enTrusT Psychotherapy, Inc.
enTrusT Psychotherapy Inc.
INFORMED CONSENT FOR PSYCHOTHERAPY CONSULTATION/TREATMENT
Welcome: We, the clinicians at enTrusT Psychotherapy, Paris Feiz, M.S., MFT and Susan L. Thrasher,
Ph.D. welcome you to our office and to your initial consultation. We look forward to meeting with you,
learning about you and your concerns, and hope you will feel “heard” and understood. Psychotherapy
is a very individual process, and the depth of the therapy depends on the client’s wants, needs, goals
and motivation to improve their circumstances. You and your clinician will develop a therapeutic
partnership, focusing on those issues which are most important to you. Because psychotherapy can
involve discussing painful, unpleasant aspects of your life, you may experience uncomfortable feelings
like sadness, guilt, anger, and frustration. This is a “normal” part of therapy and your clinician will help
you to deal with those feelings, in a trusting and non-judgmental environment. Please be aware that
the personal changes that occur in psychotherapy can have an effect on current relationships. If
extreme depression or agitation develops, your therapist may recommend a psychiatric consultation.
Before we meet with you, we want to inform you of our policies, business practices and your rights as
a client. Please read this consent thoroughly and your therapist will go over it with you and answer any
questions that might arise. This informed consent has the force of a contract, so we will not be able to
proceed with the consultation until there is an agreement on all items, and this consent is signed.
Confidentiality: What is discussed in session will be completely between you and your therapist,
with the following exceptions:
1. We are mandated reporters, so if there is suspected child, elder, or dependent adult abuse,
we are legally required to report it to the proper authorities.
2. “Tarasoff” situations; there is a serious threat to a well-identified victim. If this occurs, we
must inform the police as well as inform the potential victim.
3. If your therapist believes you are in danger of harming yourself or you are unable to care for
yourself.
4. When your insurance company is involved for billing such as filing a claim, insurance audits,
case review or appeals etc.
5. No records will be released without your signed permission except when there is a subpoena
from the court. If you are involved in matters of litigation, you may be required to sign a
release of confidential information. Think carefully and consult with an attorney
before you sign away your rights to confidentiality.
6. Records are stored in locked files, and some are stored in secured, electronic devices. All
electronic communications could compromise your confidentiality. Therefore, we encourage
you to be mindful when divulging personal information via texts/emails.
7. In couples work, your therapist will exercise discretion, but will not keep secrets from your
significant other involved in the therapy.
1600 Dove St., Ste. #325 Newport Beach, CA 92660: 949-261-6010
enTrusT Psychotherapy, Inc.
Fees/Payments: Initial consultations are 60 minutes, and sessions thereafter are 45-50
minutes. The cost of the initial session is $150.00 and the cost of follow-up sessions is
$125.00. Telephone “sessions” may be charged at approximately the same rate as a
personal consultation. Rates for professional appearances, i.e., court, depositions, school
conferences, etc., are also $125.00 an hour. Court and deposition fees are not covered by
your insurance company; therefore, you will be responsible for the total fees incurred. If you
are using your insurance, we will bill it as a courtesy. However, you will be responsible for
the full fee amount. Co-pays are due at the beginning of each session. Cash, checks and
credit cards are all acceptable forms of payments.
Notice regarding cancellations and Missed Appointments: A 24 hour notice is required for the
cancellation of appointments. A $100.00 fee will be charged to you in the event of a no-show/late
cancellation appointment (not just a co-payment). Please be advised, insurance companies do not pay
for missed appointments; therefore this cost will be paid completely by the client.
Availability: Your therapist is available for regularly scheduled appointment times. Dates of
vacations, and other exceptions, will be given out in advance when possible, and there will always be
another therapist on call. Messages for the office or your therapist may be left at 949-261-6010. You
can leave a message for your therapist at any time on her confidential voicemail. Non-urgent calls are
typically returned within 24 hours during the normal work week. If you have an immediate need to
speak with your therapist, please say so in your message, and your therapist will make every effort to
return your call as soon as possible. It is very important that you leave your call back phone number
on your message, including the area code, as your therapist may not have it with her. In the event of
a life-threatening emergency, please call 911 or go to the nearest hospital emergency room.
Termination of Treatment: Patients have the right to refuse or discontinue services at any time. In
addition, your therapist may terminate treatment if payments are not made, if there is non-compliance
with medication, treatment recommendations, and if the client is not coming to session sober. Your
therapist may also refer you if, during the course of treatment, another problem emerges which is not
within the scope of practice of the therapist.
Agreement for Psychotherapy Consultation/Treatment:
I have read this informed consent completely and have raised any questions I might have with my
therapist. I have received a full and satisfactory response and agree to the provisions freely and
without reservations.
I understand that my clinician is responsible for maintaining all professional standards set forth in the
ethical principles of her professional association, as well as the laws of the state of California,
governing the practice of psychotherapy, and that she is liable for infractions of those standards.
I understand that I will be fully responsible for any and all legal and/or collection costs arising as a
result of my contact with my therapist, including appropriate compensation for her time involved in
writing reports, letters and /or in preparing for and doing court/deposition work.
1600 Dove St., Ste. #325 Newport Beach, CA 92660: 949-261-6010
enTrusT Psychotherapy, Inc.
Authorization to Release Information:
I hereby authorize enTrusT Psychotherapy to: (1) release any information necessary to insurance
carriers regarding my illness and treatments; (2) process insurance claims generated in the course of
evaluation and/or treatment; and (3) allow a photocopy of my signature to be used to process
insurance claims.
Assignment of Benefits:
I hereby authorize my insurance carrier(s), to issue payments directly to enTrusT Psychotherapy, Inc.,
and/or my therapist for mental health services rendered to myself and/or my dependents.
This agreement constitutes the entirety of our professional contract. I have the right to keep a copy of
this contract if requested. My signature below also confirms that I have read and understand the
information in this document. My signature constitutes my agreement and compliance to this document
during the course of our professional relationship.
I hereby give my permission to: ___________________________________________ to
Clinician’s Name
conduct an evaluation and/or provide treatment.
____________________________________
Client’s Name
_________________________________
Client’s Signature
____________________________________
Clinician Signature
________________________________
Date
1600 Dove St., Ste. #325 Newport Beach, CA 92660: 949-261-6010