Informed Assent Form

Mental Health Specialty Group, P.A. working with its affiliates and its engaged clinicians and coaches (collectively, “Provider”) provides behavioral health treatment and care management services, including psychology and behavioral therapy, and other behavioral health and developmental services. When you seek services from Provider, you will be connected with a personalized care team.

Your care team is here to help you with Mental Health and other important areas of your life. When you communicate with members of your care team, we will discuss these problems. Care team members will ask you questions, listen to you and suggest a plan for improvement.

It is important that you feel comfortable talking with your care team. For many people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their doctors and therapists. Privacy, also called confidentiality, is an important and necessary part of treatment.

Confidentiality cannot be maintained when:

• You tell a care team member, or the care team learns from others, that you plan to cause serious harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the very near future. We must take steps to inform a parent or caregiver of what you have shared and how serious we believe this threat to be. We must make sure that you are protected from harming yourself.

• You tell a care team member, or the care team learns from others, that you plan to cause serious harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future. In this situation, we must inform your parent or caregiver, and we must inform the person who you intend to harm.

• You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. Examples include, but are not limited to, self-harm that can cause serious damage, engaging in risky behaviors that can harm you or others, etc. In these situations, the treatment team will use professional judgment to decide whether a parent or caregiver should be informed.

• You tell a care team member, or the care team learns from others, that you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, we are required by law to report the abuse.

• Sometimes your doctor and your Provider care team may need to work together. Your Provider care team will get written permission from your parent or caregiver in advance before information with your doctor.

Except for situations such as those mentioned above or when required by law, we will not tell your parents or caregivers specific details about what you share with us in your private therapy sessions. We will share general information with your parents or caregivers so that they can support your experience with Provider. This may include information such as scheduling details, your treatment plan and general progress that you make.  You should also know that, by law in California, your parent/guardian has the right to see any written records we keep about our sessions, unless someone on your care team determines that access to such records will be detrimental to your progress. We only put in the written record information that is relevant to your treatment.

Adolescent/Teen Informed Assent

Adolescent/Teen:

Signing indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress, you can ask your care team at any time.

I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.

Have questions? Email info@pathccm.com