Practice Policies

Agreement for Service, Informed Consent, and Client Rights

This Agreement is intended to provide Patient with important information regarding the practices, policies and procedures of Cassandra Sanchez, PsyD (herein “Clinician”), and to clarify the terms of the professional therapeutic relationship between Clinician and Patient(s). Any questions or concerns regarding the contents of this Agreement should be discussed with Clinician prior to signing it.

Therapeutic Process

You may ask questions about any procedures used during therapy or throughout the course of the psychological assessment. I will be happy to explain my approach and methods. If, at any time you are not comfortable with how we are proceeding, please let me know.

Termination

You have the right to decide not to receive therapeutic assistance or to complete your psychological assessment from me. You have a right to end treatment at any time without any moral, legal, or financial obligation other than payment of any outstanding balance due.

Clinician reserves the right to terminate therapy or psychological assessment at his discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to follow treatment recommendations, conflicts of interest, failure to participate in therapy or assessment, patient needs are outside of Clinician ‘s scope of competence or practice, or patient is not making adequate progress in therapy.

You will be encouraged to end therapy in a planned manner. Allow for one or two sessions after the decision to stop. If you wish, I will provide you with the names of other qualified professionals whose services you might prefer. At the conclusion of a psychological assessment, services will end following feedback and a copy of the psychological report being provided to the caregivers or client.

Confidentiality

One of your most important rights involves confidentiality. Within certain limits, information obtained during therapy will be kept strictly confidential, and will not be revealed to any other person without your permission. However, there are certain situations in which a Clinician is required by law to reveal information obtained during therapy to other persons or agencies without your permission, and without necessarily notifying you. These include:

• If you threaten grave bodily harm or death to another person, I am required by law to inform the intended victim(s).

• If you threaten serious injury or death to yourself, I must notify the appropriate agency, and may notify your family.

• If you reveal information regarding child abuse or neglect or elder abuse or neglect, I am required by law to report

• this to an appropriate agency.

• If you are in therapy by order of a court of law, results of treatment must be revealed to the court.

• If a court of law issues a legitimate subpoena, I may be required to provide the information specifically described in the subpoena.

• In case of children, information about therapy may be disclosed to caregivers. With adolescents, information will be disclosed only if it is important for the safety or well-being of the adolescent, as determined by the Clinician.

• In family therapy, I will maintain the confidentiality of the family, subject to the limitations stated above. It is my practice to encourage honesty and open communication between family members. Accordingly, I will not keep important information confidential between family members, unless I find that there are special circumstances such as the safety of a family member or I believe it would be helpful to the family.

• Family therapy is most successful when there is full disclosure of all issues in the treatment process. We will make the best clinical decision regarding the need for confidentiality and the family members need to be aware of pertinent issues. The health and safety of a child is guiding principal for clinical decisions leading to disclosure of information to other family members.

Availability and Emergencies

Clinician’s phone lines are confidential. Messages may be left at any time. Clinician will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. In an urgent situation, you may contact the local Mental Health Crisis Unit (Alameda County) at 800-273-8255. If you are feeling unsafe or require immediate medical or psychiatric assistance, call 911 or go to the nearest emergency room.

Fee and Fee Arrangements

The session fee will be agreed upon by you and the Clinician. Sessions longer than 50-minutes are charged for the additional time pro rata. Travel, phone calls (other than for scheduling), email, report writing, consultation with other professionals, or other work will be billed at the hourly rate. Clinician reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. You are expected to pay for services at the time services are rendered. Clinician accepts Venmo, Paypal, cash, or check. If you would like to pay for your sessions in bulk, payment will need to be received at the beginning of the month for the services rendered. Payment for psychological assessment can be completed either in full at the outset of the assessment process, or split into two payments (half at the outset of the assessment, the second half paid prior to the presentation of the psychological report and feedback). The fees for psychological assessment are set by the clinician based on the presenting referral questions, and estimated time to complete the assessment.

Cancellation Policy

A specific time in clinician’s schedule is reserved for you. In the event that you need to cancel an appointment, please give as much notice as possible. You are additionally responsible for payment of the agreed upon fee for any missed session(s) for which you failed to give Clinician at least 24 hours notice of cancellation other than in extenuating circumstances. Cancellation notice should be left on the Clinician’s phone by voice or text message or by email.

This policy both supports and honors the continuity of our work together and respects my office expenses and livelihood. You will not be expected to pay for any sessions in which I am away or have to cancel due to unforeseen circumstances. I generally take vacations on the week of Thanksgiving and the week between Christmas and New Year’s Eve.

Insurance

If you intend to use benefits of your health insurance policy, inform Clinician in advance. Clinician is not a contracted provider with any insurance company or managed care organization. Clinician will cooperate with client in providing information to an insurance company as requested by patient but is not responsible for assuring insurance eligibility for services provided. Patient is responsible for obtaining insurance reimbursement, and for verifying and understanding the limits of his/her coverage.

Professional Consultation

Professional consultation is an important component of a healthy psychotherapy practice. As such, Clinician regularly participates in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, Clinician will not reveal any personally identifying information regarding Patient.

Treatment Plan

Within a reasonable period of time after the initiation of treatment, we will explain my understanding of your situation and goals, and we will develop together treatment plan including therapeutic objectives and possible outcomes.

Clinician Background and Qualifications

Clinician is a licensed psychologist in the state of California (PSY 33090) and has specialty training working with infants, toddlers, children, parents, and families. I can provide you with additional information on my background upon request.

Risks and Benefits of Therapy

Psychotherapy is a process in which Clinician and Patient, and sometimes other family members, discuss issues, events, experiences and memories in order to create positive change so that the patient or family can experience life more fully and with more flexibility. Psychotherapy is a joint effort between Patient and Clinician. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors.

Records and Record Keeping

Clinician may take notes during session, and will also produce other notes and records regarding Patient’s treatment. These notes constitute Clinician’s clinical and business records, which by law, Clinician is required to maintain. Such records are the sole property of Clinician. Clinician will not alter his normal record keeping process at the request of any patient. Should Patient request a copy of Clinician’s records, such a request must be made in writing. Clinician reserves the right, under California law, to provide Patient with a treatment summary in lieu of actual records. Clinician also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. Clinician will maintain Patient’s records for ten years following termination of therapy. After ten years, or seven years after Patient has reached the age of 18, Patient’s records will be destroyed in a manner that preserves Patient’s confidentiality.

Use of Technology and AI

As part of our treatment or assessment engagement, we may use tools from third parties, such as Q-Global, Western Psychological Services, Psychological Assessment Resources, an electronic health record, and so forth. In addition, we may employ AI platforms such as BastionGPT or NoteZap to help summarize information and make written documentation more accessible to families. Any time AI is employed, the results are highly vetted and edited to ensure accuracy. All companies who handle our protected health information (both named and unnamed) are HIPAA-compliant and/or have signed a business associate agreement (BAA) indicating they will protect confidentiality consistent with HIPAA regulations. There is always a small risk when data is exchanged that confidential information could be leaked. Other uses for AI platforms that are not HIPAA compliant (such as ChatGPT) may include creating visuals, stories, or metaphors to help explain assessment results or complex concepts. If you have any questions regarding how we use technology to support the assessment or treatment process, please contact us for more information.

Text Messaging and Privacy Policy

From time to time, we may use SMS to communicate appointment reminders or scheduling updates. No mobile information will be shared with third parties/affiliates for marketing or promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Patient Litigation

Clinician will not ordinarily voluntarily participate in any litigation, or custody dispute in which Patient and another individual, or entity, are parties. Clinician has a policy of not communicating with Patient’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Patient’s legal matter. Clinician will generally not provide records or testimony unless compelled to do so. Should Clinician be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Patient, Patient agrees to reimburse Clinician at rate of $375/ hour for any time spent for preparation, travel, or other time in which Clinician has made himself available for such an appearance at Clinician’s usual and customary hourly rate.

Doctor-Patient Privilege

The information disclosed by Patient, as well as any records created, is subject to the doctor-patient privilege. The doctor-patient privilege results from the special relationship between Clinician and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the doctor-patient privilege. If Clinician received a subpoena for records, deposition testimony, or testimony in a court of law, Clinician will assert the doctor-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the doctor-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the doctor-patient privilege with his/her attorney.

Informed Consent

By signing below, each Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Clinician, and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Clinician. Moreover, Patient agrees to hold Clinician free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.