Gary Pence, mft
License # MFC32673

6220 LaSalle Avenue
Oakland (Montclair), CA 94611-2804

Individual, Adolescent, Couple, and Family Therapy

(925) 352-9953 



Professional standards and California state laws guarantee you the right to a confidential relationship with me. Within certain legal limits, both the fact that you are in therapy and any information you reveal during therapy will be kept completely confidential and will not be revealed to any agency or person without your written permission. Even without your written consent, however, California law requires me to break confidentiality in the following situations:

1. You reveal information to me that indicates there is reasonable suspicion of past or present child abuse or neglect or elder adult physical abuse;

2. If you threaten bodily harm or death to another person whom you identify to me, I am required by law to warn the intended victim and notify the appropriate law enforcement agencies.

3. If you are in therapy by order of a court of law, the results of treatment must be revealed to the court.

4. If a court of law issues a legitimate subpoena, I am required by law to provide the information specifically requested in the subpoena. If you reveal that you are about to take your own life, I am permitted by California law and required by professional standards to break confidentiality to the extent necessary to provide for your safety.

In the above situations, information may be released only to the appropriate family member, professional worker, or public authorities.

I have read and understand the above.

Signed:______________________________ Date:____________

Signed:______________________________ Date:____________