Informed Consent

Kory Orlanski, MFT
PSYCHOTHERAPY
License No. MFC 41661

Informed Consent Contract for Psychotherapy

The following are policies under which I operate my private practice.  Please feel free to discuss any of these with me at any time.

Confidentiality Limits and Exceptions

  1. Normally, everything we discuss will be held confidential.  Unless you provide a signed authorization, I will not speak to or correspond with anyone about you.
  2. California Law and professional ethics either mandate or permit therapists to break client confidentiality under certain circumstances.  Some ‘exceptions to confidentiality’ include situations in which there is reasonable suspicion that any of the following has ever occurred or is occurring now:
  • You or your child present a danger to yourself or others
  • A child, dependent adult, or a person over the age of 65 years is the victim of emotional, sexual or physical abuse, neglect or unjustified mental suffering

Appointments/Professional Fees

  1. Canceling or rescheduling appointments requires 48 hour notice by telephone or email to avoid having to pay the entire fee for a missed session. 
  2. As a standard business practice, each appointment ends 50 minutes from the scheduled start of the appointment, regardless of your arrival time.  I am not able to extend sessions since appointments begin on the hour.
  3. The standard fee ranges from $200.00-$275.00 based on modality (individual, couple, or family) and time per session. Fees are payable in full at each session.  I will provide a monthly statement for insurance purposes, however all fees are the responsibility of the client.
  4. Telephone conversations that last over 20 minutes are deemed to constitute a therapy session and will be billed at my standard applicable hourly rate.

Contacting Me

  1. I have a voicemail on which you can leave me a confidential message.  No one besides me has access to this voice mail account.  I will make every effort to return your call on the same day.  Messages left after 8pm may be returned on the following day.

Professional Records

  1. By California state law and the standards of practice in my profession, I am required to keep appropriate records of all treatment and services rendered.  The confidentiality of these records is closely safeguarded.

Telehealth Consent
I understand that Telehealth is a mode of delivering healthcare services, including psychotherapy, via communication technologies (e.g. Internet, Zoom or Phone) to facilitate treatment, consultation, education, and self management of a client’s healthcare.

Your electronic signature below acknowledges that you have read, understand, and agree to the content of the Informed Consent Contract.