Rob Martin LMFT #109329


APPOINTMENTS AND CANCELLATIONS Please remember to cancel or reschedule 24 hours
in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to
determine the length of time of your sessions. Requests to change the 50-minute session needs to
be discussed with the therapist in order for time to be scheduled in advance.

A $10.00 service charge will be charged for any checks returned for any reason for special

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT
LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to
you and is held exclusively for you. If you are late for a session, you may lose some of that
session time.

TELEPHONE ACCESSIBILITY If you need to contact me between sessions, please leave a
message on my voice mail. I am often not immediately available; however, I will attempt to
return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to
phone sessions. However, in the event that you are out of town, sick or need additional support,
phone sessions are available. If a true emergency situation arises, please call 911 or any local
emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your
confidentiality and the importance of minimizing dual relationships, I do not accept friend or
contact requests from current or former clients on any social networking site (Facebook,
LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise
your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic
relationship. If you have questions about this, please bring them up when we meet and we can
talk more about it.

ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of
communication through electronic media, including text messages. If you prefer to communicate
via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I
may try to return messages in a timely manner, I cannot guarantee immediate response and
request that you do not use these methods of communication to discuss therapeutic content
and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the
Internet, facsimile machines, and e-mail is considered telemedicine by the State of California.
Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of
information technology to deliver medical services and information from one location to another.
If you and your therapist chose to use information technology for some or all of your treatment,

you need to understand that: (1) You retain the option to withhold or withdraw consent at any
time without affecting the right to future care or treatment or risking the loss or withdrawal of
any program benefits to which you would otherwise be entitled. 

(2) All existing confidentiality
protections are equally applicable. 

(3) Your access to all medical information transmitted during
a telemedicine consultation is guaranteed, and copies of this information are available for a
reasonable fee. 

(4) Dissemination of any of your identifiable images or information from the
telemedicine interaction to researchers or other entities shall not occur without your consent. 

(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include,
but are not limited to improved communication capabilities, providing convenient access to up-
to-date information, consultations, support, reduced costs, improved quality, change in the
conditions of practice, improved access to therapy, better continuity of care, and reduction of lost
work time and travel costs. Effective therapy is often facilitated when the therapist gathers within
a session or a series of sessions, a multitude of observations, information, and experiences about
the client. Therapists may make clinical assessments, diagnosis, and interventions based not only
on direct verbal or auditory communications, written reports, and third person consultations, but
also from direct visual and olfactory observations, information, and experiences. When using
information technology in therapy services, potential risks include, but are not limited to the
therapist's inability to make visual and olfactory observations of clinically or therapeutically
potentially relevant issues such as: your physical condition including deformities, apparent
height and weight, body type, attractiveness relative to social and cultural norms or standards,
gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures,
physical or medical conditions including bruises or injuries, basic grooming and hygiene
including appropriateness of dress, eye contact (including any changes in the previously listed
issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence
of language and facial or bodily expression. Potential consequences thus include the therapist not
being aware of what he or she would consider important information, that you may not recognize
as significant to present verbally the therapist.

MINORS If you are a minor, your parents may be legally entitled to some information about
your therapy. I will discuss with you and your parents what information is appropriate for them
to receive and which issues are more appropriately kept confidential.

TERMINATION Ending relationships can be difficult. Therefore, it is important to have a
termination process in order to achieve some closure. The appropriate length of the termination
depends on the length and intensity of the treatment. I may terminate treatment after appropriate
discussion with you and a termination process if I determine that the psychotherapy is not being
effectively used or if you are in default on payment. I will not terminate the therapeutic
relationship without first discussing and exploring the reasons and purpose of terminating. If
therapy is terminated for any reason or you request another therapist, I will provide you with a
list of qualified psychotherapists to treat you. You may also choose someone on your own or
from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other
arrangements have been made in advance, for legal and ethical reasons, I must consider the
professional relationship discontinued.