1190 S. Bascom Ave. Suite 208 • San Jose, Ca 95128 • 408-709-9834   Schedule FREE Consultation   Schedule Appointment

Informed Consent

Informed Consent

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask your therapist any questions that you may have regarding its contents. 

Information About Your Therapist 

At an appropriate time, your therapist will discuss his/her professional background with you and provide you with information regarding his/her experience, education, special interests, and professional orientation. You are free to ask questions at any time about your therapist’s background, experience and professional orientation. 

About the Therapy Process 

It is your therapist’s intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to your therapist and the specifics of your situation, your therapist will provide recommendations to you regarding your treatment. We believe that therapists and patients are partners in the therapeutic process. You have the right to agree or disagree with your therapist’s recommendations. Your therapist will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion. 

Your therapist will work with you to develop an effective treatment plan. Over the course of therapy, your therapist will attempt to evaluate whether the therapy provided is beneficial to you. Your feedback and input is an important part of this process. It is the goal of your therapist to assist you in effectively addressing your problems and concerns. However, due to the varying nature and severity of problems and the individuality of each patient, your therapist is unable to predict the length of your therapy or to guarantee a specific outcome or result. 


All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that your therapist utilizes a “no-secrets” policy when conducting family or marital/couples therapy. This means that if you participate in family, and/or marital/couples therapy, your therapist is permitted to use information obtained in an individual session that you may have had with him or her, when working with other members of your family. 

Please feel free to ask your therapist about his or her “no secrets” policy and how it may apply to you. 

There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child, dependent adult or elder abuse. Therapists may also be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself. 

Minors and Confidentiality 

Communications between therapists and patients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, your therapist, in the exercise of his or her professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker. Patients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their therapist. 

Appointment Scheduling and Cancellation Policies 

Sessions are typically scheduled to occur one time per week at the same time and day if possible. Your therapist may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify your therapist at least 24 hours in advance of your appointment. If you do not provide your therapist with at least 24 hours’ notice in advance, you are responsible for payment for the missed session. 

Insurance Reimbursement 

Tino Silva’s practice is a “self-pay” private practice and does not work with or bill insurance company’s. At your request, he may provide a “Superbill” (insurance invoice) which has all the information required for you to submit to your insurance for a possible reimbursement. It is your responsibility to check with your insurance company to determine if there is coverage for therapy, the amount of the deductible and whether any documentation is required for reimbursement of therapy costs. If requested, Tino will provide you with a bill that can be submitted to your insurance company for your reimbursement. 

Contacting Tino Silva, Licensed Marriage Family Therapist

Between therapy appointments, you can contact Tino Silva at 669-256-0206 and leave a detailed message. Your message will be returned as soon as possible. Billing for emergency services will be done based on the clinician’s rate at 1 1⁄2 times their billable hour.  

Tino Silva’s practice is NOT a crisis center or provider. In the event of a psychological emergency or when you need to speak to someone immediately, please leave me a voicemail and then contact the Suicide and Crisis Prevention 24-hour crisis line at (408) 279-3312. If you have any questions about any of the above items, please feel free to discuss them with Tino. 

I have read and understand all of the terms and conditions stated above regarding therapy. All my questions have been answered fully. I understand and agree to the terms and conditions of this agreement.

© Tino Silva, LMFT 2019
Call Now ButtonCall Now