This is a sample, web-published version of our Informed Consent for Outpatient Psychological Services. The document signed at intake is the binding version, may include additional details specific to your clinician, and supersedes this version. Please read carefully.
1. Welcome and Purpose of This Document
This Informed Consent for Treatment ("Consent") describes the nature of the outpatient psychological services Pasadena Clinical Group ("PCG," "we," "us," or "our") offers, the rights and responsibilities of clients ("you"), the scope and limits of confidentiality, our policies on fees and scheduling, and other important information you should understand before beginning treatment. Please review it carefully and ask your clinician any questions you have.
2. Scope of Services
Pasadena Clinical Group is a California outpatient psychology practice specializing in the assessment and treatment of obsessive-compulsive disorder (OCD) and related conditions in adults. Services include:
- Diagnostic intake and clinical assessment
- Individual psychotherapy
- Structured group psychotherapy
- Intensive outpatient and short-form intensive treatment for selected presentations
- Care coordination with other treating providers (with your written authorization)
- Telehealth services for clients located in California at the time of session
3. Theoretical Orientation and Treatment Approach
Our clinical approach draws primarily on Exposure and Response Prevention (ERP), Cognitive-Behavioral Therapy (CBT), Inference-Based Cognitive Behavioral Therapy (I-CBT), and Acceptance and Commitment Therapy (ACT). Treatment is collaborative, structured around the OCD literature, and individualized to your presentation, history, and goals. Your clinician will discuss the specific treatment plan with you.
4. Voluntary Participation
Participation in psychological services is voluntary. You may decline any specific intervention, request a referral to another clinician, pause, or end treatment at any time. We encourage you to share concerns or hesitations directly with your clinician so they can be discussed openly.
5. Risks and Benefits of Psychotherapy
(a) Potential Benefits
Psychotherapy — particularly evidence-based protocols for OCD — can produce meaningful benefits, including reduced symptoms, improved functioning, healthier relationships, increased emotional regulation, and greater overall quality of life.
(b) Potential Risks
Psychotherapy can also produce temporary or unanticipated discomfort. Risks may include:
- Increased anxiety, distress, sadness, or anger as long-standing patterns are confronted
- Recall of difficult past experiences
- Temporary increases in symptoms during the early phase of treatment
- Tension or change in family or relationship dynamics as you change
- Disclosure of information to insurers and required reporters under limited circumstances (see Section 8)
ERP-based treatment specifically involves intentional, paced exposure to feared thoughts or situations and refraining from compulsions, which can produce short-term anxiety on the way to longer-term symptom reduction. Your clinician will discuss expected pacing with you and will not require you to engage in exposures you are not ready for.
(c) No Guarantee
While our clinicians use evidence-based methods and apply their professional judgment, treatment outcomes vary. We do not guarantee any particular result, recovery timeline, or symptom reduction.
6. Confidentiality and Its Limits
The information you share in therapy is generally confidential and protected by federal and California law (HIPAA, CMIA, and applicable professional ethics codes). Information will not be released to others without your written authorization, except in the limited circumstances described below.
(a) Mandated Reporting
California law requires us to report:
- Suspected child abuse or neglect (Cal. Penal Code §§ 11164 et seq.)
- Suspected elder or dependent-adult abuse or neglect (Cal. Welf. & Inst. Code §§ 15600 et seq.)
(b) Imminent Danger to Self or Others
Where we believe you are in imminent danger of serious self-harm, we may take steps to protect your safety, including hospitalization or notification of a designated person. Where you communicate a serious threat of physical violence against an identifiable victim, California law (Tarasoff/Ewing) may require us to take protective action, which can include warning the intended victim and law enforcement.
(c) Court Orders and Legal Process
We may be required to disclose information in response to a court order, valid subpoena, or other lawful process. We will, where possible, notify you in advance and seek to protect the privacy of your records.
(d) Insurance and Payment
If you use insurance for payment, your insurer may require disclosure of certain information for benefits verification, prior authorization, claim processing, and audits. Your insurer is bound by privacy laws but is outside our direct control.
(e) Consultation and Supervision
Clinicians at Pasadena Clinical Group regularly consult with one another and with outside supervisors, in keeping with professional standards of care. Identifying information is minimized in those consultations.
(f) Trainee Care
If your clinician is a doctoral trainee, their licensed supervisor will have access to your information for purposes of supervision.
For a full description of how we use and disclose Protected Health Information, please see our HIPAA Notice of Privacy Practices.
7. Group Therapy — Special Considerations
If you participate in group therapy, you will be in session alongside other clients. We expect group members to keep what is shared in group confidential, but we cannot guarantee the confidentiality of other group members. Specific group rules and expectations will be reviewed at the start of any group, and members are expected to honor those expectations.
8. Telehealth
If you receive services via secure telehealth:
- You must be physically located in California at the time of session, in accordance with state licensure law.
- You should choose a private, safe, and quiet physical environment for your session.
- You agree not to record sessions without prior written consent.
- Technology disruptions may occasionally interrupt sessions; in that event, your clinician will follow up by phone or email.
- If a clinical emergency arises during telehealth, your clinician may need to contact local emergency services or a designated emergency contact at your physical location.
9. Trainees and Supervision
Pasadena Clinical Group is a training site that may host doctoral-level psychology trainees on practicum, externship, or pre-doctoral internship. If your clinician is a trainee, you will be informed of their role and the licensed clinician supervising them. Trainees deliver care under close supervision; you may decline to be seen by a trainee at any time and request a licensed clinician.
10. Recording and Use of Technology
Sessions are not routinely recorded. Audio or video recording will occur only with your specific written authorization (for example, for purposes of supervision or training in a specific clinical context). You agree not to record sessions without our prior written authorization. Use of video conferencing platforms is governed by HIPAA-aware Business Associate Agreements; details will be provided at intake.
11. Communication Outside of Session
Email and text messaging are not fully secure communication channels and should not be used to share clinical content. We will set up appropriate communication channels at intake. Routine clinical and scheduling communication should occur during business hours through approved channels. Please do not send Protected Health Information through general contact forms.
12. Social Media Policy
Our clinicians do not accept "friend," "follow," or similar requests from current or former clients on personal social-media accounts, in keeping with professional ethics. Public reviews are voluntary and unsolicited; we cannot acknowledge or respond to them in a way that confirms a treatment relationship.
13. After-Hours and Emergencies
Pasadena Clinical Group is an outpatient practice and is not a 24/7 emergency service. If you are in crisis after hours and your clinician is not immediately available, please call or text 988, call 911, or go to the nearest emergency room. Your clinician will discuss specific between-session contact protocols with you.
14. Vacations and Coverage
Your clinician will provide advance notice of planned absences and arrangements for clinical coverage during their absence. Other Pasadena Clinical Group clinicians or designated coverage clinicians may provide urgent support during such periods.
15. Termination of Treatment
You may terminate treatment at any time. We strongly encourage at least one termination session to discuss progress, next steps, and any aftercare or referral recommendations.
We may terminate or transition treatment in circumstances including: (a) your treatment goals have been substantially met; (b) your clinical needs are outside our scope of practice; (c) extended unexcused non-attendance; (d) non-payment of fees per the schedule discussed at intake; (e) violation of practice policies, threats, or harassment; or (f) circumstances that make continued treatment unsafe or contraindicated. Where appropriate, we will provide referrals to other clinicians.
16. Fees, Insurance, and Billing
Fees and payment terms are discussed at intake and outlined in your written intake agreement. Where you use insurance, our care coordinator verifies benefits in advance and discusses expected out-of-pocket cost. Co-payments, co-insurance, and deductibles are due at the time of service. Out-of-network superbills are available on request.
Under the federal No Surprises Act, you may be entitled to a Good Faith Estimate of expected charges. Please see our No Surprises Act / Good Faith Estimate notice for details.
17. Cancellation Policy
Sessions canceled with less than twenty-four (24) hours' notice may be billed at the full session rate, except in genuine emergencies. Specific cancellation timeframes and fees will be set forth in your written intake agreement.
18. Records
We maintain a clinical record for each client in accordance with applicable California law. You have the right to request access, amendment, and an accounting of disclosures of your record, as described in our HIPAA Notice. We retain clinical records for at least seven (7) years after the last date of service for adult clients, and as otherwise required for minor clients.
19. Concerns and Complaints
If you have concerns about your treatment, we encourage you to discuss them with your clinician first. If concerns are not resolved, you may contact our Privacy Officer at 626-354-6440 or office@pasadenaclinicalgroup.com. You may also file complaints with the California Board of Psychology, the Board of Behavioral Sciences (for licensed marriage and family therapists, professional clinical counselors, and clinical social workers), or the U.S. Department of Health and Human Services Office for Civil Rights.
20. Dispute Resolution and Optional Arbitration Agreement
Pasadena Clinical Group encourages all concerns to be raised first with your clinician and, if not resolved, with our Privacy Officer. Where a dispute is not resolved through internal discussion, the parties agree to attempt mediation in good faith with a mutually acceptable mediator before pursuing other remedies.
(a) Optional Arbitration of Non-Medical-Malpractice Disputes
For disputes arising out of or relating to your relationship with Pasadena Clinical Group that are not subject to the special California rules governing medical-malpractice claims, you may agree at intake to resolve such disputes through binding individual arbitration administered by JAMS in Los Angeles County, California, under the JAMS Streamlined Arbitration Rules and Procedures. This arbitration agreement, if executed, will include a class-action waiver and a jury-trial waiver. The agreement will be presented to you separately, and your participation in arbitration will be voluntary.
(b) Medical-Malpractice Claims (California Code of Civil Procedure § 1295)
If your intake paperwork includes an arbitration agreement specifically addressing medical-malpractice claims under California Code of Civil Procedure § 1295, that agreement will appear in the form prescribed by California law, will require your separate initials, and will provide you with thirty (30) days from the date of signing to rescind the agreement by written notice. Acceptance of any § 1295 arbitration agreement is not a condition of receiving care.
(c) Class-Action Waiver.
If you agree to arbitration, you will agree to bring claims only in your individual capacity and not as a class, collective, or representative action.
(d) Limited Exceptions.
Either party may seek injunctive relief in court to protect intellectual-property rights, may bring small-claims actions for matters that qualify, and may file complaints with regulatory bodies (such as the California Board of Psychology or HHS Office for Civil Rights) without first proceeding to arbitration.
21. Acknowledgment
By signing the binding intake version of this Consent, you acknowledge that:
- You have read and understand this document;
- You have had the opportunity to ask questions and have your questions answered;
- You have been informed of the risks and benefits of psychotherapy;
- You consent to receive evaluation and treatment from Pasadena Clinical Group on the terms described above;
- Your participation is voluntary and you may withdraw at any time.
22. Contact
Pasadena Clinical Group
301 N. Lake Ave, STE 600
Pasadena, CA 91101
Phone: 626-354-6440
Email: office@pasadenaclinicalgroup.com
This document is sample/template language. Final published versions should be reviewed by California-licensed counsel.