Informed Consent

Informed Consent for Outpatient Psychotherapy

Effective date: May 6, 2026 · Last updated: May 6, 2026

1. Voluntary Participation

Psychotherapy at Pasadena Clinical Group is voluntary. You have the right to decide what to disclose, what to address, and when to stop. You may terminate treatment at any time, for any reason, without penalty. We ask only that, when possible, we have a final session to close the work well and discuss any referrals.

2. Nature of the Services We Offer

Pasadena Clinical Group is an outpatient psychotherapy practice. We provide individual, couples, family, and group therapy delivered by California-licensed clinicians and supervised pre-licensed associates. We do not provide medication management, inpatient or partial-hospital care, or emergency services. If you are in a crisis, please call or text 988 (the 988 Suicide & Crisis Lifeline) or call 911.

3. Benefits and Risks of Psychotherapy

Psychotherapy can reduce symptoms, build skills, improve relationships, and help you make difficult decisions. The evidence base for the modalities we use is strong; many clients begin to feel relief within the first six to ten sessions. There are also risks. Therapy can be uncomfortable; people sometimes feel worse before they feel better as they begin to look at painful material. Outcomes vary. There is no guarantee that therapy will resolve a particular condition, and your clinician will discuss alternatives, including other forms of care, if therapy does not appear to be helping.

4. Confidentiality — and its California Limits

Information you share in therapy is confidential and protected by federal law (HIPAA), the California Confidentiality of Medical Information Act (Civil Code §§56 et seq.), the psychotherapist-patient privilege (Evidence Code §§1010 et seq.), and the Lanterman-Petris-Short Act (Welf. & Inst. Code §5328). California law, however, requires us to break confidentiality in specific circumstances:

1. Suspected child abuse or neglect. The Child Abuse and Neglect Reporting Act (Penal Code §§11164–11174.3) requires us to report when, in the scope of our professional capacity, we have knowledge of, observe, or reasonably suspect that a child has been the victim of abuse or neglect.
2. Suspected abuse, neglect, or financial abuse of an elder or dependent adult. The Elder Abuse and Dependent Adult Civil Protection Act (Welf. & Inst. Code §15630) requires us to report.
3. Serious threat of violence to a reasonably identifiable victim. Under Tarasoff v. Regents of the Univ. of Cal., codified at Civil Code §43.92, we have a duty to make reasonable efforts to protect the intended victim, which may include warning the victim and notifying law enforcement.
4. Imminent danger to self. If we believe you are at imminent risk of suicide or serious self-harm, we may take steps reasonably necessary to keep you safe, including contacting emergency services or a person you have identified as an emergency contact.
5. Court orders, subpoenas, and other legal process. We may be required to disclose information in response to a valid court order. We will assert the psychotherapist-patient privilege on your behalf where it applies.
6. Health-care operations and payment. We disclose the minimum necessary information to your health plan to obtain authorization and payment, and to our HIPAA Business Associates (electronic health record, billing, telehealth platform) under Business Associate Agreements.

Our full HIPAA + CMIA disclosures appear in the Notice of Privacy Practices.

5. Insurance and Third-Party Payers

If you use insurance to pay for services, your insurer will require disclosure of certain protected health information, typically including a diagnosis, dates of service, and treatment progress. By using your benefits, you authorize this minimum-necessary disclosure. We will discuss the implications with you, and you may choose to pay out of pocket if you prefer not to involve your insurer. Self-pay clients receive a Good Faith Estimate under the federal No Surprises Act (see our No Surprises Act / Good Faith Estimate page).

6. Communication Outside of Sessions

You may contact us by telephone ((626) 354-6440), through the patient portal, or by email at office@pasadenaclinicalgroup.com. Email and standard SMS are not secure, and information you send through these channels may be accessed by unauthorized parties. By providing your email address or mobile number and authorizing communication through these channels in your intake forms, you accept this risk for non-urgent administrative matters such as scheduling and appointment reminders. Please do not communicate clinical content (symptoms, suicidal thoughts, crises) by email or text. Use the patient portal or call us. We do not provide therapy by email or text. If we have not heard back from you about a clinical concern within a reasonable time, we will contact you by telephone or, if necessary, ask emergency services to perform a welfare check.

7. Records and Retention

We maintain a clinical record for each client that includes intake forms, treatment plan, session notes, and billing information. California regulations governing licensed psychologists (16 C.C.R. §1396 et seq.) require records to be retained for at least seven (7) years from the date of last service for adult patients, and for minor patients, at least until one (1) year past the patient's eighteenth (18th) birthday or seven (7) years from last service, whichever is later. You have the right to inspect and copy your record (Health & Safety Code §§123100–123149.5) and to request an amendment. Psychotherapy notes as defined in 45 C.F.R. §164.501 are kept separately and disclosed only with your specific written authorization or as otherwise permitted by law.

8. Treatment of Minors

For minors under twelve (12), we generally require the consent of a parent or legal guardian. California Family Code §6924 permits a minor twelve (12) years of age or older to consent to outpatient mental health treatment if, in the opinion of the treating professional, the minor is mature enough to participate intelligently in the treatment, and the minor (a) would present a danger of serious physical or mental harm to self or others without the treatment, or (b) is the alleged victim of incest or child abuse. Where treatment proceeds under §6924, the clinician will involve the minor's parents or guardian to the extent appropriate, and as the statute requires, will document any decision that involvement would be inappropriate.

9. Couples and Family Therapy

In couples and family therapy, the relationship is the client. We do not keep secrets between partners or family members, and we will not disclose individually shared information back into the joint work without your permission. If a separate individual session is held with one party, we will discuss in advance how that information will be handled.

10. Termination of Services

Either you or your clinician may end treatment. We may end treatment when, in our clinical judgment, our services are no longer benefiting you, when there is a non-clinical conflict of interest, or for non-payment. In any of these cases, we will provide reasonable notice and offer at least three (3) appropriate referrals.

11. Telehealth, Office Policies, and the No Surprises Act

Telehealth is governed by our Telehealth Agreement. Cancellations, late arrivals, court appearances, and other administrative matters are governed by our Office Policies. Self-pay clients are protected by the federal No Surprises Act.

12. Patient Conduct and Mutual Respect

We are committed to providing a safe, respectful environment for clients, clinicians, and staff. Threatening, abusive, harassing, discriminatory, or violent conduct directed at any clinician, staff member, contractor, or other client — whether in person, by telephone, by text, by email, on the patient portal, or on social media — is grounds for immediate termination of services and, where appropriate, referral to law enforcement. Pasadena Clinical Group, its clinicians, owners, employees, contractors, supervisors, supervisees, and agents (collectively, the "Practice Parties") are entitled to the protections of California Civil Code §47 (privileged publications), Code of Civil Procedure §425.16 (anti-SLAPP), and applicable workplace-violence statutes (including Labor Code §6401.7 and Code of Civil Procedure §527.8).

13. Indemnification by Client

To the maximum extent permitted by California law, you agree to indemnify, defend, and hold harmless the Practice Parties from and against any third-party claim, demand, action, loss, liability, damage, cost, or expense (including reasonable attorneys' fees and costs) arising out of or related to: (a) your willful misconduct, fraud, or material misrepresentation in connection with your care; (b) your damage to the office premises, equipment, or records; (c) your unauthorized recording, photography, or publication of any session, clinician, or staff member in violation of California Penal Code §632 or Civil Code §1708.85; (d) any claim by a third party arising out of information that you knowingly provided to the Practice and that was false or misleading; or (e) your violation of these terms or applicable law. This indemnity does not apply to any claim arising out of professional negligence by a Practice Party (which is governed by California's Medical Injury Compensation Reform Act and the arbitration agreement below) or to any obligation that cannot lawfully be shifted to a patient.

14. Limitation of Liability for Non-Clinical Matters

To the maximum extent permitted by California law, the Practice Parties shall not be liable for indirect, incidental, special, consequential, exemplary, or punitive damages arising out of or related to non-clinical matters, including loss of revenue, loss of business opportunity, loss of data, or interruption of telehealth platforms or third-party services. Where liability cannot lawfully be excluded, the Practice Parties' aggregate liability for any non-clinical claim is limited to the fees actually paid by you to Pasadena Clinical Group in the twelve (12) months preceding the event giving rise to the claim. Nothing in this Section 14 limits any right or remedy that cannot be waived under California Civil Code §1668, the Consumers Legal Remedies Act, or any other non-waivable provision of law, and nothing in this Section 14 applies to claims of professional negligence (which are governed by the arbitration agreement below).

15. Mediation, Then Binding Arbitration — All Disputes

The parties intend that every dispute, claim, or controversy between you and any Practice Party arising out of or relating to the care, services, billing, or business relationship between you and Pasadena Clinical Group — including any claim of medical malpractice or professional negligence — be resolved through (a) good-faith negotiation, (b) non-binding mediation, and (c) final and binding arbitration, in that order, as set forth in the Arbitration Agreement below. The arbitration agreement is governed by the Federal Arbitration Act, 9 U.S.C. §§1 et seq., and, where applicable, by California Code of Civil Procedure §1295 (medical malpractice arbitration) and Code of Civil Procedure §§1280–1294.4 (California Arbitration Act). The validity, interpretation, and enforcement of this Section 15 and the Arbitration Agreement are decided by the arbitrator, except that questions of arbitrability that California courts must decide as a matter of state public policy may be decided by a court.

16. Arbitration Agreement (Required by California Code of Civil Procedure §1295)

Article 1 — Agreement to Arbitrate Medical Malpractice Claims

It is understood that any dispute as to medical malpractice — that is, as to whether any medical or psychotherapy services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered — will be determined by submission to neutral, binding arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2 — All Other Claims

It is also the intention of the parties that this arbitration agreement bind all claims that may arise out of or relate to the care or business relationship between the parties, including, without limitation: claims of breach of contract, breach of express or implied warranty, fraud or misrepresentation, intentional torts, claims under the California Confidentiality of Medical Information Act (Civil Code §§56 et seq.), claims under the California Consumer Privacy Act / California Privacy Rights Act, claims based on the Health Insurance Portability and Accountability Act (where a private right of action exists), claims under the Unruh Civil Rights Act (Civil Code §51), claims under the Americans with Disabilities Act (42 U.S.C. §12101 et seq.) other than equitable claims excluded below, claims under federal or California civil-rights statutes, and any related claim against any Practice Party. This Article 2 is governed by the Federal Arbitration Act, and any claim falling within Article 2 that is found by an arbitrator or court to be non-arbitrable will be severed without affecting the enforceability of the rest of this Agreement.

Article 3 — Persons Bound

This Agreement binds all parties whose claims may arise out of or relate to treatment or service provided to the patient, including the patient's spouse, registered domestic partner, heirs, personal representatives, beneficiaries, conservators, and any children of the patient (whether born or unborn at the time of the occurrence giving rise to the claim). In the case of a pregnant patient, the term "patient" includes the patient and the patient's expected child or children. All claims based upon the same incident, transaction, or related circumstances will be arbitrated in one proceeding.

Article 4 — Statute of Limitations and Diligence

A claim is waived and forever barred if (a) on the date written notice of the claim is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations (including without limitation Code of Civil Procedure §340.5 for professional negligence), or (b) the claimant fails to pursue the arbitration claim with reasonable diligence under the procedures of the chosen administrator.

Article 5 — Procedure, Forum, and Cost

Arbitration will be administered by JAMS or, by mutual written agreement of the parties, by the American Arbitration Association ("AAA"), in Los Angeles County, California, before a single neutral arbitrator selected under the chosen administrator's rules. The arbitration will be conducted under the JAMS Comprehensive Arbitration Rules and Procedures (or, where applicable, the JAMS Streamlined Arbitration Rules), which are incorporated by reference, except that this Agreement governs in the event of any conflict. The arbitrator will apply California substantive law to the merits of the dispute. The arbitrator may award any remedy a court could award, except as limited by Article 8 (class action waiver). Judgment on the award may be entered in any court of competent jurisdiction.

Consistent with Armendariz v. Foundation Health Psychcare Services, Inc., 24 Cal. 4th 83 (2000), and Sanchez v. Valencia Holding Co., 61 Cal. 4th 899 (2015): (i) the arbitration will provide for adequate discovery; (ii) the arbitrator will issue a written award sufficient to permit limited judicial review; (iii) Pasadena Clinical Group will pay all fees of the arbitrator and the administrator that exceed the filing fee a court would charge; and (iv) the arbitrator may award statutory remedies, including attorneys' fees and costs, on the same basis as a court.

Article 6 — Mediation Before Arbitration

Before commencing arbitration, the parties will attempt to resolve the dispute through non-binding mediation administered by JAMS in Los Angeles County, California. Mediation must be initiated within thirty (30) days after written notice of the dispute and concluded within sixty (60) days after commencement, except by mutual agreement. The parties will share mediator fees equally, except that Pasadena Clinical Group may, in its discretion, advance fees that would otherwise impose a substantial barrier to access. The applicable statute of limitations is tolled during the mediation period.

Article 7 — Equitable and Government-Filing Carve-Outs

Notwithstanding the agreement to arbitrate, either party may seek provisional equitable relief (such as a temporary restraining order or preliminary injunction) in a court located in Los Angeles County, California, to preserve the status quo or protect intellectual property, confidential information, or trade secrets, pending arbitration. Nothing in this Agreement prevents you from filing a complaint, charge, or report with any government agency — including the U.S. Department of Health and Human Services, the California Department of Justice, the California Civil Rights Department, the U.S. Equal Employment Opportunity Commission, the California Board of Psychology, the California Board of Behavioral Sciences, or the National Labor Relations Board — or from cooperating with any government investigation. Claims brought under California's Private Attorneys General Act (Lab. Code §2698 et seq.) are not subject to this Agreement to the extent required by California law (see Adolph v. Uber Technologies, Inc., 14 Cal. 5th 1104 (2023)).

Article 8 — Class Action and Representative Action Waiver

To the maximum extent permitted by law, you and Pasadena Clinical Group each agree that any arbitration will be conducted on an individual basis only and not as a class, collective, consolidated, or representative action. Class, collective, consolidated, mass, and representative actions, and the right to act as a private attorney general beyond the carve-outs in Article 7, are waived. If a court of competent jurisdiction finds this waiver unenforceable as to a particular claim, that claim (and only that claim) may proceed in court, and the remainder of this Agreement will continue in full force.

Article 9 — Confidentiality of Arbitration

The arbitration proceedings, the existence of the arbitration, and any award are confidential, except as required by law, by an order of a court of competent jurisdiction, or in connection with judicial review or enforcement of the award. Nothing in this confidentiality provision prevents a party from disclosing information necessary to comply with mandatory-reporting obligations under federal or California law, to file or support a complaint with a government agency, or to discuss the underlying facts of any claim of harassment, discrimination, or retaliation, consistent with California Code of Civil Procedure §1001 and California Civil Code §1670.11.

Article 10 — Severability and Survival

If any provision of this Agreement is held invalid or unenforceable, that provision will be limited or severed to the minimum extent necessary, and the remainder of the Agreement will remain in full force. This Agreement survives termination of services.

17. RIGHT TO RESCIND THIS ARBITRATION AGREEMENT

You have THIRTY (30) DAYS after signing this contract to rescind this Arbitration Agreement by written notice to Pasadena Clinical Group at 301 N. Lake Ave, STE 600, Pasadena, CA 91101 or by email to office@pasadenaclinicalgroup.com. After 30 days, the Arbitration Agreement is binding on you and on Pasadena Clinical Group, and you are giving up your right to a jury trial or court trial as to all matters covered by the Agreement.

18. Governing Law, Venue, and No Waiver

This consent and the Arbitration Agreement are governed by California law without regard to conflict-of-laws rules, except that the Federal Arbitration Act governs the interpretation and enforcement of the Arbitration Agreement. For any matter not subject to the Arbitration Agreement, the parties consent to the exclusive jurisdiction and venue of the state and federal courts located in Los Angeles County, California. No failure or delay by Pasadena Clinical Group to enforce any provision is a waiver of that provision or any other provision.

19. Acknowledgment

By signing this form (electronically through the patient portal or in person), you confirm that you have read it, that you have had an opportunity to ask questions, that your questions have been answered to your satisfaction, that you understand the bold-face notice required by California Code of Civil Procedure §1295 and that you have a thirty-day right of rescission as to the Arbitration Agreement, and that you consent to outpatient psychotherapy at Pasadena Clinical Group on these terms.

_____________________________________________    Date: ____________
Client signature (Treatment Consent)

_____________________________________________    Date: ____________
Client signature — Arbitration Agreement (separate signature required by Cal. Code Civ. Proc. §1295)

_____________________________________________    Date: ____________
Parent / legal guardian signature (if client is a minor)

_____________________________________________    Date: ____________
Clinician signature

Contact

Pasadena Clinical Group, 301 N. Lake Ave, STE 600, Pasadena, CA 91101 · (626) 354-6440 · office@pasadenaclinicalgroup.com