Informed consent

Informed consent

Licensed Marriage and Family Therapist#97197

Psychotherapy Services Agreement and Informed Consent

Outpatient Services Contract:
This document contains important information about Sumrah Jan’s professional services and business policies. When you sign this document, it will represent an agreement between Sumrah Jan and you, which you can revoke at any time unless Sumrah Jan has taken action in reliance on it or your health insurer requires it to substantiate claims in process; or if you have not fulfilled your financial obligations to Sumrah Jan.

Psychological Services: Psychotherapy can be a difficult as well as rewarding process. Since therapy often involves exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy can often lead to better relationships, solutions to specific problems, and a reduction in feelings of distress. Because we will work towards your goals together, it is important that you inform me of any problems or difficulties that may arise for you during the psychotherapy process. I am dedicated to professional development through ongoing training and consultation. I occasionally meet with a small group of colleagues to discuss cases. All identifying information will be withheld.


Adults:Everything we talk about in sessions will be held confidential and privileged as protected by law. No one will know the content of our counseling sessions unless you tell them or sign a release of information allowing me to disclose specific information. However, there are some situations where I am permitted or required to disclose information without your consent or authorization.
• If client poses a serious threat to himself/herself. I may enlist family members or others to protect a potentially suicidal client.
• Client threatens to physically harm an identifiable victim
• Child abuse (both past and present), elder abuse, or dependent adult abuse is suspected.
• Disclosures required by health insurers or to collect overdue fees
• If a government agency requests information I may be required to provide it.
• If a patient files a complaint or lawsuit against me, I may disclose relevant information in order to protect myself.

In the first 3 situations,I am required by law to inform any potential victims and the appropriate authorities so that protective measures can be taken. Every effort will be made to fulfill this reporting requirement in a manner that is in the best interest of those involved.I will act discreetly and wisely on your behalf, should any of these circumstances arise. The intent of my actions will always be to service in your best interest.

Children and Teenagers:My first responsibility is to honor our confidential relationship; we need to trust each other. Therefore, specific information will not be shared with your parents or others, unless you give me specific permission to do so. I may however, share generalities with your parents and offer helpful guidance to your parents and other supportive persons.
Exceptions: To protect you and help both you and your family to address and change destructive behavior, I am responsible to the appropriate agencies in the following events:
• Sexual activities if you are under the age of 14
• Abuse: physical, sexual, emotional and verbal abuse
• Potential for suicide
• Potential for homicide

Should the need to report arise, I will try my best to discuss it with you at the time, as I feel that honesty is crucial to our work together.

Sessions are by appointment. For phone contact between sessions, clients can leave a confidential voice message on my number at (925) 338-7526 and can request a call back for either scheduling or a brief check-in, not to exceed 15-minutes. I will make every effort to return calls within one business day. Due to my limited office hours, if you need to conduct the session over phone, we may need to set up a phone appointment. Phone appointments will be based on the same hourly rate as an in-office session.

For crisis emergencies requiring immediate assistance, please call 911 or call the Contra Costa Crisis Line at 1-800-833-2900.


I have received a copy of the informed consent. I realize it is my responsibility to read all the way through the consent and bring up and questions or concerns with my therapist during our session.
By signing receipt of this document, I am responsible for knowing the facts of these disclosures.
Therapist Only