About this Practice

Your provider, Jacob Wilen, is an associate marriage and family therapist with California license #141949 issued on 10/09/2023 and expiring on 10/31/25. Jacob is supervised by Brandi Kulikov-Ramirez, LMFT #134149. “Wilen Psych” and “WilenPsych.com” are used for marketing purposes only and do not represent a registered business or corporation. Mr. Wilen is an employee of Shiva Howell Marriage and Family Therapy Inc., DBA CopeHouse Collective located at 16530 Ventura Blvd #400, Encino, CA 91436. “Wilen Psych” and “WilenPsych.com” are used for marketing purposes only and do not represent a registered business or corporation.

The Therapy Process

Therapy is a collaboration between client and clinician, and we will work together to set goals and develop a customized treatment plan. I will offer feedback and recommendations and evaluate whether psychotherapy is beneficial to you. If I cannot provide the kind of help you need, I will refer you to other clinicians, groups, or treatment centers that may be a better fit. I cannot predict how many sessions you may need or guarantee results. If you have questions about therapeutic techniques, feel free to ask me. Your feedback is an important part of helping me effectively address your problems and concerns.

Communications

To reach me outside of sessions, please text or call 323-542-8255. I am generally available to respond within approximately 24 ​hours. Emergency phone consultations of five minutes or less are generally free. However, if we spend more than five minutes on the phone, if you leave more than five minutes worth of phone messages in a week, if I spend more than five minutes reading and responding to emails or coordinating care, I will bill you on a prorated basis for that time. If you cannot wait for your next appointment, we may need to schedule extra sessions. If you have a psychological emergency, dial 988 or 911 or go to your nearest emergency room. I use Google Workspace, a HIPAA-compliant phone, text, telehealth video, and email service to protect your privacy. However, risks of using electronic communication may include but are not limited to, inadvertent sending of an email or text containing confidential information to the wrong recipient, theft or loss of the computer or mobile device, and unauthorized interception by a third party through an unsecured network.

Termination of Therapy

Deciding when to stop therapy is meant to be a collaborative process. We will explore whether pausing, scheduling monthly check-ins, or terminating will be most beneficial. I recommend at least two closure sessions to reflect on your progress and identify resources to help you transition out of treatment. You are responsible for making a good-faith effort to engage in your treatment. Noncompliance with clinical recommendations, office policies, frequent cancellations, and or tardiness may necessitate early termination. If you commit violence to verbally or physically threaten or harass me, the office, or my family, I reserve the right to terminate your treatment immediately. Failure or refusal to pay for services may also lead to termination. Therapy never involves sexual, business, or dual relationships that could impair my therapeutic effectiveness. If I become aware of dual relationships, we may need to end your treatment. You have the right to terminate treatment at any time.

Online Presence

My business listings on Yelp, Google, or similar sites are not a request for reviews, testimonials, or ratings. Due to confidentiality, I cannot respond or comment on any review, whether it is positive or negative. Please consider your privacy if you rate or review my services online. I do not accept friend requests or direct messages from current or former clients on any social networking site.

Other Fees

If you become involved in legal proceedings that require my participation, you will be billed for my services even if I have been called to testify by another party. Due to the complexity of legal involvement and the interruption to my practice, I charge $500 per hour for preparation and attendance at any legal proceeding. If you are using out-of-network health insurance benefits, you are responsible for submitting your claims and managing reimbursement with your insurance company. You are ultimately responsible for payment, even if you are relying on or expecting your insurance or another third party to cover the costs of your treatment. Insurance does not cover more than 50 minutes per session of family or couples therapy. For family or couples sessions that extend to 75 minutes (recommended length), an additional balance of $50 will be due and charged to your credit card on file.

Consent for Telehealth

By engaging in Telehealth with Jacob Wilen, AMFT #141949, you understand that telehealth is a mode of providing psychotherapy via the internet or phone to facilitate treatment.

You also understand and agree to the following:

• I cannot receive therapy when physically outside of California. If I travel out of state, I will inform my therapist in advance.

• If I am in crisis, I must access care in my area. My therapist may not be able to assist me in an emergency.

• I am responsible for finding a private location free from distractions and intrusions. I am aware of potential security issues with my computer or mobile device.

• There is no guarantee that telehealth will be effective for me.

• I may not record the sessions without the therapist’s written permission.

• There will be times when technology fails, and we may need to reschedule or resort to another means of connecting.

• All mandated reporting requirements regarding Child, Elder, and Dependent Abuse and Suicidal and Homicidal Risk are still in effect (see the Notice of Privacy Practices below).

• I know that my insurance may not cover the cost of telehealth.

I understand that I have the right to have any questions answered to my satisfaction.

Notice of Privacy Practices

The Federal Health Insurance Portability and Accountability Act (HIPAA) requires mental health professionals to issue this official Notice of Privacy Practices. This notice describes how your information is protected, the circumstances under which it may be used or disclosed, and how you may gain access to it. Please review it carefully. For psychotherapy to be beneficial, it is essential that you feel free to speak about personal matters, secure in the knowledge that the information you share will remain confidential. You have the right to the confidentiality of your medical and psychological information, and this practice is required by law to maintain the privacy of that information. This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect and to provide notice of its legal duties and privacy practices concerning protected health and psychological information.

Who Will Follow This Notice

Any healthcare professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this notice. All subsidiaries, business associates (e.g., a billing service), sites, and locations of this practice may share medical information for treatment, payment purposes, or healthcare operations described in this notice. Only the minimum necessary information needed to accomplish the task will be shared, except where treatment is involved.

Uses and Disclosures for Treatment, Payment, and
Health Care Operations:

• I may use or disclose your Protected Health Information (PHI), for treatment, payment, and health care operations purposes. The following should help clarify these terms:

• PHI refers to information in your health record that could identify you. For example, it may include your name, the fact that you are receiving treatment here, and other basic information pertaining to your treatment.

• Use applies only to activities within my office and practice group, such as sharing, employing, applying, utilizing, and analyzing information that identifies you.

• Disclosure applies to activities outside of my office or practice group, such as releasing, transferring, or providing access to information about you to other parties.

• Authorization is your written permission to disclose confidential health information. All authorizations to disclose must be made on a specific and required form.

• Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. For example, with your written authorization, I may provide your information to your physician to ensure the physician has the necessary information to diagnose or treat you.

• Your PHI may be used to obtain payment for your health care services as needed. This may include using a billing service or providing you documentation of your care so that you may obtain reimbursement from your insurer.

• Health Care Operations are activities that relate to the performance and operation of my practice. As needed, I may use or disclose your protected health information in support of business activities.

Written Authorizations to Release PHI

Any other uses and disclosures of your PHI beyond those listed above will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke your authorization at any time in writing.

Uses and Disclosures without Authorization

The ethics code of the California State law and the federal HIPAA regulations all protect the privacy of all communications between a client and a mental health professional. In most situations, I can only release information about your treatment to others if you sign a written authorization. This authorization will remain in effect for a length of time you and I determine. You may revoke the authorization at any time unless I have taken action in reliance on it. However, some disclosures do not require your authorization. I may use or disclose PHI without your consent in the following circumstances:

• Child Abuse – If I have reasonable cause to believe a child may be abused or neglected, I must report this belief to the appropriate authorities.

• Adult and Domestic Abuse – If I have reason to believe that an individual, such as an elderly or disabled person protected by state law, has been abused, neglected, or financially exploited, I must report this to the appropriate authorities.

• Health Oversight Activities – I may disclose your PHI to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions. If a client files a complaint or lawsuit against me, I may disclose relevant patient information to defend myself.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding, and a request is made for information by any party about your treatment and the records thereof, such information is privileged under state law and is not to be released without a court order. Information about all other psychological services (e.g., psychological evaluation) is privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You must be informed in advance if this is the case.

• Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is a clear, imminent risk of injury being inflicted against another individual, I may make disclosures that I think are necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.

• Worker’s Compensation – I may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law that provide benefits for work-related injuries or illness without regard to fault.

Special Authorizations

Specific categories of information have extra protections by law and thus require special written authorization for disclosures.

• Psychotherapy Notes – I will obtain special authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.

• HIV Information – Special legal protections apply to HIV/AIDS-related information. I will obtain a special written authorization from you before releasing information related to HIV/AIDS.

• Alcohol and Drug Use Information – Special legal protections apply to information related to alcohol and drug use and treatment. I will obtain your special written authorization before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) I have relied on that authorization or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.

Patient’s Rights and Therapist’s Duties:

• You have the right to request restrictions on specific uses/disclosures of PHI. However, I am not required to agree to the request.

• You have the right to request and receive confidential communications by alternative means and locations. (For example, you may not want a family member to know you are seeing me. On your request, I will send your bills to another address.)

• You have the right to inspect or obtain a copy of PHI in my records as these records are maintained. In such cases, I will discuss with you the process involved.

Notice of Privacy Practices

• You have the right to request an amendment of PHI for as long as it is maintained in the record. I may deny your request. If so, I will discuss with you the details of the amendment process.

• You generally have the right to receive an accounting of all disclosures of PHI. I can discuss with you the details of the accounting process.

• You have the right to obtain a paper copy of the Notice of Privacy Practices from me upon request.

Psychotherapist’s Duties:

• I am required by law to maintain PHI’s privacy and provide you with a notice of my legal duties and privacy practices concerning PHI.

• I reserve the right to change the privacy policies and practices described in this notice. However, unless I notify you of such changes, I must abide by the current terms.

• If I revise my policies and procedures, I will notify you at our next session or by mail at the address you provided me.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services:

Contact the U.S. Department of Health and Human Services Office for Civil Rights by:

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;

2. Calling 1-877-696-6775; or,

3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

This notice will go into effect on August 17th, 2023, unless new notice provisions effective for all protected health information are enacted accordingly.

Payment Policies and Authorization

By engaging in therapy with Jacob Wilen, AMFT, you, the client or authorized representative (parent, guardian, or conservator), have authorized your credit card, debit card, or HSA/FSA card to be used to pay for any services rendered as agreed to by Jacob Wilen, AMFT and CopeHouse Collective.

You acknowledge that you will be charged the full session fee in the event the client fails to show up for a scheduled appointment or does not cancel at least 24 hours in advance. I understand that the full session fees are as follows:

$150 for 50-minutes of individual therapy and $200 for 65-minutes of family or couples therapy.

You understand that when using health insurance as payment, you are still responsible for the balance of insurance claims (co-insurance, co-pays, and/or deductibles), including a full claim if my insurance company denies, changes, or ends my coverage. I understand that my credit card will be charged after each session.

You understand that a $25.00 fee will be due for any declined credit card charge. You also acknowledge that you are responsible for maintaining accurate credit card information. The client and payee also authorize Jacob Wilen, AMFT to disclose information about client attendance and cancellations to your credit card company if a charge is disputed. You acknowledge that HSA/FSA payments could later be denied even if the payment goes through at the time it is processed, and if denied, you are responsible for the full payment by other means. You agree that this authorization is valid for the length of therapy unless other payment arrangements have been agreed upon in writing.

Couples Therapy

Couples therapy is a process of identifying interaction and communication patterns that are negatively impacting the friendship, intimacy, and fulfillment of needs of one or both partners in a relationship. Each partner will be expected to honestly examine their own interaction and communication styles, identify and express their own feelings, and make an attempt at experimenting with alternative methods of communicating and interacting. Each partner will be helped to further clarify their own values and their own level of commitment to the relationship, and the outcome of the therapy may be increased satisfaction with the partnership or increased clarity about the decision to part ways.

Your Relationship is The Client

When you attend couples therapy sessions, you as a couple are considered to be “the client” and your mental health records therefore belong to both of you. This means that except in situations requiring mandated reporting, I will need a written consent from both of you in order to disclose any information from your record to a third party.

No Secrets

As a therapist who is entrusted with information from both partners of a relationship, I have a policy of “No Secrets”, which means that I cannot promise to protect secrets of either partner from the other person, especially if the secret is harmful or destructive to the process of the therapy itself or undermines the agreed upon intention of the therapy.

Boundaries

Because the relationship is the main focus of couples therapy both partners of a couple must be present for the couples session to start. It is often not in the best interest of the couple to distribute time unevenly between partners or to have unplanned meetings with only one partner present. If one partner is late in arriving or does not show for the appointment, I reserve the right to delay the start of the session or to cancel the session if necessary.