Enrollment Forms

Consent to Treatment

Welcome to Garnica Counseling & Psychotherapy Studio. This document provides important information about professional services, policies, and your rights as a client. Please review it carefully and discuss any questions or concerns with your therapist.

Services are provided by Fatima Garnica Garcia-LMFT#95659, a Licensed Marriage and Family Therapist practicing in the state of California. Throughout this document, the terms “the practice,” “the therapist,” “I,” “me,” or “my” refer to Garnica Counseling & Psychotherapy Studio. The terms “you” or “client” refer to the individual(s) receiving services. The terms “counseling” or “psychotherapy” refer to psychotherapy services provided within the practice.

This consent applies to all psychotherapy services provided, including telehealth and any future in-person services, and is governed by applicable federal and California state laws, professional ethics, and licensing regulations.

By engaging in services and signing this document, you acknowledge that you have read, understood, and agree to the policies outlined herein, and you voluntarily consent to receive psychotherapy services. This consent remains valid until services are terminated by either party.

Consent for Teletherapy Services

Teletherapy services are provided using secure, HIPAA-compliant platforms and are governed by the same professional, ethical, and legal standards as in-person psychotherapy.

By consenting to teletherapy, you acknowledge and agree that:

• Teletherapy may involve risks such as technology interruptions or limitations to non-verbal communication
• You are responsible for ensuring a stable internet connection and appropriate device
• You will participate from a location that you deem safe and appropriate for discussing therapy-related matters
• You agree to being physically present in the agreed state of licensure the therapist is practicing under at the time of your telehealth sessions
• Teletherapy may not be appropriate for all clinical needs. If teletherapy is no longer clinically appropriate, this will be discussed and referrals may be provided as needed.

Acknowledgement of Risks of Psychotherapy Services

Psychotherapy is a professional relationship designed to support insight, emotional regulation, personal growth, and meaningful change. There are many approaches to psychotherapy, and treatment is tailored collaboratively based on your goals, preferences, and clinical needs.

Services provided at Garnica Counseling & Psychotherapy Studio are considered individual psychotherapy and may integrate trauma-informed, attachment-focused, and evidence-based interventions. The specific course of treatment is individualized and may evolve over time depending on progress, engagement, and presenting concerns.

Psychotherapy has both potential benefits and risks. Benefits may include improved emotional well-being, greater self-awareness, enhanced relationships, and improved coping skills. However, therapy is not guaranteed to produce specific outcomes.

At times, therapy may involve exploring difficult emotions, memories, or experiences and may temporarily increase emotional discomfort (such as anxiety, sadness, or frustration). These reactions are generally part of the therapeutic process and should be discussed openly in session.

Therapy appointments are scheduled for 50 minutes in length. Typically, sessions are scheduled initially once per week to establish care and may then progress to biweekly or less if clinically appropriate and continue to be clinically beneficial.

Your participation, consistency, and engagement are essential to the effectiveness of therapy. You are encouraged to ask questions at any time regarding treatment approaches, potential risks, alternatives, credentials, or the treatment plan.

You may discontinue therapy at any time. When possible, it is recommended that termination be discussed in advance so that appropriate clinical closure, recommendations, or referrals can be provided.  If, at any point, the therapist determines that services are no longer clinically appropriate or effective, this will be discussed with you, and referrals may be offered. All services rendered and reserved appointment charges are final and are non-refundable.

The therapist reserves the right to terminate services if there is non-payment of fees, repeated non-attendance, violation of practice policies, or behavior that compromises safety, professional boundaries, or the therapeutic relationship, consistent with ethical and legal standards.

Acknowledgement of Emergency Protocols

This practice does not provide emergency or crisis services.

By consenting to treatment, you acknowledge that:

• In the event of an emergency, you agree to contact 911, 988, or go to the nearest emergency room
• Email, voicemail, or electronic messaging are not appropriate for urgent or crisis situations
• For safety and legal compliance, you agree to provide and update your current physical address and location at the start of each session, as well as an emergency contact.
• To help us support you during an urgent or crisis situation, please keep your emergency contact information current. This practice requires at least one emergency contact on file, including the contact’s full name, relationship to you, and cell phone number.

Confidentiality

Your privacy and confidentiality are central to the therapeutic relationship. In general, all communications between a client and therapist are protected by law and will not be disclosed without your written authorization.

There are, however, legal and ethical limits to confidentiality, including but not limited to the following circumstances:

The therapist is required by law to disclose information if:

• There is suspected abuse or neglect of a child, dependent adult, or elder
• The therapist determines that you present a serious risk of harm to yourself or others
• You communicate a credible threat of physical violence toward another person

Additional limits to confidentiality may include:

• Court orders, subpoenas, or other legal requirements compelling disclosure
• Professional consultation with other clinicians for purposes of treatment, supervision, or quality of care (identifying information is minimized whenever possible)
• Situations involving psychiatric emergencies, which may require contacting emergency services or your designated emergency contact
• Disclosures otherwise required by law or outlined in the Notice of Privacy Practices
• Recording of therapy sessions is not permitted without prior written consent. Unauthorized recording may result in termination of the session or services.
• This policy will be reviewed further during the Initial Clinical Appointment and may be revisited throughout the course of treatment as needed.

While this summary is intended to provide clarity, confidentiality questions can be complex. You are encouraged to raise any questions or concerns with your therapist at any time.

Consent for Billing & Payments

Payment for services is the sole responsibility of the client. Garnica Counseling & Psychotherapy Studio operates as a private-pay practice that does not participate in any form or contact with health insurances or EAP Plans and does not provide superbills for Out-Of-Network Providers (OON).

By engaging in services, you authorize the therapist to charge the active payment method on file for all scheduled sessions, late cancellations, missed appointments, administrative fees, and any additional charges incurred under the practice policies.

Payment is processed automatically at the 48-hour mark prior to your scheduled session. Failure to maintain an active and valid payment method may result in cancellation of appointments or interruption of services.

You agree to remain financially responsible for:

• All therapy services rendered, each 50-minute individual therapy session will be billed at $290.00
• Late cancellations or no-shows will be charged at the full session rate
• Professional Services Outside of Sessions spent addressing non-payment, declined transactions, account follow-up, record review, treatment summaries, consultation or coordination requested, and other non-clinical administrative work. These non-session services are billed at $290.00 per hour in 15-minute increments.
• Any additional fees accrued as outlined in the practice policies
• All fees are non-refundable and non-negotiable

Fees may be updated periodically with advance written notice of 30 days. Questions regarding billing or payments may be directed to fatimagarnicapp@gmail.com.

Consent to Attendance & Cancellation Policies

Consistency is essential to the effectiveness of therapy. By engaging in services, you agree to the following:

• Appointments must be canceled or rescheduled at least 48 hours in advance to avoid being charged the full session fee
• Sessions canceled or missed within the 48-hour window are charged in full and are non-refundable
• A 15-minute grace period is provided for late arrivals; sessions not attended within this window may be considered missed appointments
• Sessions that begin late due to client delay will still end at the scheduled time
• Repeated late cancellations, missed appointments, or inconsistent attendance may result in removal from the schedule or termination of services. When possible, clients are encouraged to reschedule within the same work week.

Communication Between Sessions

Counseling & Psychotherapy is most effective when clinical work occurs primarily within scheduled sessions. Communication between sessions is intended for non-urgent, administrative, or scheduling matters only. 

The preferred method of communication between sessions and prior to enrollment is text messaging or email. Messages are reviewed during regular business hours, and responses typically occur within 24–72 business hours. Immediate responses are not guaranteed.

Extended communication outside of sessions that involve clinical content, documentation requests, or care coordination may be billed at the therapist’s administrative rate, as outlined in the Consent for Billing and Payments section and on the Good Faith Estimate.

Acknowledgement of Provider Death or Incapacity

In the unlikely event of the therapist’s death, incapacitation, or inability to continue providing services, you acknowledge that a designated professional executor or colleague may contact you to facilitate referrals, continuity planning, or transfer of records in accordance with California law and ethical guidelines.

No therapy services would continue without appropriate licensure and consent.

Consent to Use of AI-Assisted Note-Taking Tools

To support accurate and efficient clinical documentation, the therapist may use approved AI-assisted tools during or following sessions to assist with notetaking.

By consenting to services, you acknowledge that:

• AI tools are used solely for documentation support, not for diagnosis or clinical decision-making
• These tools comply with applicable privacy, security, and professional standards
• No session recordings are stored or used beyond documentation purposes
• You may request additional information regarding the use of AI tools at any time.

Final Acknowledgement

By scheduling an initial clinical appointment, participating in services or signing this consent, you confirm that you have read, understood, and agree to the policies outlined above and consent to receive psychotherapy services under these terms.

GOOD FAITH ESTIMATE

You are entitled to receive this “Good Faith Estimate” of what the charges could be for Adult Individual Counseling & Psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many individual therapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of individual therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here. 

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

The fee for a 50-minute psychotherapy visit via telehealth is $290.00.

Most clients attend one psychotherapy session per week, although the recommended frequency of treatment may be more or less often depending on your individual needs, treatment goals, and clinical recommendations.

Based on a fee of $290.00 per visit, the following are the expected charges for psychotherapy services provided by this practice.

Estimated Cost Examples

Additional Information

• Fee Policy: All fees are non-refundable and non-negotiable. Payment secures the reserved appointment time and compensates for professional services provided or time reserved on your behalf. Fees are not adjusted, prorated, or refunded for partially attended sessions, missed appointments, late cancellations, or unused time, except as otherwise required by law. Fees may also be updated periodically with 30 days’ advance notice.
• Initial Appointment: The initial appointment is a comprehensive clinical assessment intended to evaluate your presenting concerns, treatment needs, and whether this practice is an appropriate fit for your care. Participation in an initial appointment does not guarantee that ongoing psychotherapy services will be recommended or offered. If this practice is not the appropriate level or type of care, referrals to other providers or resources may be provided when clinically appropriate.
• Extended sessions may be available when clinically appropriate and scheduling permits. Additional time is billed in 15-minute increments.
• Late cancellation or missed appointment fees apply to appointments canceled with less than 48 hours’ notice or missed appointments, as outlined in the Practice Policies.
• Professional services requested outside of scheduled appointments may include record review, treatment summaries, consultation or coordination requested by the client, and other non-clinical administrative work. These services are billed at $290.00 per hour in 15-minute increments.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

The date of this Estimate begins at the time you schedule your initial appointment with Garnica Counseling & Psychotherapy Studio-Fatima Garnica Garcia, LMFT-95659.         

In addition to my private practice, I also maintain a separate, limited relationship with Octave Health, through which a small number of insurance-based openings may be available. Octave Health has their own set of office policies, cash rates, and procedures and has no affiliations with Garnica Counseling & Psychotherapy Studio.

You may view my Octave profile to check plan eligibility and current availability:👉 https://www.findoctave.com/therapist/1265775282/fatima-garnica

Please note, that insurance availability through Octave is limited and separate from my private-pay practice. Through Octave, I do not engage with insurance companies directly as Octave manages all insurance inquiries through their system including audits, chart reviews, insurance-related phone calls, or the provision of superbills

If your insurance plan is not accepted through Octave, or if only private-pay openings are available, I am happy to add you to a waitlist if appropriate, or provide at least 3 referrals to other mental health resources. 

I do not offer free consultations, as the first appointment is intentionally structured as a clinical session rather than a brief informational call. This allows us to use the time meaningfully to assess your needs and approach your care with clinical depth and integrity from the outset.

The initial session is a full clinical appointment where we explore what has brought you to therapy, discuss your current concerns, and begin clarifying goals for treatment. This session also provides an opportunity for you to experience my therapeutic style and determine whether the approach feels like a good fit.

During this session, we may:

• Discuss your reasons for seeking therapy
• Explore current concerns and relevant history to determine care needs
• Assess for symptoms and level of care needs
• Clarify goals and desired outcomes for treatment
• Review initial recommendations based on your needs
• Determine whether my approach aligns with what you are seeking
• Provide referrals if a different level of care or therapist would be more appropriate

This approach allows you to engage in the therapeutic process in a substantive way from the beginning, rather than through a non-clinical consultation. It also supports a more thoughtful and accurate determination of fit.

Determining fit is an important part of ethical and effective care. When therapy aligns with your needs, readiness, and level of support required, the work is more meaningful, focused, and sustainable. My goal is to ensure that the care you receive is appropriate, responsive, and grounded in clinical integrity—even when that means helping you connect with resources beyond this practice.

This practice operates independently of insurance networks and provides psychotherapy on a private-pay basis only with sessions priced at $300 per 50-minute session.  Insurance billing and superbills are not provided.

Many clients choose therapy without insurance when they prefer greater confidentiality, treatment autonomy, and the ability to continue care without session limits or diagnostic requirements imposed by insurance providers.Therapy remains guided by clinical judgment and your goals rather than third-party criteria.

I strictly do not interact nor maintain any form of contact with health insurances within this private-practice space.  All clinical paperworks is strictly used for the purpose of guiding treatment and does not meet health insurance guidelines for reimbursement. 

Progress in therapy often shows up as increased self-awareness, improved emotional regulation, and shifts in how you respond to patterns, relationships, and stress. Growth is not always linear—there may be periods of insight alongside moments of discomfort as deeper emotions or experiences are explored.

Therapy has both potential benefits and challenges, and while many clients experience meaningful change, specific outcomes are not guaranteed. Consistent participation, reflection, and applying insights between sessions play an important role in supporting lasting progress.

This practice is intentionally structured with a limited caseload to support thoughtful preparation, clinical focus, and continuity of care. Maintaining a smaller number of clients allows for greater presence in sessions and a more responsive, individualized therapeutic process.

This structure prioritizes quality over volume and supports a level of care that is often not possible in high-turnover or insurance-based settings.

Appointments are scheduled through the secure client portal provided by SimplePractice 👉https://fatima-garnica-garcia.clientsecure.me/. Once you are registered in the portal, you may view available times and schedule sessions directly. This self-scheduling system allows you to select appointment times that best fit your schedule while maintaining privacy and flexibility.

To secure an appointment, payment must be completed through the client portal at least 48 hours prior to the scheduled session time. Any past-due balances must also be paid in full before a session can be confirmed.

If payment is not received within this timeframe (48 hours), the appointment may be released and the time made available for other clients.

Private-pay therapy is often a good fit for individuals who value confidentiality, autonomy, and depth in the therapeutic process. Without insurance involvement, care is not restricted by diagnostic mandates, session caps, or periodic insurance audits for ongoing severity of symptoms to determine care.

Many clients seek private-pay therapy when they

• Seek consistent care with the same clinician across different stages of growth
• Desire weekly individual therapy sessions
• Have progressed beyond insurance-defined criteria yet wish to continue meaningful therapeutic work
• Desire autonomy from health insurances when determining the course of treatment
• Prefer not to involve insurance in their care

Clients seeking Private-Pay therapy here are often active and engaged in their treatment since they know what outcomes or changes they want. Clients in Private-Pay are often ready to participate in reflective insight work in-between sessions and actively integrate practical tools, structured strategies, and clinically informed interventions designed to support sustainable change beyond the therapy space.

Therefore, care within this space is intentionally structured around a limited caseload to ensure the therapist brings focused preparation, thoughtful pacing, and sustained clinical presence. This supports an experience centered on quality rather than volume.

The length of therapy varies depending on each person’s goals and the nature of the work. Some individuals seek focused support around a specific transition or concern, while others engage in longer-term therapy to explore deeper relational patterns or personal growth.

Many clients begin with weekly sessions and may later transition to biweekly or maintenance sessions when clinically appropriate.