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Authorization for Treatment and Release of Information

I hereby apply for psychological treatment at the Kieffer E. Frantz Clinic of the C.G. Jung Institute of Los Angeles. I authorize the Clinic Director to release information as necessary when assigning me to a clinic therapist. I understand that the Clinic, as part of the Jung Institute, is involved in training, and that my assigned therapist will be in the intern program or in the analyst training program. Clinic therapists come from a variety of mental health disciplines which includes psychology; marriage, family, child counseling; social work; and psychiatry. I understand that my therapist is under the direct supervision of an analyst and that my case may be discussed within the context of supervision.

Clinic policy requires one to pay for, and to attend, a minimum of one scheduled session per week. Regular attendance results in a more optimal therapeutic experience and provides needed funds for the ongoing expenses of our non-profit Clinic. If you are unable to attend a session, for any reason, you remain responsible for payment for that hour. The only exception to this policy occurs when the therapist is away or for some other reason cancels the session. You will not be billed for that hour. I understand this policy and will be responsible for payment of all scheduled sessions. The therapist may reschedule a session during the week of the regularly scheduled session depending on the therapist?s availability. The clinic does not refund fees for services rendered. If for any reason a Clinic patient has pre-paid for future sessions or has otherwise overpaid, the amount overpaid will be refunded within then (10) days of request by the patient.

Confidentiality between patient and therapist is very important in a therapeutic relationship. Even in the context of supervision, as mentioned above, names and privacy shall be carefully protected. However, there are specific circumstances mandated by California law where confidentiality between patient and therapist may or must be broken. These situations involve child abuse, elder abuse, threat of harm to oneself or to another person. Please see the Limits to Confidentiality Form for a description of these exceptions to confidentiality.Your therapist is well-informed of the mandated reporting laws. Please feel free to discuss any concerns you may have about situations where there may be limits to confidentiality.

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