Thearpy Consent Form

Please add SS# if you are planning to submit for insurance company reimbursement.

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Please read the following office policies and agreements that are offered to support our work together.  The goal is to have minimal interruptions in your therapy as well as respecting the commitment we both make to your process.  Should you have any questions about any policy, please feel free to discuss them with me. By working together, we can establish a rewarding therapeutic relationship.

Most people benefit from psychotherapy, coaching or spiritual guidance work.  Success can vary depending on particular problems and the uniqueness of each person.  Self-exploration, gaining understanding, finding ways of working with your inner life, understanding your dreams, dealing with challenges and complexes, as well as learning new skills, are helpful and contribute to change.

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I understand that all information disclosed in therapy is confidential and will not be released to a third party without my written consent, except when disclosure is required by law.  Disclosure is required in the following circumstances.

• When there is reasonable suspicion of child, dependent adult, or elder abuse or neglect.
• When a client presents a danger of violence to others.
• When a client is likely to harm him or herself unless protective measures are taken.
• Disclosure may also be required pursuant to a legal proceeding.

If you participate in marital or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that I utilize a “no-secrets” policy when conducting family or marital/couples therapy. This means that if you participate in family, and/or marital/couples therapy, I am permitted to use information obtained in an individual session that you may have had with me, when working with other members of your family. Please feel free to ask me about my “no secrets” policy and how it may apply to you.

Sessions vary in length.  If you would like additional phone time with me beyond in-session visits you understand you will be charged for phone time at the rate per hour in accordance with my fee.  You understand that if you would like to speak with me on the telephone, I am available to speak with you in 15 minute increments charged according to my full fee. Telephone consultations between office visits are welcome.   You may leave a message for me at any time on my confidential voicemail. Please know that I cannot guarantee or be responsible for confidentiality of information passed electronically. If you wish me to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal workdays (Monday through Friday) within 24 hours. If you have an urgent need to speak with me, please indicate that fact in your message.  In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance.

Your fee is based upon a 50 (individual) to 60 (couple) minute therapy session, or enrollment in a therapy group.   Payment is due at the beginning of each session to avoid distraction before you leave. Payment is due each session and it’s your responsibility to keep your appointments or to cancel with at least 48 BUSINESS hours in advance, or you will be charged your full regular fee, including if you decide to end our working together, policy applies.   48 BUSINESS hours does not include Saturday or Sunday times.  I will provide you a confirmation of your cancellation, so if you do not receive a confirmation from me, it means I did not receive your message, and you are still responsible for your apt. time. 

Please understand your regularly scheduled appointment is reserved exclusively for you, and no one else is given that time.  If you think you are going to be ill, or miss your appointment for any other reason, please let me know in advance of the notice required, in order to avoid the fee that will be charged.  The only exception to this policy is death of an immediate family member or serious life threatening emergency.

If you do not provide me with at least 48 BUSINESS hours notice in advance for regularly scheduled sessions, or 72 BUSINESS hours for extended sessions (2 or more clinical hours) you are responsible for payment in full for the missed session.  If you have scheduled an extended session and cancel with less than SEVEN DAYS in advance you understand you will be charged the full amount of the session.

If you have a balance and default on payment to me, you will be responsible for all collection and legal fees, including interest.   

Fees will be reviewed annually and may be raised.  When you go out on vacation please give me at least two weeks notice. I will inform you well in advance of my vacation schedule.

All immersions must be paid in full before services are provided.  There are no refunds or cancellations on immersions on any level. This is an investment, all-in, for yourself, your healing and transformation.  Should you have a life or death emergency and cannot attend your scheduled immersion, we will work out a rescheduled time, per Joanna’s availability. 

• Your credit or debit card will be charged in the case of a delinquent balance (15 days after an account statement requesting amount due has been sent).
  There will be a 4% convenience fee.     
• I understand and accept all of the terms regarding this billing policy.
• I give my permission for Joanna Intara Zim, LMFT  to bill my credit card for services rendered, and for appointments missed or group sessions missed where payment is due.

If you have insurance you MAY be reimbursed by the insurance company for any services paid to me.   You understand that I will not bill insurance for you and that I can submit upon your request an invoice to you, for all services rendered so that you may submit to your insurance company for reimbursement.  You understand that you are responsible to ensure that I am paid in full for any and all services provided. You understand that insurance companies will not reimburse for missed sessions or sessions cancelled outside the 48 or 72 hour cancellation policy.

Joanna Intara Zim, M.A., L.M.F.T. (38453), is trained as a Psychotherapist and a Mentor/Coach/Spiritual Guide.  If your work with her as a psychotherapist requires coaching work, she and you will discuss to make an appropriate referral for your situation. Coaching, Spiritual Guidance and Psychotherapy work are different work modalities.

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I am committing to enrolling in a self development work with Joanna Intara Zim.

Any fees not paid by 5 days after monthly payment date are subject to a 5% late fee.

Leaving therapy is an important decision, and effectively ending the therapeutic relationship is an important part of the therapeutic process. Please discuss any plan or desire to discontinue therapy to allow enough time for effective termination. 

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The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.  I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

Please click the "NEXT" button below to proceed. 

Sessions vary in length.  If you would like additional phone time with me beyond in-session visits you understand you will be charged for phone time at the rate per hour in accordance with my fee.  You understand that if you would like to speak with me on the telephone, I am available to speak with you in 15 minute increments charged according to my full fee.  Telephone consultations between office visits are welcome.   You may leave a message for me at any time on my confidential voicemail. Please know that I cannot guarantee or be responsible for confidentiality of information passed electronically. If you wish me to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal workdays (Monday through Friday) within 24 hours. If you have an urgent need to speak with me, please indicate that fact in your message.  In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance.

Petaluma Office

My office address is 155A Kentucky Street, Suite No. 4 between Western and Washington Streets. Please wait outside Suite No. 4 until your appointment beings.  I will come and greet you at the start of our appointment time.  There is free 2 hour street parking at the adjoining streets.  Please come up the stairs.  There are some chairs to sit in.

Above is the consent form, to be completely filled out before the session starts. You can either email it back to me, or give it to me at the beginning of the session.  I prefer payment at the beginning of the session to avoid distraction and disruption of the flow of the session when you leave.

I kindly ask for 48 Business Hours cancellation notice should you be unable to come.  More about this above.

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I’m looking forward to our meeting. Video sessions are provided on ZOOM Video conferencing software which you will need to download onto your phone or computer. I will give you our meeting room number. PLEASE DO NOT CLICK ON THE MEETING ROOM LINK UNTIL THE START OF OUR MEETING AS YOU WILL INTERRUPT THE PRIOR SESSION!   I recommend having paper and pen close by for any notes you may wish to take.  I also recommend turning of all other devices and having a glass of water available should you feel thirsty.

If we are meeting by FaceTime on iPhone please make sure I have your correct Facetime phone number in advance of our call.  Feel free to let me know if you have any further questions.

Looking forward to meeting you and being of service.

Thank you for completing the consent form. If you leave this page, your information will NOT be saved, SO be sure to complete your transaction by pressing the BUY button.