CONFIDENTIALITY: According to California Law ALL information related to mental health is confidential, including the fact that you even attend counseling. This ensures your privacy.

EXCEPTIONS: Billing information to Insurance Companies, Victim of Crime Board, County Agency, or any other Agency involved in payment of your session fee.

MANDATED REPORTING LAW: Therapists are mandated by California Law to report to the appropriate authorities any suspicion of the following; *elder abuse  *child abuse *danger to self, others, or property *inability to care for personal needs (dressing, eating, oriented to time and place) *entered into a court case
VOLUNTARY RELEASE:

You may release your own confidential information for certain purposes (e.g., working with a social worker, layer, etc.). This requires your signed permission and a record of released information is kept in your file.

 

COURT ORDER:

Records May be required for, and/or a therapist may have to testify in criminal or civil proceedings.

 

CONDIDENTIALITY IN THE COMMUNITY;

Small town concern; Since this is a small town/community and counseling is confidential, it may become awkward if we see each other in town. I will not acknowledge clients outside of the office. This is not meant to be rude or hurtful but rather to protect your privacy. If you say HI I will say HI back. In addition, if you know people who come to the agency for services, please respect their confidentiality and privacy by not discussing the fact they attend with anyone else.

 

I have read, discussed, and understand the above information. I understand the importance of confidentiality and will respect the privacy of fellow clients.

 

 

PSYCHOTHERAPY TREATMENT AUTHORIZATION

 

Authorization is hereby given for psychotherapy treatment for my minor child

*I understand everything said in session is confidential by California law. Parents are also excluded in this confidentiality law. If information is given parents should know, the therapist and the client will work out how to tell the parent.

*I understand there are exceptions to this law as follows;

            If child abuse is suspected

            If elder abuse is mentioned

            If client is in danger of harming self, others, or others property

            If client is unable to care for self (if a minor, minor is living independently)

*I understand I must sign an authorization for exchange of ANY information, so the therapist may communicate with individuals outside of this office. Those “others” may include teachers, doctors, previous therapists, and/or another parent or caregiver.

*I understand this authorization can be changed and/or revoked in writing at any time.

 

AUTHORIZATION FOR EXCHANGE OF INFORMATION

 

Authorization is hereby given for the exchange of relevant information regarding the above mentioned minor client between Yvonne Sinclair M.A., MFCC and ;

When is there a time,

When you can speak out,

Open your mouth,

And give a great shout.

 

Tell another person,

Just how you feel,

When do you get,

Your end of the deal,

 

When is enough,

Finally enough,

And when does the going,

Stop getting tough,

 

When can you relax,

When is your brake,

When do other people,

Stop being fake.

 

I almost think,

People never stop Hating,

But until they do,

I’ll be waiting……….

 Written by a 14 year old young man……PUBLISHED

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your health information. I encourage you to read it in full.

My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at 916-434-2877.

If you have any questions about my Notice of Privacy Practices, please contact me at 898 5^th Street, Suite E, Lincoln California.

I acknowledge receipt of the Notice of Privacy Practices of Lincoln Counseling Center and Yvonne Sinclair M.A., MFCC.

  INABILITY TO OBTAIN ACKNOWLEDEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 I made good faith attempts to obtain my clients acknowledgement of his or her receipt of my Notice of Privacy Practices, including the following;

 However, because of the following;  I was unable to obtain my client’s acknowledgement.

NOTICE OF PRIVACY PRACTICES

        All information obtained from you is protected and kept confidential. With the following exceptions;

            Therapists are mandated by California law to report to the appropriate authorities any suspicion of the following; Elder abuse, Child abuse, Danger to self, others or property,

Inability to care for personal needs (dressing, eating, oriented to time and place)

            Your confidential information can be released for certain purposes, such as working with a social worker, lawyer etc. This requires your signed permission and a record of released information is kept in your file.

            Records may be required for, and/or a therapist may have to testify in criminal or civil proceedings. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.

USES AND DISCLOSURES

            Your protected health information is never sold, rented, transferred, exchanged, and/or used for non-healthcare related purposes including marketing activities without your written authorization. Your protected health information is disclosed to third-party entities without your written authorization for the purpose of treatment or to obtain payment for treatment, and for healthcare operations.

CERTAIN CIRCUMSTANTES

            Your protected health information can be disclosed without your written authorization in certain limited circumstances; Medical or mental health emergencies, Situations required by law-see above.   For any other purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information. You can revoke that authorization in writing at any time.

 

PATIENT RIGHTS

You have the right to request in writing in inspect and /or receive a copy of your health information*

You have the right to request an alternate means or location to receive communications regarding your health information.

You have the right to request in writing to amend, correct, or delete any recorded health information within our possession.*

You have the right to request in writing to restrict some of the uses and disclosures of your health information*

You have the right to request in writing an accounting of certain disclosures of your health information that were made by this office;*

*Conditions and Limitations may apply.

CHANGES TO THIS NOTICE;

We reserve the right to change privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, an updated notice will be posted and a copy made available to you.

PROSPECTUS;

Primary target for this book is any couple perceiving they have trouble in their relationship, from small communication problems to domestic violence. Secondary market would be any couple wanting to enhance their relationship through better communication skills or ideas and exercises to increase their emotional and physical intimacy.

The market would be huge for this book. It is a concise easy to follow relationship healing and enhancement program. The market would include any couple or individual seeking help or information on relationship.” More than one million people search for “marriage counseling” on the internet each 30 days.

This book addresses the problem of relationship snags. It walks the couple or individual through relationship healing and/or learning tools to enhance the relationship. It addresses the common problem of communication failure, fighting that does not resolve issues, domestic violence and anger expression, family of origin issues along with co-dependent behaviors, and help for creating emotional intimacy that lasts.

 The new breakthrough method of this book is that all the tools for relationship health are in one place. The book steps the reader through from beginning communication all the way to Hot Monogamy. It is easy to follow and uses time tested methods that work for couples.

 Key Selling Points:

  

objective: MENTAL HEALTH PROVIDER
	CURRICULUM VITAE
Experience
	August 1, 2001 to Present   Director-Lincoln Counseling Center  Private Practice as Licensed Marriage Therapist n  Counseling clients; groups, individuals, families, children, couples, court ordered clients, CPS and Victim of Crime referrals, school referrals. n  Issues; Not limitied to the following; Anger management, couples, family therapy, parenting, abuse counseling, domestic violence, Attention Deficit Disorder, Mood disorders, transgenerational parenting, blended families, sexual disorders, and self actualization. n  Modalities; Traditional talk therapy, sandtray worldplay therapy, art therapy, play therapy, and hypnosis.   Webmaster: author: E.Vaughn’s Complete Guide to Hot Monogamy -eBook and Eight Audiobook CDs E.Vaughn’s Surviving Infidelity -Audiobook CD Anger Management in Seven Easy Steps for Adults -Audiobook CD and workbook E.Vaughn’s Guide to Taming Angry Kids -Audiobook CD and workbook E.Vaughn’s Scoop for Angry Teens -Audiobook CD and workbook Instructional and Eduational Program for Anger Management for Parents -Audiobook CD and workbook
	August 1, 2001 to January 1, 2002   REACH Counseling – (Private Counseling Agency) n  Counseling Clients:Individuals, families, and children n  Consultation for the agency in play therapy, art therapy, and sandtray world play therapy. Contact person: Kathy Ellis, LMFT, Director
	November 1997 to August 2001   Cross Creek Family Counseling  (Private Counseling Agency) n  Counseling Clients:  Individuals, families, couples, groups, and children. n  Parent Partner  Developed and facilitated educational forums for parents and caregivers. Assembled and supervised distribution of handbooks for parents on discipline and parenting helps. Provided individual support for parents. Managed new client communication:      Responded to potential client’s inquiries about therapy.      Facilitated client’s first appointment for intake, gathering information regarding symptoms, explaining confidentiality, setting fees, and making alternate referrals when needed. n  Conducted consultation and education for staff: Children’s therapeutic issues,Therapy techniques, such as Sand Tray/World Play, Art Therapy, Talk therapy, and Play Therapy Parent Partner: Developed and facilitated educational forums for parents and caregivers. Assembled and supervised distribution of handbooks for parents on discipline and parenting helps. Provided individual support for parents.
	December 1993 to November 1997 Associated Family Therapy for Effective Recovery (A.F.T.E.R.) (Private Counseling Agency) n  Counseling clients, individuals, families, children, couples, court ordered clients, CPS and Victim of Crime referrals. n  Independently created a board game for groups to teach the difference between aggressive, passive, and assertive behavior. This game was used to teach clients to notice offender behavior verses victim and/or healthy behavior. n  Developed and facilitated groups for children on anger management. n  Supervised court ordered parent visits. n  Developed and supervised “Grandparents United, “a support group for grandparents and other transgenerational caregivers. n  Presented workshop; specifically chosen by the parents of “Parents United” to create and facilitate a workshop for member of Parents United. n  Co-facilitated counseling groups: Group titles included; Communication, Boundaries, Parenting, Adults molested as children, From Victim to surviving and thriving, Sex offenders, Molest dynamics, Dysfunctional family systems, and Non-offending parents.
	Created and Presented Workshops for Community Groups n  Parenting Tips to Reduce Stress n  Prevention of Child Sexual Abuse n  Survival Plan for Unplanned Parenthood: Grand parenting and transgenerational parenting issues n  Sand Play World Play Therapy Demonstration n  Assessing, Managing, and Treating the Anxious or Phobic Dental Patient
Education
	Masters in Counseling Psychology National University n  Graduated with distinction. Certified Sand play Therapist-80 hours completed in 1995 Hypnotherapy – 72 hours completed in 1994 n  Clinical Hypnotherapy and Advanced Hypnotherapy training and practicum program… Additional Training Attended: 2009 n Medical Errors in the Mental Health Profession         2 Hours n Sexual Abuse in Children                                                      2 Hours   nUnderstanding Fetal Alcohol Syndrome & Fetal Alcohol Spectrum Disorders                                                           3 Hours n Obesity in Children                                                                                                  2 Hours n Utilizing Cultural Competence in Mental Health Practice                                                                                                        1 Hour n Understanding Methamphetamine for Mental Health Professionals                                                                         1 Hour n Dealing With Difficult People When They Are Not Our Clients                                                                                      2 Hours n Understanding Trauma in Children                                                         2 Hours n Interventions to Help Heal Traumatized Children  2 Hours n Strength-Based Supervision                                                                       2 Hours n The Mental Health Provider's Guide to Applied Behavior Analysis                                                                                 2 Hours n Understanding Infant Mental Health                                            3 Hours n Autism Spectrum Disorder in Children                                         2 Hours n Understanding Asperger Syndrome                                                         2 Hours n Alzheimer Diagnostic Basics for Mental Health Professionals                                                                        2 Hours n Law & Ethics                                                                                                                    6 Hours 2007 n  Law and Ethics – 6 hours n  Asperger’s Disorder – 3 hours n  Cybersex Addiction – 3 hours n  Human Sexuality – 5 hours n  Effect of Divorce and Remarriage on Children – 1 hour n  Mental Status Exam – 1 hour 2006 n  Art therapy for Anxiety – 6 hours n  Treating Children-Legal Issues – 2 hours n  Child Abuse Reporting for MFT’s-2 hours n  Confidentiality – 2 hours n  The Dangerous Patient and the Therapist’s Duty – 2 hours 2005 n Human Awareness Institute Level One workshop, The     Miracle of Love – 48 hours n Human Awareness Institute Level Two workshop, Loving Yourself– 48 hours n  Aging, Mental Health and Long-aterm Care – 3 hours 2004 Spousal/Partner Abuse-7 hours Healthy Personality/ Subjective well-being – 6 hours Law and Ethics – 6 hours n    Depth Oriented Brief Therapy – 12 hours 2003 n  Current Issues in Nutrition, Health, and Weight – 6 hours n  The Psychology of Creativity-6 hours n  The Developing Mind-6 hours 2002 n  Art and Play Therapy with School-aged Children – 6 hours n  Child and Family Law for Psychotherapists – 6 hours n  Clinical Supervision – 6 hours 2001 n  HIV/AIDS – 7 hours n  OCD client – 6 hours 2000 n  Advances in Treating Complex Psychological Trauma and PTSD – 6 hours n  Listening to the Body – 6 hours n  Personality Disorders in Social Work and Behavioral Health – 7 hours n  Really a Bad Kid: Using the Special Ed Not System to Remedy Behaviorally Disturbed Youth – 2 hours 1999 n  Understanding and Treating Reactive Attachment Disorder- 6 hours n  Mind-Body Spirit (hypnosis) – 7 hours 1997 n  Self Esteem and Health – 6 hours 1996 n  Art and Play Therapy – 14 hours n  Anger Management for Children – 6 hours n  The Abused Woman – 3 hours n  The Angry Couple – 3 hours 1995 n  Health-related Pleasures – 6 hours 1994 n  Adolescent and Adult Sand play Therapy – 14 hours n  Attention Deficit and Hyperactive Disorder – 6 hours n  Art Therapy in Treatment of the Sexually Abused – 6 hours n  Recognizing and Reporting Child Abuse – 8 hours n  Removing Barriers to Greater Self-esteem – 6 hours   Bachelor of Science in Dental Hygiene Loma Linda University
activities
	Member CAMFT (California Association of Marriage and Family Therapists) Member AAMFT (American Association of Marriage and Family Therapists)

Your Honor,

In the summer of 2010, I was assaulted by three boys. Two of the perpetrators were passive participants. The defendant was an active participant, who verbally abused me, threw stones at me, and pulled a knife, and continued to threaten with the knife. The defendant later threw a bike at me in a public park. The bike hit my calf and I still have a scar from this injury. My behavior inside and outside of my regular environments has been different since this event.

            While I was being assaulted, I felt scared and concerned. I could not and did not understand what had driven this boy to do such a thing. I was scared because I did not know what would happen to me, or what he would do next. I did not react because that would have encouraged the defendant to be more abusive and even, perhaps, more violent. I was currently under the supervision of a baby sitter and helping to care for my 4 younger siblings.  I also did not want harm to come to them, so I was careful not to antagonize the defendant with any remarks or gestures.

            After the incident, I was very nervous for three reasons. I did not want them to follow me and then egg the house or hurt me or my family. I was also nervous because I didn’t want any one who didn’t need to know to get involved. (Explain this previous sentence a little more) I was very nervous because I thought that when I went to that park again, the boys would harass me or harm me further. Therefore, I did not leave the house for a matter of days.  (Was this “days” or did the days actually turn into weeks?)

            I have been greatly affected by this event. Shown by My varying mood levels have varied more than usual and my declining grades have declined. I have also been very anxious in public places. My guidance counselor has noticed changes in my play habits and in my attitude levels. (You could explain the “changes”) I would very much appreciate that the defendant learns the consequences of such actions with firm chastisement. I would like him to understand that his violent behavior was not only hurtful to me, but also had a negative effect on my family. I would like him to at least have severe enough consequences to deter him from this kind of behavior in the future. Consequences of such behavior need to reflect past actions. Thank you for your time and your patience for my impact statement.

Sincerely, Victim of Assault