Hope for Healthy Families Counseling Center

8788 Elk Grove Blvd, Bldg 1, Suite L

 Elk Grove, California 95624

 Phone (916) 686-9209 Fax (916) 667-3239




Information revealed during therapy is protected by professional and ethical standards. All material is confidential and not released without your written consent except information related to suspected child abuse, elder or dependent adult abuse, and situations involving imminent harm to oneself or others.


Informed Consent

The process of therapy requires courage, commitment, and risk taking. There may be times when the information discussed in a therapy session will cause distressing feelings and/or thoughts. At times, you may experience physical symptoms because of processing distressing information. Please share this with me, so we may explore together ways in which you can manage these feelings and thoughts. Because every person is different, there is no way to predict how you will respond to the process of therapy, or how long the process will take for you. Your therapy session is 50 minutes. If your session goes longer there may be an additional charge.



Under the Health Insurance Portability and Accountability Act of 1996, we are required to provide a Notice of Privacy Practices regarding your Protected Health Information (PHI). This is posted on the wall in the office.



Your therapist is a Marriage and Family Therapy Trainee, Registered Associate Marriage and Family Therapist, Professional Clinical Counselor Trainee, a Mental Health Practitioner, or a Clinical Psychological Trainee earning hours toward graduation or licensure and is under the clinical supervision of Executive Director, Regina Isabel K’Burg, Licensed Marriage and Family Therapist #86991.


Fees and Payment

Your fee will be discussed with you prior to the first session. We request that you pay your fee at the time of each session, unless other arrangements have been made ahead of time. If your fee was established using a sliding scale, and your financial situation changes significantly during treatment, your fee will be renegotiated. We accept cash, personal checks, cashier checks, major credit cards, and PayPal. Returned checks will incur a $25 fee. Your fee is _____/session. Please keep in mind, additional fees may incur during your treatment for any phone consultations, report or letter writing, or time spent working on your case outside of session. If any written documentation of your therapy is needed, therapist need a two-week notification of the document to be written and payment of document is due at time of request. Letters are a $25 fee and fees for reports will depend upon time spend on writing the report.  



We have allocated your appointment time just for you. Cancellations or changes in session dates or times must be made 24-hours in advance. If an appointment is cancelled or missed without 24-hour notice, you will be charged for the session. If a third party is paying for your session, you will be responsible for any late cancelation or no show fees.


Your signature indicates that you have read and agree to abide by the above policies.


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Signature                                                                                                             Date

Counselor’s Initials ___________