Your privacy matters.

This is to inform you that there may be limits to confidentiality given the risks inherent to the use of internet that would not necessarily exist for an in-person session.

All telehealth sessions are treatment sessions in the course of care and will be billed as such.

Dr. Fairfax's Notice of Privacy Practices

As a client of an California licensee you have the following rights:

- To expect that a licensee has met the minimal qualifications of training and experience

required by state law;

- To examine public records maintained by the Board and to have the Board confirm

credentials of a licensee;

- To obtain a copy of the Code of Ethics;

- To report complaints to the Board;

- To be informed of the cost of professional services before receiving the service:

- To be assured of privacy and confidentiality while receiving services as defined by rule

and law, including the following exceptions:

1. Reporting suspected child abuse, elder abuse or disabled abuse,

2. Reporting imminent danger to client or others,

3. Reporting information required in court proceedings or by client's

insurance company, or other relevant agencies, and for the management of your case

including insurance billing, initial reports to referring agencies, authorization for continued

treatment from an insurer,

4. Providing information concerning licensee case consultation or

supervision;

5. Defending claims brought by client against licensee. To be free from being the object of discrimination on the basis of race, religion, gender,

or other unlawful category while receiving services.

6. In disaster relief efforts if your welfare is at stake.

With your written permission, we may disclose to a person you identify, treatment,

information that directly relates to the person's involvement in your care or pays for your

treatment.

Confidentiality

Discussions between a therapist and a client are confidential. No information will be released

without the client's written consent unless mandated by law. Possible exceptions include, but

are not limited to, the following situations:

- If there is an real and imminent danger to you or others,

- If there is suspected abuse of a minor or disabled and/or elder adult,

- If there is information required by your insurance company or other relevant agency,

- If you are in court proceedings and confidential information is required, where

appropriate releases have been signed, or you have been court ordered to participate in

counseling,

- When defending claims brought against licensee,

- If in case consultation or supervision.

  If you have any questions regarding confidentiality, you should bring them to the doctor's

attention when you ask this topic be discussed further. No information is shared for mailing

lists or any other commercial venture. By signing this information and consent form, you are giving your consent to Dr. Fairfax to share confidential information with all persons mandated by law, and the agency that referred you, and the managed care care company and/or insurance carrier responsible for providing your mental health care Services and payment for those services, and you are releasing and holding harmless Dr. Fairfax from any departure from your right of confidentiality that may result.

Therapist

JAIN FAIRFAX, Psy.D., a licensed Marriage, Family Therapist engaged in private practice

providing mental health care services to clients, is an independent contractor/ provider for

various managed care entities. Dr. Fairfax abides by the Code of Ethics for therapists adopted

by the Board of Behavioral Science Examiners, Sacramento, California.

Philosophy and Approach

Thank you for selecting me to be your therapist. While it may not be easy to seek help from a

mental health professional, it is hoped that you will be better able to understand your

situation and feelings and move toward resolving your difficulties. As your therapist, I will

use my knowledge of human personality development and behavior, will make observations

about situation as well as suggestions for new ways to approach them. I use an eclectic

approach with a strong reliance on systems theory, looking at how patients perform in their

lives, homes, work settings and communities.

It will be important for you to explore your own feelings and thoughts and try new

approaches in order for change to occur. You may bring other family members to a therapy

session if you feel it would be helpful or this is recommended by your therapist.

Risks of Therapy

Therapy is the Greek word for change. During the course of our work together, you may learn

things about yourself that you don't like. Often, growth cannot occur until you experience

and-confront issues that induce you to feel sadness, sorrow, anxiety, anger, or pain The

success of therapy depends on the quality of the efforts your put into your inner work and the

realization that you are responsible for lifestyle changes and/or choices that may result from

therapy. Specifically, one risk of marital therapy is the possibility of exercising the

separation option.

Formal Training and Education

I hold a Doctorate in Psychology from Southern California University for Professional Studies

and a Masters in Counseling Psychology from the University of San Francisco. Both degrees

meet the requirements to be licensed as a Marriage and Family Therapist in California.

Special training was taken in Eye Movement Desensitization and Reprogramming (EMDR),

clinical hypnosis, play therapy, art therapy, and current trends in psychopharmacology. To

maintain my license, I am required to participate in annual continuing education, taking

classes that are relevant to this profession. I may substitute professional supervision for part

of this requirement.

Relationship

Our relationship as patient and therapist is a professional and therapeutic one. In order to

preserve this relationship, it is imperative that we not have any other type of relationship.

personal and business relationships undermine the effectiveness of the therapeutic relationship. The therapist cares about helping you but is not in a position to be your friend or

to have a social or personal relationship with you. Gifts, bartering, and trading services are

not appropriate and should not be shared between any patient and therapist.

Office Procedures

Appointments are made by calling (707) 526-2580 Monday through Friday between the hours

of 10 AM and 6 PM. Saturday, by special arrangements.

Cancellations must be received 24 hours before your missed appointment, otherwise you will be charged for the customary fee. You are responsible for calling and rescheduling your appointment. Third party payments (insurance) don't usually cover missed appointments and so the fee will be your responsibility.

Therapy sessions are 50 minutes. The number of visits varies greatly.

Phone calls: Calls not to place appointments and for therapy, advice, and information are

charged at the rate for office visits.

After Hours Emergencies: If you do not feel safe and/or are in danger of hurting yourself or

someone else, call 911 or Sonoma County Psychiatric Emergency Hot line...(707) 576-8181. To leave a message for Dr. Fairfax, call (707) 526-2580. Messages are reviewed several times a day. When away, someone covers Dr. Fairfax's calls.

Payment for Services 

The charge for your initial session is $140.00. This includes the visit, case planning, and

assessment. The charge for regular office visits is $130.00, unless other arrangements have

been made because of patient needs or insurance coverage

Dr. Fairfax does not normally accept assignment of insurance companies but may be required

to do so in connection with certain managed care contracts. Dr. Fairfax will look to you for full

payment of your account, and you will be responsible for all charges unless otherwise agreed

upon. Different co-payments are required by various group coverage plans. Your co-payment

is based on the Mental Health Policy selected by your employer or purchased by you. In

addition, the co-pay may be different for the first visit than for subsequent visits. you are

responsible for and shall pay your co-pay portion of Dr. Fairfax's charges for services at the

time the services are provided. It is recommended that you determine your co-payment

before your first visit by calling your benefits off ice or insurance company.

Although it is the goal of Dr. Fairfax to protect the confidentiality of your records, there may

be times when disclosure of your records or testimony will be required by law.

Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure

of your records or testimony is required by law, you will be responsible for and shall pay the

costs involved in producing the records and the therapist's normal hourly rate for the time

involved in preparing for and giving testimony. Such payments are to be made at the time or

prior to the time the services are rendered by the therapist.

If you have questions or problems concerning your counseling, you may contact

Dr. Fairfax 

or 

The Board of Behavioral Sciences

400 R. Street, Suite 3150

Sacramento CA 958.l4

(916) 44s-4933

This notice was published and becomes effective April 14, 2003.