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Terms and Policy

Informed Consent
Informed Consent for Mental Health Services

Robert A. Marselle, Psy. D., RN
27201 Tourney Road, Suite 210
Valencia, California 91355


Welcome to my practice. This document contains valuable information about my professional services and business policies. It also provides summary information about the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex but significant, it is important that you understand them when you sign this document. It will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.


On or any other online media: You are never obligated or required to purchase any product or services offered online, in order to obtain professional services. Any written material for purchase or advice given online is not part of professional service. Professional services include only offerings made at and are strictly limited to your account and login. Please, beware that you may have arrived at from a clicking a portal to this site; you have no obligation to register. Registration and creation of an account do not obligate you to obtain professional services. Once you make an appointment and have been notified in person or on video, the professional doctor-patient relationship begins.

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should know. As your therapist, I have corresponding obligations to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, improved skills for managing stress and resolutions to particular problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. To be most successful, you will have to work on issues discussed, outside of sessions.


Appointments will ordinarily be 45-50 minutes in duration, once per week. Although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you. If you need to cancel or reschedule a session, I ask that you provide 24 hours notice. If you miss a session without canceling or cancel with less than 24-hours notice, my policy is to collect the full amount of your session and or co-payment amount. It is important to note that insurance companies do not provide reimbursement for canceled sessions, therefore you will be responsible for the entire fee. If it is possible, I will try to find another time to reschedule the appointment. Also, you are responsible for coming to your session on time, if you are late, your appointment will still need to end on time.


You are expected to pay for services at the time of your session or you may authorize the session fee be charged to your credit card on file. My office reserves the right to engage an attorney or collection agency to secure payment if necessary. If you do not attend the session and a 24-hour cancellation has not been made, you will be charged the full session amount. My office will provide you with a receipt for any fees you pay at your request.


My practice accepts and will bill Medicare for eligible members. I am in network with many insurance companies but not all. Prior to your first session, my office will gladly verify your benefits and coverage and inform you of your copayment responsibility pursuant to the terms of your insurance policy. We will also provide the service of billing your insurance once you have agreed to assign benefits to me. This means you agree to allow your insurance company to pay me directly for services billed. You will be responsible for any deductible, copayment or coinsurance pursuant to the terms of your insurance policy. Your insurance company will always provide you with an Explanation of Benefits (EOB) so you are kept informed of what is being billed and paid on your behalf. Please review the correspondence you receive from your insurance company carefully and if a check is issued to you for my services in error, you are responsible to provide that same payment to me. My office will provide you with a receipt for any fees you pay at your request.


I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment with your diagnosis and topics we discussed. All medical, social, and treatment history records I receive from other providers, copies of documents I send to others, and your billing records are also kept confidential.  Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted or upsetting to untrained readers. For this reason, I recommend that you initially review them with me or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.


1. Everything we discuss will be held confidential. Unless you provide a signed authorization, I will not speak to or correspond with anyone about you or your treatment.

2. California law and professional ethics either mandate or permit therapists to break client confidentiality under certain circumstances. Some exceptions to confidentiality include, but are not limited to, the following situations in which there is reasonable suspicion that any of the following has occurred or is occurring now:

* You or your child presents a danger to self or others;

* A child or dependent adult is the victim of emotional, sexual or physical abuse, neglect
or unjustified mental suffering;

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

* Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to: protect the client/patient, psychologist, or others from harm. In situations when there is cause for serious concern about a client harming someone, the clinician must breach confidentiality to warn the identified victim/third party about imminent danger, the danger must be imminent and the breach of confidentiality should be made to someone who is in a position to reduce the risk of the danger. People who would be appropriate recipients of such information would include the intended victim and law enforcement.


Digital and cellular forms of communication are very convenient but in many cases, are not secure and can be intercepted. Your registration on allows you to access a military grade encrypted server where you may email me any questions or concerns with the security that the cannot be intercepted and will remain confidential. If you send me a message through your personal email account (I.e. gmail, yahoo, aol, etc.) I will not respond except to acknowledge receipt as these services are not secure. 

All clients will have access to my direct cell phone number for emergencies, however, any voicemail or text messages sent will not necessarily be secure and therefore confidentiality cannot be assured. If you initiate contact with me in this manner, you are assuming that risk and I cannot be held liable for any breach in confidentiality.


While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless he/she agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child's agreement, unless I feel there is a safety concern (see also above section on Confidentiality exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.

When contacted by parents and requested to treat a child under the age of 14, I reserve the right to require one or both parents to see me without the child present, at least once. Since as a therapist my contact with the child is far less than the parents, often times it is necessary to get the parents involved in the treatment plan in order to effectuate change at home. 

Often I may not be immediately available as I am with clients or otherwise engaged. At these times, you may send me a confidential email message through your secure patient portal once you have completed the initial registration. (Standard email accounts are not secure and I will not respond to emails without a signed consent.) I will make every effort to respond to you within 24 hours, but if you feel you cannot wait for a response, please go to your local hospital emergency room, or call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.


If you are unhappy with what is happening in therapy, I hope you will speak with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. Therapy never includes physical or sexual contact of any kind. If at anytime you have a formal complaint, you may contact The Consumer Affairs Department at the California Board of Psychology. There is a notice clearly posted at my office with their contact information.

Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

( Type Full Name )
Terms of Agreement
Psychotherapy can be a life changing event. Like anything else, you get out of it what you put into it. There are terms to follow in order to provide a secure and completely confidential therapeutic framework of security and foster a desire for your participation.

1. Dr. Marselle will ask you to verify your identity by a government-issued photo ID that you can show him during the initial session or with a Smart Card. You are encouraged to ask questions about the doctor during your session or you can read about his background, practice and approach on Psychologists are licensed, and Dr. Marselle is licensed in California with two professional licenses, Clinical Psychologist, and Registered Nurse. The board contacts are and

2. Dr. Marselle needs to verify your current location at the time of the session and has another form that requires completion online that has the emergency contacts in your area. Hospital, ambulance service, police, etc. You will have to designate a support person and supply the appropriate contact information in case there is a need to do so. An emergency management system needs to be set up. For example, a lot of people that use TeleHealth because they live in a rural area, or there is a mental or physical disability that prohibits the ability to get to emergency services.Knowing how to reach your first responders is necessary and a part of the plan for your safety.

3. Appropriateness for video conferencing determined at each session by asking if you are alone or who might be able to hear the audio of the meeting. You can have people in the meeting if you need them. They may include spouse, nurse, caregiver, etc. You do not have to sign a release because you imply consent by them being present, but you will be asked in some circumstances to verify that you want a third party present. These are some of the terms for distance treatment. An Iinformed Consent form is digitally signed. Dr. Marselle will review conditions for an informed consent to be sure you understand reporting laws and confidentiality.

4. Your prescribing and treating medical doctor information is required if there are medical issues.

5. Equipment requirements and your ability to problem solve your end of the connection are necessary. You need a computer with a webcam and audio capabilities such as speakers or headphones. Lastly, a good stable Internet connection is required. A weak signal can be disruptive and can be a safety issue if there is a connection loss on either end. A plan of reestablishing contact by telephone will be necessary.

6. Dr. Marselle provides the latest in encryption technology for video sessions and record keeping. His complete technical set up is HIPPA compliant for the regulation of digital data as stated by law. All pertinent digital data is backed up and kept on HIPPA compliant servers located in two different states in case of a disaster at one of the locations. No third party has access to any of your data. All data is encrypted and has encrypted login procedure.

7. Payment and billing information are required.
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