Consent for Individual Mental Health
Consent for Individual Mental Health Services
I hereby agree to participate in individual therapy services through California Consortium for Prevention and Intervention (CalCPI) and understand the risks and benefits as explained by CalCPI prior to starting services.
I understand that all information regarding services is confidential and will not be released to any other agency or individual without my knowledge and consent; except as required by law. CalCPI strictly conforms to the Health Insurance Portability and Accountability Act (HIPPA). I understand that there are legal limits to confidentiality and CalCPI, is required to report any behaviors that are clinically judged to be a “danger to self; danger to others; or gravely disabled” and or/ having knowledge of abuse and/or neglect of those who are minors, elderly, or disabled.
I further understand that my mental health clinician may provide services through secure teletherapy or in-person and may consult with other mental health professionals affiliated with CalCPI, including the use of graduate student clinicians under the direct supervision of experienced licensed mental health clinicians Please contact Dr. Mitchel Casados, Ph.D., the Director of Clinical Training for any questions or concerns. Dr. Casados can be contacted at mcasados@calcpi.org..
For this particular case, a graduate student-clinician may be used in consultation with a licensed psychologist. I acknowledge this arrangement and consent to it:
[ ] I understand that graduate student clinicians may be used as part of my assessment.
I will inform CalCPI staff if there are any changes to my address, phone number, or any status that would affect the delivery of individual mental health services (e.g., enrollment in Medicare or Medi-Cal; if I change insurance coverage; or if I receive services from another agency or any other mental health provider).
I understand that if I am experiencing a medical emergency during my individual mental health session or while waiting for my appointment, CalCPI, and my mental health clinician will contact emergency medical personnel to assist me.
I will make every effort to meet with my clinician for my appointments as scheduled. If my appointment needs to be canceled or rescheduled, I will give at least 24-hour notice whenever possible. I understand that if a pattern of missed appointments is established it may jeopardize the continuity of services and services may be terminated unless clinically contraindicated.
If you need to talk with us when the office is closed, you may call and leave a message with CalCPI’s voicemail. CalCPI does not offer 24-hour coverage. In case of an emergency, please call 911 or go to your nearest emergency room.
I have been given a full explanation of this consent and I agree to follow the program guidelines stated in this document.