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

Licensed Psychologist, PSY7350
(510) 654-2420


Patient's Name:

Child's Name:

Parent's Name:

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. Parents and Guardians of Minor Children:
Communications between child and therapist are confidential except under the exclusions given above. I understand that Dr. Keller is providing psychotherapy and will not provide any custody evaluations or recommendations of any kind regarding visitation or disputed arrangements between parents. I agree that I will not request Dr. Keller's records for use in a custody dispute. I understand that for treatment to be effective, I must cooperate in working with Dr. Keller including meeting with Dr. Keller as requested.


DateParent or GuardianWitness

5. 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.

6. I have received a copy of this form.


DateParent or GuardianWitness

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