.

Appointments:  Standard therapy sessions are 50 minutes long. 

Cancelled Appointments: If you need to cancel a session, please call 24 hours in advance. There will be no charge for sessions cancelled with 24 hours notice. If less than 24 hours notice is given, and the session can be rescheduled in that week, there will not be a charge. Session fee is charged for missed appointments without above outlined notice. 

 Telephone Communication

You may leave a message anytime at my office # (323) 327-2399. I will return your call as soon as possible. I check my voicemail frequently,  Monday through Saturday, and will return your  call at my first available opportunity. If there is an emergency on Sunday, please call your hospital emergency room or call 911.

If an emergency situation arises and you need to speak with your therapist directly, please indicate it clearly in your message, be certain to leave a phone number where you can be reached, and your therapist will return your page as soon as your therapist is free to do so.

If you need immediate help in an emergency situation, you may go directly to your local emergency room; or you can call the suicide hotline (866) 784-2433, the Psychiatric Emergency Team (800) 854-7771 or 911.  

Payment: Please pay at each session, unless other arrangements are made. Session fee is $140. Your therapist will be happy to answer any questions regarding the fee during the initial session. Please ask your questions at the beginning of the therapy session. 

 

Insurance:  I can process payment through PPO insurance as an out-of-network provider

 

ACKNOWLEDGEMENT OF RECEIPT OF THERAPY INFORMATION AND TREATMENT CONSENT FORM

 

CLIENT:_______________________________________________________

 

I HAVE READ THE ABOVE INFORMATION. I UNDERSTAND AND FULLY ACCEPT THE CONDITIONS AS STATED IN EACH PARAGRAPH OF THIS CONSENT.

 

_____________________________________________________________________

Child/Minor’s Signature          Date                                 Print Name 

       

_____________________________________________________________________

Mother/Guardian’s Signature                 Date                                 Print Name

 

_____________________________________________________________________

Father/Guardian’s Signature                   Date                    Print Name

 

 

______________________________________________________________________

Steven Monroe, LMFT  #92746             Date