Disclosure Statement & Agreement for Services

Purpose of this agreement

This statement explains the professional relationship, services, fees, privacy practices, and responsibilities involved in psychotherapy. Informed consent is an ongoing conversation. You are encouraged to ask questions at any time, and you may decline or withdraw consent for a particular intervention.

Therapist disclosure and supervision

Angelique M. Chess-Stiles is a California Registered Associate Marriage and Family Therapist, AMFT #150029. She practices under the clinical supervision of Shannon Vitro, Licensed Clinical Social Worker, LCSW #74811. As part of supervision, relevant clinical information may be discussed with the supervisor to support treatment quality and legal and ethical practice.

Angelique earned a Master’s degree in Marriage and Family Therapy from California State University, Chico. Her postgraduate training includes Emotionally Focused Individual Therapy, an Emotionally Focused Couples Therapy externship, Gottman Method Levels I and II, EMDR basic and advanced training including DeprEnd, intermediate-level Somatic Experiencing training, Dialectical Behavior Therapy, expressive arts, visual journaling, Polyvagal-informed therapy, and Sensate Focus. A training description does not represent certification unless a certification is specifically stated.

Services and therapeutic approach

Services may include individual, couples, relationship, family, or group psychotherapy; EMDR; and somatic or expressive interventions when clinically appropriate. Treatment is collaborative and may explore emotions, relationships, behavior patterns, trauma, identity, and nervous-system responses. Psychotherapy can offer meaningful benefits, but it may also bring temporary discomfort or difficult memories to the surface. Outcomes cannot be guaranteed.

Fees, payment, and insurance

• Psychotherapy sessions: $195.
• Couples, EMDR, or somatic-focused sessions: $250.
• Accepted payment methods: Visa, Mastercard, Zelle, and Venmo.
• Sliding-scale appointments may be available for qualifying incomes, depending on availability.

Payment is due at the time of service unless another written arrangement has been made. The practice is not accepting insurance at this time. Upon request, a superbill may be provided for you to submit to your insurer for possible out-of-network reimbursement. Reimbursement is determined by your insurance company and is not guaranteed. Uninsured or self-pay clients may request a Good Faith Estimate of expected charges.

Scheduling and cancellations

Appointments are reserved specifically for you. Cancellations or rescheduling requests made with less than 48 hours’ notice, as well as missed appointments, are charged the full session fee unless otherwise agreed. Fees for late cancellations or missed appointments are due before the next visit. Insurance plans generally do not reimburse these charges.

Confidentiality and its limits

Psychotherapy records and communications are generally confidential. Information may be disclosed with your written authorization or when disclosure is required or permitted by law. Examples can include suspected abuse or neglect of a child, older adult, or dependent adult; a serious threat of harm; a medical emergency; a valid court order signed by a judge; or other legally mandated circumstances. When feasible, Angelique will discuss a required disclosure with you before taking action.

Confidentiality can be more complex in couples, family, and group services because more than one person participates. The expectations and limits that apply to those services will be discussed before treatment or group participation. Participants are expected to respect one another’s privacy, although the conduct of other participants cannot be guaranteed.

Minors

When a client is a minor, parents or legal guardians may have rights to information and records. Privacy expectations, parental access, consent, and any legally permitted exceptions will be discussed at the beginning of treatment and revisited as needed.

Communication and emergencies

Email, text messages, and voicemail are intended primarily for scheduling and brief administrative communication and may not be fully secure. Do not use them for urgent or highly sensitive clinical information. Angelique does not provide crisis or emergency response services and may not be immediately available between sessions.

If you are in immediate danger or experiencing a life-threatening emergency, call 911 or go to the nearest emergency department. In the United States, you may also call or text 988 for the Suicide & Crisis Lifeline.

Telehealth services

Telehealth may be available when the client is physically located in California. Before telehealth begins, the potential benefits, risks, technological limits, privacy considerations, and alternatives will be reviewed and consent obtained. At each telehealth session, Angelique may confirm your identity, current location, and emergency contact information. You are responsible for choosing a safe and private setting, free from distractions, interruptions, and competing responsibilities such as children or work demands, and for using a sufficiently secure device and internet connection. Angelique may pause or end a session early if she determines that the environment is not sufficiently private, safe, or therapeutically workable. Rescheduling or an alternative format may be recommended when appropriate.

Somatic work and co-regulating touch

Somatic therapy may include attention to posture, movement, breath, physical sensations, boundaries, and nervous-system responses. Some body-based interventions may not be appropriate for every client and are always optional.

If therapeutic touch is considered, its purpose, location, alternatives, potential benefits, and possible risks will be discussed in advance. Touch will be used only with specific, voluntary consent and within professional boundaries. You may change your mind, pause, or stop an intervention at any time without affecting your access to other therapeutic support.

Records, consultation, and privacy

Clinical records are maintained as required by applicable law and professional standards. Angelique may consult with her supervisor or other professionals when clinically useful. Identifying details will be limited when possible, and consultants are expected to protect confidentiality. A separate privacy notice may provide additional information about uses of health information and your rights.

Ending services

You may end therapy at any time. When possible, a final session can help review progress and plan next steps. Angelique may recommend pausing or ending services when treatment is no longer beneficial, the requested care is outside her scope or competence, fees remain unresolved, safety or boundary concerns interfere with treatment, or another level of care is more appropriate. Reasonable referral or transition support will be offered when appropriate.

Questions or concerns

Questions and concerns are welcome and can often be addressed directly in therapy. You may also contact supervising clinician Shannon Vitro, LCSW #74811, using the contact information provided in your finalized client paperwork. Information about California behavioral-health licensees, registrants, and the complaint process is available from the California Board of Behavioral Sciences.