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Marriage & Family Therapist Individual, Couple and Family Psychotherapy Certified Addictions Treatment Counselor License mfc# 52336

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Lori Sherer, M.A., LMFT

Marriage & Family Therapist

Individual, Couple and Family Psychotherapy

Certified Addictions Treatment Counselor

License MFC# 52336


CATC#133685-IV (858) 531-8305


The following information is provided to acquaint you with the policies and procedures of this office and to better assist you in your efforts towards personal growth.

I. Your Rights as a Client
1. You have the right to ask questions about any procedures used during therapy.
2. You have the right to decide at any time not to receive therapy from Lori Sherer, LMFT. If you wish, she will provide you with the names of other qualified professionals whose services you might prefer.
3. You have the right to end therapy at any time without any moral, legal or financial obligations

other than those already accrued.

II. Confidentiality
1. Within certain limits, information revealed by you during therapy will be kept strictly

confidential and will not be revealed to any other person or agency without your permission.

At times therapy will involve participation of more than one family member and/or significant

persons. While Lori Sherer will attempt to follow your wishes, she does not guarantee

confidentiality among participants in the therapy.
2. There are certain situations in which Lori Sherer is required by law to reveal information

obtained during therapy to other persons or agencies without your permission. These

situations include:
a. If you threaten bodily harm or death to another person. Lori Sherer is required by law

to inform the intended victim and appropriate law enforcement agencies.

b. If you threaten bodily harm or death to yourself, Lori Sherer will inform the

appropriate law enforcement agencies and others (such as a spouse, friend, or an

inpatient psychiatric institution) who could aid in prohibiting you from carrying out

your threats.

c. If you reveal information related to the abuse or neglect of a child, dependent adult,

or elderly person, Lori Sherer is required by law to report this to the appropriate


3. If you are the guardian of a minor or are a minor, please read the following: By signing below, I give my consent for Lori Sherer to conduct therapy sessions with the minor listed below. I have also been informed of the limitations to confidentiality in terms of treatment of the minor. I understand that special care and sensitivity may be required in releasing information to me about certain topics such as substance use and sexual activity. I accept Lori Sherer's judgment in regards to releasing information related to the treatment of this minor. In addition, I understand that if at any time Lori Sherer believes this minor is in danger of hurting him or herself, I will be notified immediately.

4. I understand that no promises have been made to me as to the results of treatment or of

any procedures provided by this therapist.

5. I am aware that I may stop my treatment with this therapist at any time. The only thing I

will be responsible for is paying for the services I have already received. I understand that

I may lose other services or may have to deal with other problems if I stop treatment. (For

example, if my treatment has been court-ordered, I will have to answer to the court.)

III. Therapy Services and Fees
1. An Individual Therapy hour is fifty minutes. Therapy sessions for couples and families are

eighty minutes. You are encouraged to schedule appointments as you feel will be of need to

you. If you are unable to attend your scheduled appointment, you must call 24 hours in

advance or you will be charged the fee for the session.

2. Payments are required at the time of your appointment, unless other arrangements have been

made in advance. If at any point in the course of treatment you are unable to pay for your

fee, please communicate this to your therapist and your fee will be negotiated.
3. Lori Sherer can be reached at (858) 531-8305, Monday through Friday 8am to 8pm. If you

have a counseling emergency after hours, please call the San Diego Access and Crisis Line at (888) 724-7240.

I acknowledge that I have received, have read (or have had read to me), and understand the "Informed Consent " form for the therapy I am considering. I have had all of my questions fully answered.

Client Signature: _____________________________________ Date: ___________________________

Client Signature: _____________________________________ Date: ___________________________
Client Signature: _____________________________________ Date: ___________________________
Client Signature: _____________________________________ Date: ___________________________

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