Informed Consent

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For (clients full name):
Client Date of Birth

This form is to be completed by the client (or parent/guardian if client is under the age of 18).

Please download and review the TuckerWorks Notice of Privacy Practices HERE. A paper copy is available on request.

Please initial each statement
to verify understanding

FINANCIAL TERMS: Payment for services is due prior to or on the date of service. Our usual and customary fees for services are as follows: Gottman Love Lab Assessment (three 90 min. sessions)- $1,449.00; Individual Assessment + EMDR Therapy 1:30 – $480.00; Weekend Intensive Sessions – $4,688.00; Gottman Follow-up Therapy- Extended Session 1:30 $360.00; EMDR Extended Session 1:30 – $360.00. Individual Therapy follow-up sessions 0:50 – $200.00. If you are using your health insurance, is an out of network providers. You will need to pay for services directly and then seek reimbursement from your insurance carrier on your own. On request, will provide a superbill and invoice detailing services provided on the www.tuckerworks.org website. If a third party other than insurance will be covering payment, formal written payment arrangements between and the third party should be made prior to your first appointment. Phone/Zoom consultations longer than 15 minutes are billed at $60 per additional 15 min. increment.

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CANCELLATIONS/MISSED APPOINTMENTS: You are welcome to cancel or reschedule your appointment without penalty up to 24 hours prior to your scheduled time. Services are not refundable if canceled less than 24 hours in advance of the appointment. Refunds will be given minus any card processing fees. If an appointment is missed, canceled, or rescheduled with less than 24 hours’ notice you will be billed according to the scheduled fee and you will lose your recurring appointment schedule if any. Three cancellations in a row will result in the termination of your treatment for one year. Love Lab Assessments: A single $250 fee will also be deducted from the refund if either partner activates their GottmanConnect.com account.

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APPEALS AND GRIEVANCES: You have the right to submit a complaint directly to at any time you have a complaint about any aspect of your care. If you are not satisfied with the response you receive, you may submit the complaint directly to the California Board of Behavioral Science. While TuckerWorks therapists may have taken training in Gottman Method of couples therapy and EMDR, and may have become a Certified Gottman and EMDR Therapist, TuckerWorks therapists are completely independent in providing you with clinical services and are fully responsible for those services. The Gottman Institute, EMDRIA or their agents have no responsibility for the services you receive.

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TREATMENT PHILOSOPHY: Treatment begins with an evaluation where you and clarify your problems, define goals, and create a treatment plan. Evidence‑based, brief, goal‑focused therapy is used. Your plan may include groups, readings, assignments, or medical evaluations as needed, and we can review what your health plan covers.You agree to follow the plan, keep appointments, and avoid any non‑prescribed mood‑altering substances. Progress is reviewed regularly and the plan updated as needed. Services end when goals are met, when progress stalls, or whenever you choose. If treatment ends early, will help connect you with appropriate alternative care.

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EMERGENCIES: If you are in imminent danger call 911, or your nearest police department or emergency room. is available 24 hours a day by phone in the event of emotional crises by calling his office number at (909) 389-2414 and leaving message and number at the prompt regarding the nature of your crisis. Calls from active clients will be responded to within 24 hours. In the event of a planned absence, will notify you of a backup professional for emergency contact. Most insurance carriers also provide 24 hour, 365 day a year telephonic emergency service.

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CONFIDENTIALITY: is a private practitioner and other professionals at the 315 West Colton Ave., Redlands, CA address do not have access to confidential information about your treatment. All information between and a client is held strictly confidential unless:

  • You authorize release of information with your signature (or parent/guardian)
  • You present an imminent danger to others
  • You present a physical danger to self
  • Child or elder abuse is suspected

In the latter three cases, is required by law to inform potential victims and legal authorities so that protective measures can be taken.

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COUPLES THERAPY AND CONFIDENTIALITY: Both partners must provide their consent to release couples counseling records. If one partner does not provide consent, records will not be released. As a condition for couples therapy, all affairs must be stopped before therapy begins. Any affair — past or current — must be disclosed, either prior to starting therapy or during the therapeutic process.

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FAMILY THERAPY AND CONFIDENTIALITY: Family members may consent to release of family counseling records. All individuals who participated in the family therapy must provide their consent to release family counseling records. If one party does not provide consent, records will not be released.

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CONSENT FOR TREATMENT: “I further authorize and request that , carry out psychosocial examinations, treatments, and/or diagnostic procedures which now or during the course of my care as a client are advisable. I understand that the purpose of these procedures will be explained to me upon my request and are subject to my agreement. I also understand that while the course of my treatment is designed to be helpful, it may at times be difficult and uncomfortable. Some or all of my difficulties may not be remedied by the treatment.”

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RELEASE OF INFORMATION TO THE HEALTH PLAN: “If I seek insurance reimbursement, I acknowledge that the release of information for claims, certification/ case management/quality improvement, and other purposes related to the benefits of my health plan. I have received a copy of Notice of Privacy Practices.”

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DUAL RELATIONSHIPS:“I understand that my relationship with Mr. Tucker is now and will be in the future solely a professional relationship and that we will have no shared interests or activities outside of psychotherapy services.”

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Full Name of The Responsible Adult Consenting to Treatment (required)
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