Image by Johannes Plenio

Our Team 
TELEHEALTH

Telehealth Informed Consent Form​

I​ hereby  consent  to  engaging  in teletherapy with my existing therapist at Renewing Hope Family Counseling Center, Inc. I understand that “teletherapy” includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data,  and education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental information, both orally  and  visually,  to  Renewing Hope Family Counseling Center, Inc. via the teletherapy service, Doxy.me (a HIPAA compliant video platform service).

 

I understand that I have the following rights with respect to teletherapy:

 

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons (e.g. hacking); and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse.

(4) I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.

(5) I understand that I have a right to access my medical information and copies of medical records in accordance with California law.

(6) I understand that, per the ethical guidelines of the state of California, teletherapy services can ONLY be provided to those residing in the state of California at the time of service. 

(7) I also understand that teletherapy is not always a covered service by my insurance plan, and it is my responsibility to check with my individual plan to determine if teletherapy is authorized. The patient will ultimately be responsible for all fees related to teletherapy that insurance does not cover. 

(8) Teletherapy will be billed at the same rate of individual therapy services. 

(9) Teletherapy is a temporary service that is being offered to all Renewing Hope Family Counseling Center, Inc. clients due to extreme circumstances as a precautionary measure. Once these circumstances abate, therapy sessions will return to in-person services as previously scheduled.

 

Please contact 951-465-3664 directly if you have any questions. 

 

Please confirm with the therapist that you have read and understand the information provided above. 

Our Therapists

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Cassondra Marie Rose

Licensed Marriage and Family Therapist,

Lic # 87026, President

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Licensed Marriage and Family Therapist,

Lic # 99929,

Clinical Supervisor -Spanish

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Maya Yvette Barnett

Licensed Marriage and Family Therapist,

Lic # 110873

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Tara Hawkins

Licensed Psychologist,

Lic # 30703

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Paul James Lorona

Licensed Marriage and Family Therapist,

LMFT # 80000

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Jose Ventura Campos

Licensed Clinical Social Worker,

LCSW # 92977

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Anne Victoria Brazdzionis

Licensed Practical Clinical Counselor, Lic # 7123

Practice Supervisor

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David Robert Bales

Licensed Marriage and Family Therapist,

LMFT # 127648

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Mercedes Borrayo

Licensed Marriage and Family Therapist,

Lic. #81029 Spanish

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Lori Reynolds

Licensed Family Marriage and Family Therapist,

Lic #103567

Clinical Supervisor

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Weeda Nawabi

Associate Marriage and Family Therapist,

Lic # 112346

Supervised By:

Brenda Bulnes-Gerardo

Lic # 52875

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Jackeline Guzman Gonzales

Associate Marriage and Family Therapist,

Lic # 280066

Supervised By: Leticia Sarinana,

Lic # 99929

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Diane Marie Campbell

Associate Marriage and Family Therapist,

Lic# 77798

Supervised By:

Brenda Bulnes-Gerardo

Lic # 52875

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Amber Michelle Estrada Villalta

Associate Marriage and Family Therapist

Lic. #128118

Supervised By:

Brenda Bulnes-Gerardo, Lic #52875

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Brianna Ramming

Licensed Marriage and Family Therapist, Lic. 107405

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Fresvinda Chue

Licensed Marriage and Family Therapist,

Lic. #121001

Alexis Johnson

Associate Marriage and Family Therapist,

Lic # 

Supervised By Cassondra  Marie Rose, Lic. #87026

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Lynda Carraway

Associate Marriage and Family Therapist,

Lic # 94451

Supervised By Lori Reynolds, Lic. #103567

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Shelby Anne Allen

Associate Marriage and Family Therapist, Lic#120137

Supervised By:

Cassondra Marie Rose, Lic # 87026

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Laura Andrea Gutierrez

Licensed Marriage and Family Therapist,

Lic # 122169

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Mali M Reynoso

Licensed Marriage and Family Therapist

Lic. #119885

San Jacinto

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Jessica Anita Balderas

Associate Marriage and Family Therapist

Lic# 120438

Supervised By: Leticia Sarinana, Lic # 99929

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Briana Nicole Henry

Licensed Marriage and Family Therapist, Lic # 104847

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Brenda Bulnes-Gerardo

Licensed Marriage and Family Therapist,

Lic. #52875

Supervisor- Magnolia

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Alanna Marie Villanueva

Licensed Clinical Social Worker,

Lic. #90181

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Guadelupe Buitron

Associate Clinical Social Worker

Lic. #103907

Supervised By  Leticia Sarinana, 

Lic, 99929

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Psychiatry Appt
Karen Rightler
PMHNP-BC
Lic.# NP95017405

Bertha "Betty" Vaughn

Associate Marriage and Family Therapist

Lic. #127990

Supervised By  Leticia Sarinana, 

Lic, 99929

Edgar Cantera

Associate Clinical Social Worker

Lic. #91501

Supervised By Lori Reynolds, Lic #103567

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Jacqueline Gonzalez

Associate Marriage and Family Therapist

Lic. #113958

Supervised By Leticia Sarinana, Lic #99929

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Sherry Mellott

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Farshid Yadegar

Psychologist

Lic. # 22681

Marriage and Family Trainee

Supervised By Cassondra Marie Rose,

Lic #80726

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Sharayza Rachael Jackson

Shaila C. Eslick

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Sonia Marie Garcia

Associate Marriage and Family Therapist

Lic. #116227

Supervised By Leticia Sarinana, Lic #99929

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Sarah Ann Perez

Associate Clinical Social Worker

Lic# 87385

Supervised By Lori Reynold,

LMFT, 103567

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Danielle Louise Holloway

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Ruby Pena

Associate Clinical Social Worker

Lic# 85955

Supervised By Leticia Sarinana, Lic 99929

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To Be Announced

Psychiatry Appt
Gloria Sudeta
PMHNP-BC
Lic.# 95003639