Disclosure Statement & 

Agreement for Services

This document is intended to provide important information regarding your treatment. Please read it carefully and ask any questions you may have regarding its contents.

 This statement applies to

Carolyn B Cooper, MS, LMFT

(CA Lic. No. 44480) since 2007

My post-graduate education and training includes EMDR Certification, a Substance Abuse Professional Certificate, Problem Gambling training, and HeartMath's "Resilient Heart" certification in biofeedback.

After the 3-year Somatic Experiencing (SE) training, I pursued Co-Regulating Touch (CT) skills for trauma therapists, and healing complex and developmental (childhood) trauma with Kathy Kain's and Steve Terrell's "Somatic Resilience & Regulation"course. Five years of teaching assistantships in SE trainings enhanced my understanding, ability to track and engage the autonomic system as it relates to psychotherapy.

Committed to providing the highest level of service, I continue to develop my skillfulness through continuing education, consultations, intensives and through regular personal work. Please feel free to ask questions any time about my professional background, experience and orientation.

Additional information: LinkedIn.

Primary Qualifications:

· Licensed Marriage & Family Therapist (LMFT) since 2007

· Somatic Experiencing Practitioner (SEP) since 2014

· California Office of Problem Gambling Authorized Outpatient Services Provider 2011 - 2017

· EMDR-IA Certified EMDR Practitioner 2009 - 2019

· Substance Abuse Professional (SAP) 2007- 2017

Fees and insurance:

$275 Psychotherapy Intake & Individual Therapy Session (50 minutes)

$200 Case Management/Collateral (50 minutes, pro-rated if brief)

$2400 Expert Witness Daily Fee

$300 Expert Witness Hourly Fee

$1500 Extreme Hardship Evaluation & Letter

$1575 Initial SAE/SAP Evaluation with treatment recommendations and necessary follow-up to the first meeting

$325 Follow-up SAP Evaluation with recommended testing schedule and any necessary follow-up insurance/EAP not accepted for SAP/SAE Evaluations

Payment & Billing

Payment is due at the time services are rendered. Please make clear if you wish to discuss an alternative payment procedure. I will notify you at least 30 days in advance of any fee increases. Zelle is preferred, but other options include IvyPay, a secure portal created for therapists by Square. If you wish to use a credit card, HSA or FSA, IvyPay is the best option. Venmo & PayPal may also be used.

Please indicate whether you wish to submit billing statements to a health insurance plan, or that you require an annual statement for itemized tax deductions. Know that not all therapy services are covered. Plans generally limit coverage to certain diagnosable mental and/or behavioral conditions which create significant functional impairment to education, employment and/or social activities. Benefits and coverage, including reimbursement rates, coinsurance payments (copays), deductibles, etc., vary widely. It is your responsibility to verify and know the specifics of your coverage.

Appointment Scheduling and Cancellation Policy

Therapy sessions are typically scheduled to occur one time per week at the same time and day if possible. We may adjust to a different frequency depending on the nature and severity of your concerns and goals. Your consistent attendance and participation in any suggested extra-session activities (journalling, yoga, meditation, addressing health concerns, etc.) contributes greatly to a successful outcome.

To cancel or reschedule an appointment, please notify me at least two business days in advance of a scheduled appointment. If you do not, your signature below indicates your agreement to pay in full for the missed session. Also, please be aware insurance companies do not pay for missed or cancelled sessions.

Exceptions to Confidentiality

Most communications between us will be held in strict confidence unless you provide explicit permission to release information about your treatment or assessment.

If you participate in conjoint (marital, family or group) therapy, then I will not disclose confidential information about your treatment to a third party (other than your insurance/payer), unless all participants provide written consent to release information.

Therapists are legally mandated to report known or suspected instances of child abuse, dependent abuse, and elder abuse to respectively appropriate protective authorities. Therapists are also required by law to break confidentiality if a client presents a danger to someone else or to self.

Please notify me if you release information to another provider or to a potential employer. We will discuss what you wish to be shared.

Minors and Confidentiality

Communications between therapists and clients who are under 18 years old are confidential. However, parents and legal guardians who consent to treatment are often involved in the treatment plan to support active engagement and wellness goals. Consequently, I may exercise professional judgement to share information if we are unable to collaboratively determine how this information may be shared. Clients who are minors and their parents are urged to discuss any questions or concerns they have on this topic, and to bring them up in session.

Therapist Availability Between Sessions

Occasional telephone consultations between office visits are sometimes necessary to communicate unexpected absences or to request additional support. You may leave a message at any time on by voicemail, email or text. Such contact should be brief as more important issues are better addressed within regularly scheduled sessions.

Calls and email exchanges regarding issues that require more than 10 minutes to sufficiently resolve will incur a fee pro-rated to the time spent. Should such contact occur more than once or twice monthly, additional sessions may be suggested to better address your issues.

Non-emergency calls are returned the next business day. During absences, we will work together to help you develop arrangements for continued service with another professional if needed. I will provide contact information for a trusted colleague in the event a crisis requires contact prior to my return.

24-hour support cannot be guaranteed, so establishing additional support sources is strongly encouraged and may become a focus of treatment.

If you reach out to vent and/or request a return call, please be sure to indicate which you need - in addition to your name, number, and a brief message.

Termination of Therapy Services

The length of your treatment and the timing of the termination of services depends on the specifics of your treatment plan and the progress you hope to achieve. We will discuss a plan for termination as you approach the completion of your therapy goals. If you or your therapist determine that you are not benefitting from treatment, either of you may elect to initiate a discussion of treatment alternatives. These may include referrals, changing treatment plans or organizing additional sources of symptom management.

Substance Abuse Professional (SAP) & Extreme Hardship Evaluations

Assessments, recommendations and letters of completion are released after payment is made. If you use a check or money order to pay for services, all letters will be mailed no earlier than 2 weeks after received.

For SAP evaluations, any recommendations must be completed within the period specified on your letters, or your employer will be notified that you are noncompliant. If you have extenuating circumstances (e.g., illness, significant loss), you must notify this SAP evaluator at your earliest possible convenience to seek an appropriate time extension.

Somatic Experiencing & Co-Regulating Touch

When appropriate, and according to my clinical judgment, I may propose the incorporation of Somatic Experiencing (SE) and/or Co-regulating Touch (CT) into our work together.

Developed by Dr. Peter Levine, SE is a nervous system-oriented approach to the resolution and healing of trauma supported by evidence-based research. It is based upon observations that wild prey animals, though threatened routinely, are rarely traumatized by their experiences into mood or anxiety disorders. Animals in the wild utilize innate mechanisms to regulate and discharge high levels of arousal associated with defensive survival behaviors. These mechanisms provide animals with a build-in immunity to trauma that enables them to return to normal in the aftermath of highly charged, life-threatening experiences.

SE integrates awareness of bodily sensations, emotions, thoughts, behaviors and images to help people renegotiate and heal, rather than relive or re-enact trauma. SE's guidance of this integration allows highly aroused survival energies to be safely experienced and gradually discharged. When mutually agreed upon and applied appropriately, SE may employ touch to support the completion of survival impulses or to increase enervation/reduce constriction in parts of the body dissociated due to overwhelm. SE titrates experience or breaks into small incremental steps what might otherwise overwhelm an individual.

SE can result in several benefits, such as relief of traumatic stress symptoms, increased resilience and resourcefulness. Like any other treatment, it may also have unintended side effects, such as sleep disturbances, frightening memories, or other unfamiliar and uncomfortable body sensations/symptoms. Such reactions are not uncommon and can be attended to in the course of our work together.