Informed Consent for Psychological Services
Federal and State regulations require that all licensed psychologist provide a statement describing services and your rights regarding your personal health information. The following document includes information about my practice and information required by the Health Insurance Portability and Privacy Act (HIPPA) which provides privacy protections and patient rights regarding the use of Personal Health Information (PHI). By signing this document you are indicating that you have read it in its entirety and understand the information contained in this document.
Three Bridges Psychology and Mediation has both licensed and unlicensed clinicians. All unlicensed clinicians are supervised by Dr. Janella Street. If you are working with an unlicensed clinician, Dr. Street will review the content of the sessions with your clinician verbally and sign all notes related to your treatment. You have the options of contacting Dr. Street directly at any time for any reason by calling (510) 847-7452 x 5.
Confidentiality:
As an individual or couple in engaged in a therapeutic relationship you have privileged communication under the law. This means that with some exceptions anything that you say during therapy, information obtained about you from another source, and even the fact that you are a client is confidential and cannot be disclosed to others without your written consent.
Limits to Confidentiality:
The above-mentioned privileged communication has limits which are allowed under the law. Disclosure without your written consent or authorization may be made to the extent a recipient needs to know the information, if the disclosure is:
- To a current health care provider
- To a former or future health care provider, unless you request in writing that I not do so
- To public health authorities when required or when needed to protect the public
- To the courts under a proper subpoena or court order
- To licensing/certification boards if I am under disciplinary investigation
- To collections agencies for the purpose of collecting on unpaid dept
Under the following circumstances reporting to the proper authorities and/or family member with or without consent is mandatory by law:
- If a child, disabled adult, or elderly person has been abused or neglected If the minor is a danger to him/herself and/or others
- To the local health officer, under specific circumstances, with respect to an HIV positive individual when there is the issue of putting partners at risk for infection.