Professional Disclosure Statement-Minors

Holly LaBarbera, LMFT #84042

3100 Mowry Avenue, Suite 410, Fremont, CA 94538 (510) 402-2855

Introduction
This agreement is intended to provide you with important information regarding Holly
LaBarbera’s professional services and business policies. It will provide you with an
overview of the therapy process and responsibilities of both Holly LaBarbera (me) as the
therapist and you as the responsible adult and minor client. If you have any questions or
concerns regarding the contents of this document, please discuss them with me.

Therapist Qualifications
I, Holly LaBarbera, am licensed with the State of California’s Board of Behavioral Sciences as
a Licensed Marriage and Family Therapist (LMFT# 84042). A Marriage and Family
Therapist is a mental health professional working with children, teens, individual adults,
couples, families, and groups to relieve mental, emotional, and relational concerns of all
kinds.

About the Therapy Process

It is my intention to provide services that will assist you in reaching your goals. Based upon
the information that you, the responsible adult and the minor client provide to me, and the
specifics of your situation, I will provide recommendations to you, the responsible adult
and/or the minor client, regarding your treatment. I believe that therapists and clients are
partners in the therapeutic process. You, the responsible adult and the minor client, have
the right to agree or disagree with my recommendations. I will periodically provide
feedback to both the responsible adult and the minor client regarding their progress and
will invite joint participation in the discussion.

Benefits and Risks of Therapy

A minor client will benefit most from psychotherapy when his/her parents, guardians or other
caregivers are supportive of the therapeutic process. Psychotherapy is a process in which therapist
and client, and sometimes other family members, discuss a myriad of issues, events, experiences
and memories for the purpose of creating positive change so client can experience his/her life
more fully. It provides an opportunity to better, and more deeply understand oneself, as well as
any problems or difficulties client may be experiencing. Psychotherapy is a joint effort between
client and therapist. Progress and success may vary depending upon the particular problems or
issues being addressed, as well as many other factors.

Participating in therapy may result in a number of benefits to client, including, but not limited to,
reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors,
improved interpersonal relationships, increased comfort in social, school, and family settings, and
increased self-confidence. Such benefits may also require substantial effort on the part of client,
as well as his/her caregivers and/or family members, including an active participation in the
therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There
is no guarantee that therapy will yield any or all of the benefits listed above.

Participating in therapy may also involve some discomfort, including remembering and
discussing unpleasant events, feelings and experiences. This discomfort may also extend to other
family members, as they may be asked to address difficult issues and family dynamics. The
process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which
therapist will challenge the perceptions and assumptions of the client or other family members,
and offer different perspectives. The issues presented by client may result in unintended
outcomes, including changes in personal relationships.

During the therapeutic process, many clients find that they feel worse before they feel
better. This is generally a normal course of events. Personal growth and change may be easy
and swift at times, but may also be slow and frustrating. Due to the varying nature and
severity of problems and the individuality of each client, therapist cannot predict the length
of client’s therapy or to guarantee a specific outcome or result. Clients should address any
concerns he/she has regarding his/her progress in therapy with therapist.

Client’s Rights
As a client you deserve to always be treated with respect and dignity. If you, the responsible
adult or the minor client has any questions or concerns about my counseling techniques or
suggestions, I invite you both to discuss them with me. As a client, you are in complete
control and may end our counseling relationship at any time, though I do generally
recommend that you participate in a termination session. A termination session will give us
both an opportunity to reflect on our work together and discuss any issues that may seem
unresolved or unclear.

Confidentiality
The information disclosed by client is generally confidential and will not be released to any
third party without written authorization, except where required or permitted by law.
Exceptions to confidentiality include reporting child, elder and dependent adult abuse;
when a client makes a serious threat of violence towards a reasonably identifiable victim; or
when a client is dangerous to him/herself.

Responsible adults should be aware that therapist is not a conduit of information from
client. Psychotherapy can only be effective if there is a trusting a confidential relationship
between therapist and client. Although the responsible adult can expect to be kept up to
date as to client’s progress in therapy, you will typically not be privy to detailed discussions
between therapist and client. However, the responsible adult can expect to be informed in
the event of any serious concerns therapist might have regarding the safety or well-being of
client, including suicidality.

Professional Consultation
Professional consultation is an important component of a healthy psychotherapy practice.
As such, I regularly participate in clinical, ethical, and legal consultation with appropriate
professionals. During such consultations, I will not reveal any personally identifying
information about you.

Records and Record Keeping

I may take notes during session, and will also produce other notes and records regarding
your treatment. These notes constitute my clinical and business records, which by law, I am
required to maintain. Such records are my sole property. I will not alter my normal record
keeping process at the request of any client. Should you request a copy of my records, such a
request must be made in writing. I reserve the right, under California law, to provide you
with a treatment summary in lieu of actual records. I also reserve 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. I will maintain your records for
ten years following termination of therapy. After ten years, your records will be destroyed
in a manner that preserves your confidentiality. Notes maybe kept on an online encrypted
system. Please discuss with me any issues you have with this process.

Fee and Fee Arrangements

The usual and customary fee for service is $125.00 per 50-minute session. I reserve the
right to periodically adjust these fees. You will be notified of any fee adjustment in advance.
Payment in full is due at the start of each session and can be made by cash, checks, and
credit card.

The agreed upon fee between the therapist and patient is ___________. Client initials: __________

From time-to-time, I may engage in telephone contact with you for purposes other than
scheduling sessions. In addition, from time-to-time, I may engage in telephone contact with
third parties at your request and with your advance written authorization. You are
responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls
longer than ten minutes. Clients are expected to pay for services at the time services are
rendered.

I understand that I am financially responsible to therapist for all charges.

______________________________________________
Name of Responsible Party (Please print)

____________________________________________________ ____________
Signature of Responsible Party (and relationship to Patient) Date

______________________________________________
Name of Responsible Party (Please print)

____________________________________________________ ____________
Signature of Responsible Party (and relationship to Patient) Date

Cancellation Policy
Client is responsible for payment of the agreed upon fee for any missed session(s). You are
also responsible for payment of the agreed upon fee for any session(s) for which you failed
to give the therapist at least 24 hours notice of cancellation.

Responsible party initials: ___________ _____________

Client initials:_____________

Insurance
I am not a contracted provider with any insurance company, managed care organization.
Should you choose to use your insurance, I will provide you with a statement, which you can
submit to the third-party of your choice to seek reimbursement of fees already paid.
Availability/Crisis
I have a confidential voicemail system that allows you to leave a message at any time. I will
make every effort to return your call the same day or within 24 hours, but I cannot
guarantee calls will be returned immediately. If you need someone to speak with
immediately you may call CRISIS HOTLINE at 855-278-4204. In the event that you are
feeling unsafe or require immediate medical or psychiatric assistance, you should call 911
or go to the nearest emergency room.

Acknowledgement
By signing below, responsible adult(s) and/or minor client acknowledges that you have
reviewed and fully understands the terms and conditions of this Agreement. You have
discussed such terms and conditions with therapist, and have had any questions with
regard to its terms and conditions answered to your satisfaction. You agree to abide by the
terms and conditions of this disclosure and consent to participate in psychotherapy with
therapist. Moreover, you agree to hold therapist 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.

_______________________________________________________
Client Name (please print)

_______________________________________________________ _____________
Signature of Client (if client is 12 or older) Date

_______________________________________________________
Name of Responsible Party (please print)

_______________________________________________________ _______________
Signature of Responsible Party (and relationship to client) Date

_______________________________________________________
Name of Responsible Party (please print)

_______________________________________________________ _______________
Signature of Responsible Party (and relationship to client) Date