Lori Klett Roberto, Ph.D.
Clinical Psychologist
(916) 206-1741
www.DrLoriRoberto.com
2001 N Street, #220
Sacramento, Ca 95811
INFORMED CONSENT FOR SERVICES & OFFICE POLICY AGREEMENT
Welcome to my practice. Please note any questions you may have and we’ll discuss them at our first appointment.
When you sign this document, it will represent an agreement between us.
PSYCHOLOGICAL SERVICES
I am licensed by the California Board of Psychology as a Psychologist (PSY #20491). I received my B.A. degree in
psychology from UC Irvine, my M.A. in psychology from San Diego State University, and my Ph.D. doctoral
degree in Clinical Psychology from DePaul University. I would be happy to answer any questions regarding my
training and work experience.
My services include psychotherapy (also called therapy or counseling), coaching, consultation, groups, workshops,
and educational lectures. How we work together will depend on the particular concerns you bring forward, as well
as your goals. There are many different methods I may use in the course of working with you, but I encourage you
to take an active role in the process, both during sessions and at home.
Psychotherapy can have benefits and risks. It can involve discussing unpleasant aspects of your life and can evoke
a variety of negative feelings. The process of making change can be frustrating or difficult, and sometimes results in
decisions or changes that may or may not be supported by others in your life. Benefits may include improved
relationships, better self-awareness, solutions to specific problems, improved moods, better stress management, or
improved motivation for living a healthier life. Although most people find the benefits outweigh risks, there is no
guarantee that psychotherapy or other services will yield positive or intended results.
The first 1 to 3 session(s) involves an assessment of your concerns from a broad perspective, clarification of your
goals, and my recommendations for treatment. You should evaluate this information along with your own opinions
of whether you feel comfortable working with me. You have the right to ask questions about the treatment plan and
any risks or benefits. You have the right to refuse anything that I suggest. If I believe your needs are beyond my
expertise/scope of practice, I will suggest referrals.
CONFIDENTIALITY
In general, privacy of communication between a client and a psychologist is protected by law, and I can only release
information with your written permission. However there are exceptions to confidentiality when disclosure is
required, or may be required by law, which are detailed in the HIPAA Notice of Privacy Practices. I do consult
regularly with other professionals regarding my clients, but your name and other identifying information will never
be disclosed and confidentiality will be maintained.
PROFESSIONAL FEES
The appointment fee is $125 for a 45-50 minute session. Any other professional services such as telephone
conversations lasting longer than 10 minutes; report writing; attendance at meetings with other professionals you
have authorized; preparation of records or treatment summaries, or time spent performing any other service you
may request of me will be prorated at $125 per hour. Fees for groups/workshops vary. If you have legal
proceedings that require my participation, you will be expected to pay for my professional time even if I am called
to testify by another party. I charge $250 per hour for preparation and attendance at any legal proceeding (with a 4
hour minimum).
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BILLING AND PAYMENTS
You are expected to pay for each appointment at the time of service. Please have payment ready at the beginning of
each session to maximize our time for talking. Bounced checks may incur services fees up to $35. If your account
is unpaid for more than 60 days and arrangements have not been agreed upon, I have the option of using legal
means to secure the payment. This may involve hiring a collection agency or going through small claims court. In
most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of
services provided and the amount due.
MEETINGS/CANCELLATION POLICY
Most clients find weekly appointments helpful, although we may meet more or less often depending on your
individual needs. Because your appointment time is reserved exclusively for you, you must contact me a minimum
of 24 hours in advance to reschedule or cancel an appointment. If you miss a session without canceling, or cancel
with less than twenty-four hours notice, you are responsible for the full appointment charge. If you are using
insurance benefits, please be aware that you (not the insurance company) would be responsible for this late cancel
or no show charge. If you repeatedly miss or cancel appointments, services may be terminated.
TERMINATION
My ultimate goal is to help you find solutions and seek resolution to your concerns. For some clients, this happens
in a few sessions, and for others this is a longer process. As we work together, I will ask for your honest feedback
about your experience and welcome any questions about your progress. You have the right to terminate services
with me at any time. I can also terminate treatment and facilitate a referral. If I determine you are not sufficiently
benefiting from treatment, it is my ethical duty to refer you to alternative care.
INSURANCE REIMBURSEMENT
Services may be covered by your health insurance. However, insurance companies do not reimburse all conditions
and may limit services. It is important that you find out exactly what outpatient mental health services your
insurance policy covers if you wish to utilize your insurance. If I am not a contracted provider for your insurance
plan, I am happy to provide you a “superbill” that you may submit to your PPO insurance company for
reimbursement. This form indicates that you have paid my fee in full and any reimbursement from insurance will
then be sent to you. You should also be aware that insurance companies require a clinical diagnosis and sometimes
require additional clinical information, such as treatment plans or summaries, or copies of the entire record (in rare
cases). This information then becomes part of the insurance company files and part of your health care record.
If you are eligible for Medicare or a Medicare beneficiary, it is very important that you discuss this with me before
beginning psychotherapy; if you become eligible or a beneficiary during our work together, it is very important that
you let me know right away.
CONTACTING ME AND SOCIAL MEDIA POLICY
I am often not immediately available by telephone, however you may leave a voice mail and I will make every
effort to return your call the same day during normal business hours Monday through Friday. If you are in need of
emergency services, you should call a 24 hour crisis line (916) 732-3637, go to your nearest emergency room, or
dial 911.
You may email or text me for limited purposes, such as scheduling, but you should be aware that confidentiality
cannot be assured with email. Clinical concerns should be shared in person or over the phone. To protect your
privacy and maintain professional boundaries, I do not accept friend requests on Facebook or other social
networking sites.
PROFESSIONAL RECORDS
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The laws and standards of my profession require that I keep records. You are entitled to receive a copy of the
records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send
them to a mental health professional of your choice or send you a summary of the records. Because these are
professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review
records in my presence so we can discuss the contents. Clients will be charged my professional fee prorated for any
time spent preparing for and reviewing information requests.
MINORS
If a client is under eighteen years of age, the law may provide parents/legal guardians the right to examine treatment
records. However, it is my policy to request an agreement from parents/legal guardians that I will use my clinical
discretion regarding disclosure, based on the age of the minor, the clinical issues, and goals of treatment. Typically
I will share general information about treatment and overall progress, however I will disclose necessary information
if there is a serious safety risk to the minor client. I can also convey specific information to parents/legal guardians
with permission.
CALIFORNIA BOARD OF PSYCHOLOGY
The California Board of Psychology regulates the practice of psychology. If you are ever unhappy with my services
or our work together, I hope you'll talk about it with me so that I can respond respectfully to your concerns. I will
take your criticism seriously. You may also direct inquiries/complaints to: Board Of Psychology, 2005 Evergreen
Street, Suite 1400, Sacramento, CA 95815.
-----------------------------------------------------------------------------------------------------------------------------I acknowledge receipt of and acceptance of this Informed Consent for Services & Office Policy
Agreement from Dr. Lori Roberto and I agree to abide by its terms (freely and without reservations)
during our professional relationship.
Signature __________________________________________
Date ________________________
Printed Name _______________________________________
Parent/Guardian Signature (if applicable) _______________________________ Date ____________
Printed Name _______________________________________
If Using Insurance Benefits:
Insurance Company _________________________________
Phone (___)_____________________
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Name of Primary Insured _______________________________________________
Primary Insured Date of Birth: _________________
Primary Insured Address: _________________________________________________________________
Your Relationship to Primary Insured (if not yourself) _________________________________________
Member ID # _________________________________ Group # __________________
Mental Health Pre-authorization # (if applicable)___________________________
Co-pay $ ___________
AUTHORIZATION: I authorize Lori Klett Roberto, Ph.D. to release any psychological/mental health
information necessary to process and secure payment from my insurance company or its intermediaries. I
authorize my insurance carrier or its intermediaries to make payment directly to Dr. Lori Roberto for
psychological services, when it is billed on my behalf. However, I understand that I am financially
responsible for all charges whether or not paid by my insurance company. Furthermore, I understand that
in the event of a no show or cancellation with less than 24 hour notice, I will be personally responsible for
the full contracted rate of the session.
Signature __________________________________________
Date ________________________
Printed Name _______________________________________
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