Professional Services Agreement

Please read the following carefully. By signing this agreement, you agree to the acceptance of these terms. Should you have any questions concerning this agreement please ask me in person, call or email my office. All clients engaging in a counseling relationship must be 18 years or older or must be accompanied by a parent or guardian at the initial appointment.

Education and Experience

I am a Licensed Mental Health Counselor (LMHC) Marriage, Family Therapist (MFT) and Child Mental Health Specialist (CMHP) with over 14 years of experience working with children, adolescents, adults and families in agencies and private practice settings. I hold a Master's of Science in Counseling Psychology (MFCC/MFT) from California University, Chico (MS, 1998)

I am deeply committed to supporting and encouraging children, teens, adults and families in their process of healing from: anxiety, depression, grief and loss, trauma and stress, attention-deficits, impulsivity, addiction, mood swings, relationship conflicts, parent-child issues, adoption and attachment issues, physical and sexual abuse issues, and self-harming behaviour among teens and young adults.

Treatment Philosophy

I maintain a strength-based and solution-focused approach to counseling. It is my goal in counseling to encourage individuals to become more accepting and aware of their unique strengths as well as their limitations, and to assist my clients in taking greater pride and ownership of the power and responsibility they possess to direct and alter the course of their own thoughts, feelings and actions in life.

Methods and Approaches

Depending on the individual needs of my client, I draw from a variety of clinical and therapeutic approaches including: Dialectical Behaviour Therapy (DBT), Cognitive Behavioural Therapy (CBT), Expressive Art & Play, Gesalt, Jungian and Family Systems Psychotherapy.

Your Legal Rights and Limits Regarding Privacy and Confidentiality

To continue my professional development and provide you with the best quality of care, I consult regularly with a team of other professional counselors. Should I discuss your therapy with other counselors, I will only relate the content of our work together. Unless we form a special agreement, you will not be named, nor will I share any details of you life that might identify you. If you have any concerns or questions about this please let me know.

For parents of children under the age of 13: you have the right to full access to the content of the therapy sessions. However, in order for therapy to be most effective, it is important to maintain confidentiality between the client and myself. For this reason, I ask you to honor this confidentiality, and for you to understand that if material arises that I believe you may need to know about, I will inform you directly. I will provide you with general updates of you child's progress, but I will omit specific details unless I believe them to be necessary. Please let me know if you have further questions or concerns regarding this policy prior to the onset of my services.

Evaluation for Services

Prior to onset of counseling, you will be asked to provide me with specific information regarding your current situation as well as any background information which will help me support you in determining your needs and goals in counseling. This can be accomplished during an intake session, or you can choose to complete a Counseling Intake Form via email prior to your first counseling session.

Fees and Scheduling

My rate for a 45-60 minute counseling session is___________. For a 90 minute couples or family session, my rate is __________. Payments are to be made to: Jane V. Farley, prior to the onset of each session, so that we may spend all of the session focusing on your needs and goals in counseling. In the event that payment becomes a barrier to you, we can discuss my sliding fee scale alternative therapy referral options. Occasionally I find it necessary to increase my fee due to inflation. If this occurs during your treatment, you will be given a month's notice prior to the increase. If you have any questions regarding payments, I encourage you to ask.

If you are intending to use insurance mental health benefits to pay for all or part of your treatment costs, you should be aware that my contract is with you, not your insurance company. Although I am happy to assist you with acquiring reimbursement from your insurance company, you are financially responsible for payment of all fees up-front. You should also be aware that there are certain treatment circumstances for which insurance companies generally do not provide payment: i.e. missed but scheduled sessions, telephone consultations, etc.

PLEASE NOTE: When we make an appointment, I am committing to hold that time for you. If you are unable to keep your scheduled appointment for any reason, please give me at least 24 hours advance notice or you will be charged the full amount for the time reserved for you. If I miss a scheduled appointment without notifying you, I will make up the session with you without charge. Regardless of whether you are here to begin your session on time, I will need to end the session at the scheduled time. If I am late in beginning the session, I will make up the time for you.

Phone Contact and Email Policy

If you need to contact me between sessions and would like me to call you back, please request that in your message and leave your phone number even if you think I already have it. It is my policy to try and return calls within 24 hours. However, there are times where I may miss your call or where I may be unavailable for longer periods (e.g. out sick, on vacation or handling crisis calls) or unavoidably detained. Therefore, if you are needing more immediate assistance or are having a mental health emergency, you need to call: the SF Crisis Line at: 1-800-273-TALK (1-800-273-8255), Child Crisis Services tel: (415) 970-3800 or the Suicide Prevention Hotline at: 1-800-273-TALK (1-800-273-8255). If you are afraid of harming yourself or others, you need to call 911 or go to the nearest Emergency Room where professionals are trained to assist you. Email and texting are NEVER to be used as a method of communication during a crisis or for "counseling". For changes in scheduling, please call and leave me a voice message: (310) 498-0080.

Referrals for Additional Services

If either you or I determine that you need additional services not offered by me in my practice, I will provide you with referrals whenever possible. However, it is your responsibility to contact and accept these services and their outcomes.

Termination of Services

As my client, you may choose to terminate the counseling relationship at anytime. As your counselor, I may terminate the relationship if I feel you have reached your goals, or if you are not progressing under my care, or require additional services outside of the range of my scope in practice. I look forward to working with you and assisting you in achieving your personal goals in counseling.

Sincerely, Jane V. Farley, LMHC, MFT


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Parent/Guardian Signature (if under the age of 18)


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