Your selection

Therapy fee adjustment

What are you seeking help for?

Choose any topics that fit. No contact information is requested on this page.

What would you like support with?

Have you had sessions with Liberation Institute before?

No, this is my first timeYes, my last session was less than 6 months agoYes, my last session was 6 months ago or more

How did you hear about us? Optional

Private contact information

Request an intake meeting

Before we connect

Review both documents in the tabs below, then confirm. Nothing opens in a new tab.

Before your intake meeting

Consultation Terms

These terms describe the initial consultation offered by the Liberation Institute.

Agreement

You agree to receive consultation and referrals from the Liberation Institute. Services at this stage do not include and are not meant to be psychotherapy or clinical psychological services. Referrals for those services may be available at the Institute or elsewhere.

Consultation fee

The current standard consultation fee is $30, payable at the time of the appointment. If this fee causes financial hardship, discuss that with the clinician conducting the consultation. Donation-based group therapy may be available on a sliding scale as an alternative for ongoing support.

Confidentiality

Calls, conversations, and written communications with the Institute, its consultants, and counselors are kept confidential except when you authorize a disclosure or the law requires disclosure. Examples include suspected abuse and a serious threat of harm to yourself or another person. Questions can be discussed with the consultation clinician.

I have read and agree to the .I acknowledge that I received and reviewed the .

Our therapists are supervised student trainees.Our therapists are unlicensed student trainees working under the supervision of licensed professionals. What we offer is supportive, weekly, consistent talk therapy.

The intake meeting usually costs $30.If a lower fee is approved before the meeting, the approved rate applies instead. Ongoing therapy is $30–130 per session.

Acknowledging the privacy notice confirms receipt. It is separate from agreeing to consultation or authorizing treatment.

Your responses have stayed anonymous until this point. Share the best way for our intake team to reach you.

Contact method

EmailPhone call

HIPAA

Private intake details

Help us prepare for your intake

These details help the intake team prepare and find a meeting time that works.

What name do you go by?

When could you meet for your intake?

Our intake appointments are scheduled about a week in advance. We have appointments seven days a week, from early in the morning into the evening. Choose two or three times that could work for you, and we’ll confirm one with you.

Option 1

DayTime

Option 2

DayTime

Option 3 · Optional

DayTime

This doesn’t book an appointment. Our intake team will confirm a time with you.

Private intake details

Your preferences

Optional. Share anything that would help us prepare. You can leave this page blank.

What matters to you in a therapist match?

Choose any priorities, then use the box below to tell us the specifics. We will consider them when matching, based on availability.

Tell us more about your goals, preferences, or anything you want us to understand

Accessibility needs

HIPAA

Your intake meeting

Your intake is a 50-minute meeting. We want to get to know you a little better. We’ll ask about what you’d like to work on in therapy, your goals, and a little about your history. It helps us decide together whether we’re a good fit for what you’re looking for.

The intake is not a therapy session. It’s the first step in getting you connected with those services.

The therapist who meets with you for the intake may or may not be the therapist you work with afterward.

We offer supportive, weekly, consistent talk therapy with supervised student therapists.

What happens next: The steps that follow set up your care record and the agreements you will sign. When you submit at the end, your request and your signed agreements go securely to our intake team.

Protected care record

Set up your care record

You are now entering private identity information for your care record. We collect these details only when you are preparing to begin care.

Legal nameName you go byDate of birth

Today’s date

Recorded automatically when submitted

Mailing address

I confirm that I am a resident of California.

Contact on file: . Communication preference: not selected.

HIPAA

Online care and safety

All care is online. These details help your clinician respond safely if an urgent concern comes up during a session.

Online care requires a private space.I can join online care from a private, confidential location.

In the unlikely event of an emergency, who would you like us to contact?

Please choose someone we can reach. “N/A” cannot be accepted for this safety step.

First nameLast namePhoneRelationship

Nearest hospital

Enter a ZIP code, then choose a result to fill the hospital details.

ZIP code

HIPAA

Treatment agreements

Review your treatment agreements

These agreements apply to ongoing care and are separate from the earlier consultation terms. Review both in the tabs below, then confirm. Nothing opens in a new tab.

Before ongoing treatment begins

Mental Health Treatment Agreement

This agreement describes the professional services and policies that apply to psychotherapy at the Liberation Institute.

Psychological services

Psychotherapy may support relationships, self-awareness, and relief from distress. It also involves risks, including uncomfortable feelings when difficult experiences are discussed. Symptoms or feelings may temporarily get worse before they improve. No specific outcome is guaranteed.

Staff interns and supervision

Many Institute therapists are working toward professional licensure and receive weekly supervision from a licensed therapist. They may discuss a case in individual or group supervision while protecting confidentiality. Concerns about fit can be discussed with the therapist or the Institute.

Sessions, fees, and attendance

Sessions are generally 50 minutes and occur weekly unless another arrangement is made. The contribution is based on ability to pay and is due for each session.

At least 24 hours notice is required to cancel or reschedule. Late arrival shortens a session, and arrival more than 15 minutes late may result in cancellation. Repeated missed sessions may lead to termination.

Ending treatment

You may end therapy at any time. The therapist may recommend one or more final sessions to review the work and support a positive ending.

Emergencies

The Liberation Institute does not provide emergency or crisis services. Call 911 or use appropriate local crisis resources in an emergency. A therapist may not be immediately available but will respond according to the communication expectations established with you.

Professional records

Professional standards require the therapist to keep treatment records. You may request access or a summary subject to applicable law and limited safety exceptions. Reasonable preparation or copying fees may apply.

Confidentiality and its limits

Suspected child, elder, or dependent-adult abuse may have to be reported
A serious threat of harm may require protective action
A court order may require testimony or records
You may authorize a specific release
The therapist may consult with supervisors or professional colleagues who are bound by confidentiality

Complaints

Complaints about licensed or registered professionals may be directed to the California Board of Behavioral Sciences. Complaints about other Institute services may be directed to the Liberation Institute.

Authorization for treatment

Accepting this agreement authorizes evaluation and mental health treatment by the Liberation Institute. You may request a copy, ask questions, refuse a technique, and discontinue treatment. Any permission to share information with a visitor or third party is handled separately.

Type your full legal name to sign

Initial each section above; your initials stamp in as you do.

I consent to using electronic signatures on this document.

To sign: initial every section, enter your full name, consent to electronic signature.

Any permission to share information with a partner, visitor, provider, or agency would be requested separately and would identify exactly what may be shared.

HIPAA

Still need help

Tell us what's going on

Please reach out and we will try to refer you. If you are experiencing an emergency, please dial 911 or contact your treating physician.

Reach us directly

This page cannot pass your message along, so please contact our team yourself. Someone will respond and help you find care.

Call415-606-5296 ext. 102 Emailincoming@liberationinstitute.org

Liberation Institute does not provide emergency or crisis services. If you are in San Francisco, you can also call the San Francisco Mobile Crisis at (415) 970-4000 or San Francisco Suicide Prevention at (415) 781-0500.

Payment agreements

Review your payment agreement

Your contribution is $60 per session. Review the agreement in the tab below, then confirm. Nothing opens in a new tab.

Your contribution per session, in dollars

Choose any whole-dollar amount from $30 to $130 on the sliding scale.

Contribution and cancellation policy

Payment Agreement

The Liberation Institute is a nonprofit community resource supported in part by client contributions.

Sliding scale

The current contribution range is $30-$130 per session based on ability to pay. Everyone receives the same quality of care. Couples and families should consider combined income when choosing a contribution.

Current guidance

$1,599 monthly income and below: $30
$1,600-$1,999: $35
$2,000-$2,599: $40
$2,600-$2,999: $50
$3,000-$3,499: $60
$3,500-$3,999: $70
$4,000-$4,499: $80
$4,500-$4,999: $90
$5,000-$5,499: $100
$5,500-$5,999: $110
$6,000 and above: $130

Changes and scholarships

Tell your therapist if your financial circumstances change so the contribution can be reviewed. Reduced-contribution scholarships may be available. Proof of income is requested only as part of a scholarship application. Contributions are reviewed periodically.

Payment timing

Payment is required according to the arrangement made with your therapist. The payment method and any recurring arrangement should be confirmed before sessions begin.

Cancellation policy

Give at least 24 hours notice to cancel or reschedule. A cancellation or missed session with less notice may be charged the full agreed contribution. Contact the therapist as soon as possible when you cannot attend.

I have reviewed and agree to the .I understand that cancellations with less than 24 hours’ notice may be charged the full session contribution.

HIPAA

Your intake packet is ready.

Review the summary below. Submitting now signs and sends your request — your care record and signed agreements go securely to our intake team.

Care: Group inquiry
Route: CA intake
Contact
Name you go by
Legal name
Support areas: 0 selected
Therapist preferences: None selected
Care format: Online
Emergency contact
Contribution: $60 per session
Agreements: Privacy notice, consultation, treatment, telehealth, payment, and cancellation

Secure submission: Your request will be separated into identity, care, consent, workflow, and financial records. Select submit when you are ready.

What are you seeking help for?

Request an intake meeting