** Therapy is a procedure that involves mutual responsibility between patient and therapist. Should you choose to proceed, this process will begin with your trust in and commitment to the treatment process, and my commitment to you to address your questions and concerns as they come up during session. It also involves my commitment to you as your therapist, helping you develop more harmony in your thoughts, feelings, behaviors and personal values, while you discover more rewarding ways of relating.

** Since therapy is a clinical process, it involves a professional arrangement which is regulated by laws, ethics, your rights as a client, and my standard business practices. Before therapy can begin, your agreement to the business practices described will require initials and signatures

** If at any time you would like your therapist to collaborate with other people in your life, it will be important for you to let this therapist know. We will discuss your choice to disclose information and decide together if it is in your best interest. A release of information will then need to be signed.

Payment of Fees

1.) The standard fee is $180 per (45) minute session for an initial appointment or family services. Individual therapy is $160 per (45) minute session.

2.) Canceling or rescheduling appointments requires a 24 hour notice by telephone to avoid having to pay a courtesy lowered fee of 100.00 for a missed session. No emails please. SMS texting would appreciated.

3.) Written reports or documents needed to be filled out will require 2 weeks notice and the fee for such services is $140 per hour.

4.) Telephone conversations between us, for any reason, in excess of (15) minutes per day may be billed proportional to your hourly fee.

5.). I have a biller Barb Cunningham who will manage bills and questions about payments. She can be reached at bjcbilling@gmail.com

6.) Copays or payments are due at the time of session and can be paid via Zelle at drpepp07@gmail.com.

Confidentiality Limits and Exceptions

1.) As a standard, 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.) If you choose to break confidentiality in any way (ie. Sending me an email, applying for insurance reimbursement, telling anyone about your therapy, limits of SMS texting or choosing Telehealth in front of others). I cannot control, or be held liable for the outcome.

3.) I am not accepting court mandated therapy or able to sign off for therapy for courts.

California law and professional ethics include the following as exceptions to break confidentiality within the therapeutic relationship:
• When there is a reasonable suspicion that you are likely to harm yourself or others
• A child or dependent adult is a victim of emotional, sexual or physical abuse, neglect or unjustified mental suffering

A dependent adult or any person over the age of 65 is the victim of physical abuse, emotional abuse, abandonment, forced isolation, fiduciary abuse or neglect

Questions arising from authorized federal officials conducting national security and intelligence activities

Medical, Psychiatric, Psychological and Custody Evaluations

1.) If medical, psychiatric, psychological or custody evaluations seem to be warranted, we will discuss the nature of these evaluations and appropriate referrals will be provided.

2.) This therapist will not take on clients who are seeking therapy in order to have custody evaluations conducted or to have information sent to the courts. If you are not seeking a neutral place for your child to receive child-centered therapy, you will be referred to seek a custody evaluator who specializes in these matters. Therapy will be terminated if this is the case.

3.) Certain medications that ease emotional suffering may be prescribed before and/or during the course of treatment. This therapist is not an M.D. and cannot prescribe medications. Referrals will be provided as needed.

Limits of Communication

1.) Every effort will be made to assist you, especially during crisis. However, there may be times when contacting you won't be possible. Therefore, you must agree to first call 911 or go to the nearest hospital Emergency Room for assistance, any time you suspect you are in crisis.

2.) As a standard business practice, each appointment ends 45 minutes from the scheduled start of the appointment, regardless of your arrival time. Unfortunately, I am not able to extend sessions if you are running late.

3.) I can be reached via text messaging or voice mail at (619) 789-4880. Please see the opt in and out of SMS messaging for more information. I will do my best to return calls as quickly as possible. However, due to my being here by appointment, calls may not always be able to be returned from outside the office.

4.) Your "caller Id" or "call blocking may also prevent my returning calls from outside the office.

5.) If necessary, my voice mail will provide you with the crisis and access line phone number (1800-479-3339).

6.) If this therapist is out of town, you will be notified in advance and an alternate therapist will try to be made available in my absence.

Authorization to Commence Psychotherapy

Your signature below will verify that you have read the information in this authorization and that you asked questions about anything that you have not understood. By signing, you freely acknowledge your willingness to undergo treatment using psychotherapy methods, as deemed appropriate and in accordance with this Informed Consent.

You also agree to enter into a professional business arrangement according to all business practices outlined in this agreement. You accept full financial responsibility for payment of all fees and services as
describe, regardless of insurance coverage or any other "third party" payers.

You will also be releasing me of any liability that directly or indirectly results from disclosure or exchanges of any information covered in this agreement. At your request, a copy of this document will be provided to
you.

Authorization for Telehealth Psychotherapy

Telehealth Psychotherapy can be conducted in any location that you select, including your home, place of work or school. You do not need to come in for an appointment. You can select to either meet via an online video appointment or to receive a telephone appointment by your provider. Some clients prefer video method so they can be seen, while others prefer to meet by telephone.

Whichever method you select, it is important that you secure a private location for yourself so the information you are sharing is private.
Your therapist will not be responsible for confidentiality if you choose to speak freely in front of others. However, your therapist will maintain a secure location for your sessions and privacy on her end. No video or audio recording will ever occur by your provider. This provider asks that you also do not record sessions of any kind to maintain the confidentiality of your therapeutic time. Please be sure to use a network that is private and secure for yourself prior to logging into a session. Your Telehealth sessions are covered the same way as in person appointments by your insurance.

By signing below, you are agreeing to Telehealth psychotherapy and understand the importance of preventive measures for confidentiality.

Your therapist will not be held liable for others over hearing if private space has not been secured.

Information and Consent for SMS, MMS Messaging and Emails

By signing this consent you are agreeing to Subscribe to SMS messaging and email from your Psychologist. Your electronic signature is your consent to receive recurring informational SMS, MMS or email messages from Psychologist from my designated business line on my mobile phone to your provided mobile number or landline. You will be signing to opt in through my website www.drtorypepper.com in this consent form. Understanding that a consent to receive SMS messages is not a condition for beginning psychotherapy. This is a standard service available on most carriers to reach your Psychologist more quickly and to schedule, change, or cancel appointments more efficiently. Standard rates may apply. You can also request additional information by texting HELP or sending an email to drpepp07@gmail.com. Service will continue until you cancel by texting STOP or UNSUBSCRIBE to (619) 789-4880. Messaging frequency will vary. You may opt back in at any time by texting START or SUBSCRIBE to this number as as well.

No mobile information will be shared with third parties/affliliates for marketing or promotional purposes from my website. All the above categories exclude text messaging orginator opt-in data and consent, this information will not be shared with any third parties.

All user phone numbers are stored under contacts in my designated business line within my mobile phone. No other data is saved on my mobile device.