Susan Zaro, MFT
License #32333
(650) 948-9224

OFFICE POLICIES & GENERAL INFORMATION
AGREEMENT FOR PSYCHOTHERAPY SERVICES
This form provides you (client) 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 ____. 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. Susan Zaro, will use her clinical judgment when revealing such
information. Susan Zaro, will not release records to any outside party unless she is 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 Susan Zaro, becomes concerned about your personal safety, the possibility of you injuring someone
else, or about you receiving proper psychiatric care, she will do whatever she 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, she 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 Susan Zaro , 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. Susan Zaro, MFT has no control or knowledge over what insurance companies do with the
information she submits 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 soon will also 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. Medical data has been reported to have been sold, stolen, or accessed by enforcement

agencies; therefore, you are in a vulnerable position.

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 Susan Zaro 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
Susan Zaro to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records
be requested.

Consultation: Susan Zaro consults regularly with other professionals regarding her 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 appropriate, upon your request, Susan Zaro
will release information to any agency/person you specify unless she concludes that releasing such
information might be harmful in any way.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Susan
Zaro between sessions, please leave a message on the answering machine (650)948-9224 and your call will
be returned as soon as possible. Susan Zaro checks her messages a few times a day (but never during the
night time), unless she is out of town. Susan Zaro checks the messages less frequently on weekends and
holidays. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to
someone right away, you can call Stanford University Medical Center at (800) 756-9000. The Police (911),
or the 24-hour Psych. Emergency (650)573-2662 .

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay
the standard fee of $200 per 60 minute session at the end of each session or at the end of the month unless
other arrangements have been made. 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 Susan Zaro if
any problem arises during the course of therapy regarding your ability to make timely payments. Clients
who carry insurance should remember that professional services are rendered and charged to the clients and
not to the insurance companies. Unless agreed upon differently, Susan Zaro will provide you with a copy
of your receipt on a monthly basis, which you can then submit to your insurance company for
reimbursement if you so choose. 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.

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 precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement
of Susan Zaro 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 Santa Clara, CA 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, Susan Zaro 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. Susan Zaro 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. this therapist 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, the therapist is likely to draw on various
psychological approaches according, in part, to the problem that is being treated and his/her assessment of
what will best benefit you. These approaches include behavioral, cognitive-behavioral, EMDR,
biofeedback, psychodynamic, existential, system/family, developmental (adult, child, family), or psychoeducational.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment,
Susan Zaro will discuss with you her working understanding of the problem, treatment plan, therapeutic
objectives, and his/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, Susan Zaro’s 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 Susan Zaro does not provide, she has an ethical obligation to assist you in obtaining
those treatments.

Termination: As set forth above, after the first couple of meetings, usually within one to three
meetings, the therapist will assess if she can be of benefit to you. Susan Zaro does not accept clients who,
in her opinion, she cannot help. In such a case, she will attempt to give you a number of referrals that you can
contact. If at any point during psychotherapy, she assesses that she is not effective in helping you reach the
therapeutic goals, she is obliged to discuss it with you and, if appropriate, to terminate treatment. In such a
case, she would give you a number of referrals that may be of help to you. If you request it and authorize it
in writing, Susan Zaro will talk to the psychotherapist 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, Susan Zaro
will assist you in finding someone qualified, and, if she has your written consent, she 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, Susan Zaro 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 objectivity, clinical judgment, or therapeutic effectiveness
or can be exploitative in nature. The therapist will assess carefully before entering into non-sexual and
non-exploitative dual relationships with clients. Consequently you may bump into someone you know in
the waiting room or into your therapist out in the community. Susan Zaro will never acknowledge working
therapeutically with anyone without his/her written permission. Many clients choose their therapist
because they know her before they enter into therapy with her and/or are aware of her stance on the topic.
Nevertheless, Susan Zaro will discuss with you, his/her client/s, the often-existing complexities, potential
benefits, and difficulties that may be involved in such relationships. 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 Susan Zaro if the dual relationship
becomes uncomfortable for you in any way. She will always listen carefully and respond accordingly to
your feedback. The therapist will discontinue the dual relationship if she finds 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 48 hours (2 days) 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.
I have read the above Agreement and Office Policies and General Information carefully; I
understand them and agree to comply with them:
_______________________________________________________

Client name (print) Date Signature

_________________________________________________________
Client name (print) Date Signature
_________________________________________________________
Therapist Date Signature