L. Eileen Keller, Ph.D.
5435 College Avenue, Suite 201
Oakland, California 94618

Licensed Psychologist, PSY7350
(510) 654-2420


I understand and consent to the following:

1. I authorize and request my treating provider to carry out psychological treatment.

2. I acknowledge that I am being informed that under California law:
   a. If a patient communicates to a therapist a serious threat to harm an identifiable person, the therapist must warn that person and the police.  
   b. If the therapist suspects child abuse or neglect, or abuse of a helpless adult or of an elder, a report must be made to the designated agency.  
   c. If a patient seems dangerous to self or others or unable to care for him/herself, then hospitalization may be required.  

3. I understand that:
    a. Information and records--otherwise confidential-- concerning me and or my family must be provided in the event of a court order.  
    b. I understand that Dr. Keller consults professionally and confidentially with colleagues.  

4. My consent is for me and any minor children. Consent is voluntary and, except for Items 2 and 3 (limits on confidentiality) and urgent consultations, I may withdraw my consent to future disclosure at any time by writing a letter to Dr. Keller.

5. I have received a copy of this form.



This consent is in effect for the duration of treatment up to three years.