Therapy Consent Form - Raven Avery, AMFT @ Sacred Path Holistic Therapy, PhD Candidate

Limits & Liabilities

Limits of Service and Assumption of Risk

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.

I understand and consent

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Limits of Confidentialities:

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written, may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions. Please check each box you understand.

Duty to Warn and Protect - If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.

If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.

Prenatal Exposure to Controlled Substances - Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.

Minors/Guardianship - Parents or legal guardians of non-emancipated minor clients have the right to access the clients’

Insurance Providers - Insurance companies and other third-party payers are given information that they request regarding services to the clients. The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

Telehealth Consent - even if therapy sessions are scheduled to be in person, this will give permission if ever we need to meet online. Check each box as you understand them.

I authorize Sacred Path to use appropriate telecommunication technologies for the purposes of evaluating and diagnosing my medical condition and any health complaints.

I understand that technical issues may arise before or during telehealth sessions and, on occasion, my appointments may not start or end at agreed-upon times.

I accept that medical professionals will attempt to contact me using video conferencing software. However, I also understand that other communication channels, such as telephone calls, may be used in case of internet connectivity or other issues.

I understand that my insurance plan may not encompass telehealth services. In cases where my insurance plan does not cover any expenses which have been incurred, I will be personally liable to cover these expenses.

I give Sacred Path permission to access my medical records for the purposes of ongoing documentation, evaluation, and analysis. I understand that all confidential information will be kept private.

Select Which Payment Option You Will Be Using:

Venmo @ raverylove (820) 380-8001

Stripe @ https://buy.stripe.com/00gg0F3ny0ot51e3ce

Apple Cash @ 510-203-8350

Will you be needing a Super Bill for billing your insurance? Super bills are provided monthly.

Which location will you be attending therapy?

1390 Price St Pismo Beach, CA 93449 (therapy offices are located upstairs)

3220 South Higuera Street, San Luis Obispo, CA 93401 (Suite 231B)

If you need to cancel or reschedule, provide at least 24 hours’ notice. When 24 hours’ notice is given, your payment will be all right applied as a credit toward your next scheduled session. Cancellations made with less than 24 hours’ notice are nonrefundable.

I understand and agree

I need an alternative format to consent

Therapy Consent Form - Raven Avery, AMFT @ Sacred Path Holistic Therapy, PhD Candidate

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