FAMILY MATTERS COUNSELING & ASSESSMENT SERVICES
CHARREE KASHWER, PH.D., LMFT (#34634)
1412 17TH STREET SUITE 258
BAKERSFIELD, CA 93301
(661) 809- 8554
CONSENT FOR TREATMENT
CONFIDENTIALITY: Information disclosed in sessions is considered confidential and will not be revealed to anyone
without your written permission, except where disclosure is permitted by law and deemed to be in the best interest of the client.
The following are exceptions to confidentiality:
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When there is reasonable suspicion of child, elder or dependent abuse or neglect;
When the client presents a serious danger of violence to others or property of others;
When the client presents a serious danger of harm to himself or herself;
Pursuant to a lawfully issued subpoena.
Additional exceptions include:
Minors: When minors (under the age of 18) are seen in therapy, the parent or guardian holds the legal privilege regarding
release of information.
Groups: Group therapy participants are expected to honor and respect the privacy and confidentiality of other group members.
However, confidentiality can not be guaranteed.
Consultation: On occasion, I seek consultation with colleagues in order to improve and enhance treatment on a specific case.
However, identifying information will not be revealed.
CANCELLATIONS: A 24-hour advance notice of cancellation for scheduled appointments is appreciated. You will be
responsible for the entire session fee if you do not cancel a scheduled appointment. There will be a $25 fee for sessions
canceled with less than three (3) hours notice. A message may be left at (661) 809-8554.
EMERGENCIES: You may leave a message at (661) 809- 8554 at anytime and your call will be returned as soon as possible.
Matters than need immediate attention should be directed to either the Crisis Stabilization Unit, which is open 24-hours a day,
at (661) 868-8000, or 911.
PAYMENT FOR SERVICES: Your fee will be __________ per 50 minute session, and is to be paid at the beginning of
session; checks are to be made payable to Charree Kashwer. Additional services (court appearances, third-party reports, phone
therapy sessions, psychological assessment, etc.) will also be billed at the hourly rate.
Additional Billing-Related Information & Policies:
a. Client accounts are not to accrue an unpaid balance for more than two sessions. After two sessions of unpaid balances,
services may be withheld until the account is paid in full. I reserve the right to submit past-due accounts to a collection agency
or pursue matters in a small claims court.
b. My fee-schedule is reviewed annually and, after notification, may be altered.
c. There will be a $20 service charge for each non-sufficient fund (NSF) check, and fee repayment, along with the service
charge, is to be paid by CASH or MONEY ORDER only. Two, or more, NSF checks may, depending on the circumstances,
require that all future fees be paid by cash or money order.
INSURANCE AND OTHER CONTRACTUAL REIMBURSEMENT:
______Services will be provided and charged directly to the client, not to an insurance or contracted organization. Client is
expected to pay fees as indicated above and assumes full responsibility for obtaining reimbursement from their insurance or
contracted organization, if applicable. Monthly insurance statements may be provided, upon request, which may be submitted
to the insurance carrier. OR
_______ Therapist will bill insurance company for fee reimbursement. Client is responsible for co-payments and fees for
missed appointments or late cancelations, as well as fees that the insurance company will not cover (e.g. court appearances).
CLIENT CONTACT INFORMATION
Client’s Name:_______________________________ DOB:__________________________
For Minors, Name of Parent(s):___________________________________________________
Address:_____________________________________________________________________
number/street
city
zip
Home Phone:
(
) ____________________
May I leave a message? Y / N
Cell Phone:
(
) _____________________
May I leave a message? Y / N
Work Phone:
(
) _____________________
May I leave a message? Y / N
Email:
________________________________
May I email you? Y / N
Would you like to receive a text message reminder of scheduled appointments? Y / N
Emergency contact: _____________________________________________________________
Name
Phone
Relationship
INSURANCE INFORMATION
Insurance Company:_______________________ Phone Number: ______________________
Member ID#:____________________________ Group #:_____________________________
Insured’s Name:__________________________DOB:________________________________
Authorization #: _________________________ # of Sessions Authorized:__________ Co Pay:$________
I read, understand, and accept the conditions stated in this consent.
Client’s Signature
Date
Parent/Guardian Signature (if client is under 18)
Date
Therapist’s Signature
Date
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