Telemedicine Consent Forms

Clearwater Telemedicine Consent

It may be helpful, and save time at the initial meeting, to read through and sign forms outlining our office policies, and issues about confidentiality.  The two forms below detail this information, and can be signed and brought to the intake appointment.  In general, we do not release any information without written consent by the client (in the case of children, consent by the client’s guardian) unless there is a life-threatening situation in which we are required by law to act to protect.  Texts, phone calls, and some other communications by electronic devices cannot be completely secured, and as such may not be completely confidential.

Office Policies & Consent Form

HIPPA Notice of Privacy Practices

Clearwater’s payment policies are outlined in the form below.  This form needs to be completed and signed by clients over the age of 18, by parents for clients under the age of 18, and by both the client and the guarantor of payment when the guarantor is different from the client.  We require 24 hours notice of cancellation for individual appointments or we charge, and we do not refund payments for skills classes under any circumstances.  Payment can be made by credit card (Mastercard or Visa), check or cash.  We do not accept third party payments (including insurance and Medi-Cal) and we charge for our time if we need to contact insurance companies on your behalf.  If the client is not the financial guarantor, we request that the client sign permission for us to communicate with the guarantor about attendance and missed sessions, as this is essential financial information.

Again, it can facilitate the start of services to download and complete this form prior to the first appointment.

Clearwater Payment Policy

Sometimes clients are working with other mental health professionals on an on-going basis, and want these professionals to coordinate care with Clearwater.  For each such contact, we require a completed Release of Information form which allows us to exchange relevant health care information.   You will need to complete one form for each individual or organization with whom we will be communicating.

Consent of Release of Information

Clients in Full DBT at Clearwater will be asked to sign a DBT treatment agreement after a few sessions with your primary therapist.  In addition, we will provide you with written information about our phone coaching policies.  These forms will be discussed in therapy, but are provided here for convenience.

DBT Treatment Agreement

Phone Coaching Agreement

Consent of Email & Text

Assessment Forms

Clearwater Assessment Policies: Licensed

Clearwater Assessment Policies: Assistants