Client Forms

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 These go to every new client, whatever kind of therapy you're starting. 

1. Porta Verum Office Policies 

The main agreement between you and your therapist — what therapy is, how sessions work, and how we handle your privacy. If you read only one form, read this one.

• The first 2–4 sessions are an evaluation, so you and your therapist can both decide whether it's a good fit
• Sessions are typically weekly — 45–53 minutes with insurance, 50 minutes private pay, about 45 minutes for children
• What you share is confidential, with specific legal exceptions: risk of harm to yourself or others, suspected abuse of a child, elder, or dependent adult, and court orders
• Porta Verum is a group practice, so your therapist may discuss your care with other clinicians on the team — all bound by the same confidentiality
• Recording sessions is not permitted without written consent from everyone present, including your therapist

2. Informed Consent for Telehealth

For sessions by video — how the platform works, and what's different from meeting in person.

• Sessions run on Telehealth by SimplePractice; no password needed, and please don't share your appointment link
• Video means easier access and no commute, but also the risk of dropped connections and technical trouble
• Either of you can end a video session and switch approaches if the connection isn't good enough
• Telehealth is not for emergencies — call 911, or call or text 988
• Includes a section on TelePlay Therapy for children: how to set up the space, and what parents can expect

3. Notice of Privacy Practices

Your HIPAA rights — how your health information can be used, when it can be shared, and what control you have over it.

• Your information can be shared without your signature for treatment, payment, and basic practice operations
• Psychotherapy notes are held to a higher standard and need your specific written authorization to release
• You can request a copy of your record (within 30 days), ask for corrections, and get a list of who it's been shared with
• You can ask to be contacted a particular way — a specific phone, a different address — and reasonable requests will be honored
• Your information is never sold and never used for marketing

4. Attendance Policy

How to cancel or reschedule, and what happens if you miss a session.

• Cancel at least 24 hours ahead — easiest through your client portal
• Cancellations inside 24 hours are charged a $120 fee to the card on file
• Missing a session without canceling ("no-show") carries the same $120 fee
• Insurance does not cover these fees, and they are non-refundable
• Serious illness or a family emergency can waive the fee — but you have to let us know before the session, not after

5. BBS Complaint Notice to Clients

Required by California law — how to file a complaint about your provider, and every clinician's license details.

• The Board of Behavioral Sciences handles complaints about LCSWs, LMFTs, LPCCs, and registered associates
• You can reach the Board at bbs.ca.gov or (916) 574-7830
• Every Porta Verum clinician's license type, number, and expiration date is listed on the form

6. Retainer Agreement and Policies for Legal Situations

What happens, and what it costs, if your therapist is subpoenaed or drawn into a legal matter. Signed by everyone, whether or not you're currently involved in one.

• Your therapist provides treatment — not court testimony, custody evaluations, or reports; you'll be referred elsewhere for those
• Court or deposition involvement requires a $3,500 retainer paid at least a week in advance
• Hourly rates run from $200 (preparation) to $350 (testimony), with a $1,000 non-refundable minimum
• Also covers records requests: 25¢ per page plus $110/hour for preparation, and $300 for a treatment summary

7. Credit Card Payment Authorization

Permission to keep a card on file and charge it automatically for sessions and fees.

• A card on file is required — we'll need it at least 48 hours before your first session
• It covers copays, deductibles, private pay fees, and any late cancellation or no-show charges
• Payment is charged the day of service, through autopay
• Charges are non-refundable unless there's an error, which we'll correct promptly
• Let us know right away if your card changes

Some of our clinicians use AI-assisted tools to help write session notes. If yours does, you'll receive this form — and you can decline it.

8. Consent for Use of AI-Supported Clinical Documentation Tools

Permission for your therapist to use AI tools to help draft session notes. Entirely optional.

• AI is used only to assist with documentation. It does not provide therapy, diagnose, or make clinical decisions
• Your therapist reviews everything and remains fully responsible for what's in your record
• Some tools involve temporarily recording and transcribing sessions — only ever with your consent
• You can decline and receive exactly the same care; your therapist will write notes manually instead
• You can withdraw consent at any time in writing, and it applies going forward

9. Couple Therapy Policy: Limited Secrets Policy

How your therapist handles information one partner shares privately — worth understanding before couples work begins.

• Your therapist holds no view on whether you should stay together or part — those questions get explored openly, and your goals lead the work
• Anything you share individually — by phone, email, or otherwise — may be relevant to the couple's work
• Your therapist reserves the right, though not the obligation, to bring that information into a joint session
• In couples work, confidentiality protects the two of you as a unit; it does not create separate private channels between each partner and the therapist

For clients under 18. Both parents or guardians must sign, whether married, separated, or divorced.

10. Consent for Treatment of Minors

A parent or guardian's permission for their child to begin therapy.

• Signed by the legal guardian to authorize treatment
• What your child discusses in session is confidential and released only with proper permission
• Confidentiality limits are spelled out in the Office Policies form, which you'll also sign
• You can revoke consent at any time, in writing

11. Treating Children of Separated or Divorced Parents

How child therapy works when parents are separated — and what your therapist will and won't do in a custody situation.

• Both parents normally need to consent before treatment can begin, and you'll need to provide current custody orders
• Your therapist does not perform custody evaluations, make visitation recommendations, or write reports to the court
• Your child's records can only be released by court order — not by either parent's signature
• Both parents receive evenhanded updates on goals and progress, though session details stay private to the child
• Parents are expected to attend parent-only sessions every 4–6 weeks

12. HCFA-1500 Consent

Lets us bill your insurance directly and have payment sent to us rather than to you. You sign this one.

• Authorizes release of the medical information insurers require to process a claim (Box 12)
• Authorizes your insurer to pay us directly (Box 13)
• Read alongside the HCFA-1500 Notification below, which shows you the actual claim form

13. HCFA-1500 Notification

The claim form itself, sent so you can see exactly what's being submitted on your behalf. Review only — nothing to sign.

• Page 1 is the standard CMS-1500 claim form with our practice details filled in
• Page 2 carries the federal notices: Medicare and TRICARE certifications, and the Privacy Act statement explaining how claim information is used
• Worth a look if you want to understand what insurers receive when a claim is filed

14. Private Pay Agreement

Sets your session rate when you're paying directly rather than through insurance.

• States your specific per-session fee for a standard 50-minute session
• Payment is due in full at the time of service
• Late cancellations and no-shows carry the $120 fee
• Reduced fees are available for financial hardship — please ask

Note: Our clinicians have different rates. This one is an example only. You'll receive the one matching your agreed fee.

15. Agreement to Opt Out of Using Insurance

For clients who could use their insurance but choose to pay privately instead.

• Nothing is billed to your insurance, so these sessions won't count toward your deductible
• You're responsible for the full session fee, set in a separate Private Pay Agreement
• You can switch to using insurance later — tell us in writing, and it applies going forward only
• Sessions already paid privately can't be billed retroactively

16. Responsibility for Payment

Confirms who is financially responsible for the therapy — used when someone other than the client is paying.

• Payment is due at the time of service unless otherwise agreed
• The rate comes from either the Private Pay Agreement or the insurer's Explanation of Benefits
• Late cancellations and no-shows carry the $120 fee
• Paying for someone's therapy does not give you access to their confidential information

17. Informed Consent for Services from a Supervised Registered Associate

For clients working with one of our pre-licensed associate therapists — what supervision means for your care.

• Your clinician holds a qualifying graduate degree and is completing the supervised hours required for licensure
• Their work is supervised by Paula Kettula, LCSW, who holds final professional and legal responsibility for your care
• You are legally the supervisor's client, and your case is discussed in supervision — protected by the same confidentiality
• You can ask about your clinician's training, request a licensed clinician instead, or contact the supervisor directly at any time
• If your clinician leaves the practice, the supervisor will help you transfer or find a referral

Questionnaires and brief measures sent through your client portal before your first session. They let your therapist arrive already understanding your situation, so the first session is spent on you rather than on paperwork.

18. Intake Questionnaire — adults

The main background form for adult clients.

• Starts with the two big ones: what brings you in, and what you'd like to get out of therapy
• Covers past therapy, current symptoms, medical history and medications, family and relationships, and any trauma history
• Includes direct questions about self-harm and thoughts of suicide — standard for a safe intake, and honest answers help your therapist support you properly
• Ends on your strengths, supports, and identity — what matters to you, not only what's hard
• Takes most people 20–30 minutes; write "N/A" for anything that doesn't apply

19. Adolescent Intake Questionnaire — ages 14–17, completed by the teen

The young person's own version, in their words rather than a parent's.

• Asks what they want help with, and has them rank their concerns on a 1–10 scale
• Covers school, grades, friendships, and how daily life is going
• Asks openly about substance use, relationships, and mental health history
• Ends with family relationships and who's in their corner — their "inner circle"
• Written to be answered privately and honestly, protected by the same confidentiality rules

20. Child Intake Questionnaire — completed by a parent about their child

Background on your child, including early history a young child couldn't report themselves.

• Starts with why you're seeking therapy for your child and what you hope it achieves
• Covers household and family situation, school history, pediatrician, and current medications
• Asks about pregnancy, birth, infancy, and developmental milestones — useful context for understanding your child now
• Includes medical, behavioral, and family history checklists
• Around 22 questions; write "N/A" for anything you don't know or that doesn't apply

21. ACEs — Adverse Childhood Experiences, adults 18+

A brief, widely used screener about difficult experiences before age 18.

• Asks yes-or-no questions about abuse, neglect, and household stressors during childhood
• Early adversity shapes stress responses and coping patterns well into adult life — knowing your history helps your therapist understand what you're carrying
• Short to complete, though the subject matter can be heavy; you can pause, and you can raise anything it stirs up in session

22. CATS — Child and Adolescent Trauma Screen, completed by a caregiver

A screener for children who may have experienced frightening or overwhelming events. Two versions, one for ages 3–6 and one for 7–17.

• Asks whether your child has been exposed to specific potentially traumatic events
• Then asks how often you've noticed particular stress reactions since
• Helps your therapist tell ordinary distress from trauma-related symptoms, which are treated differently

23. GAD-7 — anxiety, adults

A seven-question measure of anxiety symptoms over the past two weeks.

• Takes about two minutes
• Gives your therapist a baseline, and repeating it later shows whether things are shifting
• A screening tool, not a diagnosis — your therapist interprets it alongside everything else

24. PHQ-9 — depression, adults

A nine-question measure of depression symptoms over the past two weeks.

• Takes about two minutes
• Tracks mood, sleep, energy, appetite, and concentration, and includes one question about thoughts of self-harm
• Used at intake and periodically afterward, so you and your therapist can see change over time
• A screening tool, not a diagnosis

25. Tips for Therapy Success — recommended reading

Not a form to complete — a short read about what therapy actually feels like, including the uncomfortable parts.

• Showing up consistently matters more than people expect; the rhythm of sessions is part of how the work happens
• Feeling stuck, bored, or like you're not progressing is normal — and worth raising rather than sitting on
• Wanting to quit, especially when things get hard, is a common and meaningful part of the process
• Sometimes it isn't the right fit, and saying so is a healthy thing to do
• Therapy is meant to end — the goal is you living well, not staying in therapy forever