6529 Riverside Avenue, Suite 133
Riverside, CA 92506
(951) 684-2627



This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Quality Life Psychiatric & Psychological Group, Inc. (hereinafter QLG) treating personnel. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. QLG will use their clinical judgment when revealing such information. QLG will not release records to any outside party unless they are authorized to do so by all adult family members who were part of the treatment.

Emergencies: If there is an emergency during our work together, or in the future after termination, where QLG becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, they will do whatever they can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, they may also contact the police, hospital or the person whose name you have provided on the biographical sheet.

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct QLG, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier. QLG has no control or knowledge over what insurance companies do with the information they submit or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and will be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access.

Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone (also cordless phones) communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be easily compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes in emergency situations.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on QLG to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation: QLG consults regularly with other professionals regarding their clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.
*Considering all of the above exclusions, if it is still divorce and custody disputes,appropriate, upon your request, QLG will release information to any agency/person you specify unless QLG concludes that releasing such information might be harmful in any way.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a voice mail message at (951) 684-2627 and your call will be returned as soon as possible. QLG personnel check their messages a few times a day unless they are out of town, in which case another colleague’s number will be available. If an emergency situation arises, please indicate it clearly in your message and/or call the emergency number that is available. If you need to talk to someone right away and it is an emergency, you can call the police (911), a 24-hour crisis line (951) 686-HELP, or the 24-hour Psych. Emergency (951) 358-4881.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee per fifty (50) minute session at the end of each session unless other arrangements have been made. Standard fees are as follows: Psychiatrist – $350.00, Clinical Psychologist – $200.0, Licensed Clinical Social Worker and Marriage Family Therapist – $150.00. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify QLG if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance will have their professional services charged to their insurance companies. Clients are responsible for their co-pays and any deductible that may apply at the time of their session. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. The client is responsible for any charges that are not covered by their insurance.

DELINQUENCY AND INACTIVITY: Referrals for alternate mental health treatment options will be given to the client or caregiver in cases where accounts have become delinquent for more than 60 days. Cases that have become inactive for more than 60 days, except in cases where other arrangements have been made, as in ‘pulse’ pattern of therapy, will be referred to other mental health professionals for further treatment.

MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of QLG and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Riverside County, California, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, QLG can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits; however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psycho-educational.

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, I will discuss with you (client) their working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

Termination: As set forth above, after the first couple of meetings, I will assess if they can be of benefit to you. QLG does not accept clients who, in their opinion, they cannot help. In such a case, they will give you a number of referrals that you can contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist or psychiatrist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist or psychiatrist, I will assist you in finding someone qualified, and, if I have your written consent, I will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, QLG will offer to provide you with names of other qualified professionals whose services you might prefer.

Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs my objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. I will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. Many clients may know each other and QLG personnel from the community. Consequently you may bump into someone you know in the waiting room or into me out in the community. I will never acknowledge working therapeutically with anyone without his/her written permission. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your, the client’s, responsibility to communicate to me if the dual relationship becomes uncomfortable for you in any way. I will always listen carefully and respond accordingly to your feedback. I will discontinue the dual relationship if I find it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.

CANCELLATION:Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

Social Media Use

Quality Life Group encourages you to engage in open discussion on our social media sites. We look forward to reading your comments about your experiences. We do make reasonable efforts to monitor all of our social media channels to ensure that posted comments are appropriate.

We do not comment on patient’s medical status

We may receive requests on our social media channels from concerned individuals asking for information about a particular diagnosis or treatment plan.

Social Media Terms & Conditions

You agree not to post content that is illegal, obscene, defamatory or threatening or abuse intellectual property rights on Children’s Hospital Los Angeles sites.

Syndication or Repurposing of Quality Life Group Content

In general, Quality Life Group supports the distribution of its content through social media sharing mechanisms provided that sharing is done in a way that retains all rights of content origination accruing to Quality Life Groups with regard to content ownership and copyright.

In cases where individuals or institutions wish to syndicate Quality Life Group’s digital content, we require that you:

Regardless of whether you are granted prior authorization to syndicate or modify our digital content, Quality Life Group retains the right to demand immediate removal of our content from another website for any reason.