The Bear Care Clinic is located in White Bear Lake Area High School.

5045 Division Ave., White Bear Lake, MN 55110

Park in the main lot on Division Ave. and enter MAIN ENTRANCE/DOOR A

Mental Health appointments are for children of all ages who live or attend school in the White Bear Lake Area School District. All mental health services are of no cost to the patient or family. We do not bill insurance for counseling.

(651) 444-6750

BearCare@RiseUpHealthClinics.org

Students under the age of 16 require parent/guardian consent for health services. Students 16 years and older may complete this form themselves per state law.

Dear Patient and Family,

This document provides important information about our mental health professional service policies. Please read it carefully and note any questions you might have so you can discuss them with your therapist. Once you sign this consent form, it will constitute an agreement between you and your child, the therapist, and Rise Up Health Clinics: Bear Care. 

Bear Care, a school-based health clinic, offers no-cost mental health counseling. Our therapists are licensed clinical social workers and graduate students. Interns are supervised by a licensed clinical social worker and clinic staff. All of this means that interns receive professional oversight and have many points of contact related to their work with patients.

Counseling and therapy are the processes of assessing and treating mental health issues. A variety of therapeutic techniques can be utilized to deal with the problem(s) that bring people to therapy. These services require your participation and cooperation. 

Counseling and therapy have both benefits and risks. Possible risks include the experience of uncomfortable feelings such as sadness, anxiety, anger, frustration, or the recall of unpleasant past events. The patient/family will be given contact information for after-hours care should they need service after clinic hours. The patient/family may contact the clinic if they need service prior to the next scheduled appointment. However, please note that the clinic operates part-time, and emails and voicemails are only answered on open clinic days.

Potential benefits include a significant reduction of specific problems. Our therapists will do their best to provide a positive therapeutic experience. However, therapy remains an inexact science, and no guarantees can be made regarding the results. There are alternatives to counseling and therapy for addressing mental health issues. This includes consulting with your primary care provider for medical options. You may also choose not to seek any treatment. This option increases the risk of the current mental health issues becoming more difficult to cope with.

Sincerely,

The Bear Care Clinic

Part One: Release of Information

Sometimes the therapist may need to work with members of the school staff in order to coordinate services and provide the best quality care for the patient. This may involve sharing limited but necessary information.

This authorization expires one year from today. You may cancel this authorization at any time by writing a note of cancellation and giving it to the Bear Care Clinic. When you give or cancel your authorization, it is effective from that day forward. This authorization is voluntary, and the patient will not be denied treatment if you decline to sign this authorization. You have a right to receive a copy of this authorization.

Part Two: Limits of Confidentiality 

By checking the box below, I agree to and understand the following:

As a general rule, the therapist will keep the information shared in therapy sessions confidential unless there is written consent signed by you or, in some cases, the patient, to disclose certain information to other parties. There are, however, exceptions to this rule that are important for you to understand before personal information is shared in a therapy session. In some situations, therapists may be required by law or the ethical guidelines of their profession to disclose information, whether or not they have your permission.

Confidentiality cannot be maintained when:

• The patient tells the therapist they plan to cause serious harm or death to themselves.
• The patient tells the therapist they plan to cause serious harm or death to someone else.
• The patient is doing things that could cause serious harm to themselves or someone else, even if they do not intend to harm themselves or another person. 
• The patient tells the therapist that they are currently being abused – physically, sexually, emotionally, or have been in the past. 
• Interns share patient information during routine supervision with the licensed clinical social worker. 
• Communicating with parent(s) or guardian(s)

Except for situations such as those mentioned above, therapists will not tell parents or guardians specific things patients share in private therapy sessions unless the patient gives consent.

Part Three: Statements of Understanding and Written Acknowledgement of Consent for Treatment

By checking the box below, I agree to and understand the following:

• I will ask questions as needed.
• No one has promised me definite results.
• Treatment goals are reviewed and revised if necessary. The therapist may want to discuss these revisions with me.
• The therapist may be a Master of Social Work (MSW) graduate student who is overseen by MSW faculty and will collaborate with their advisors to support the therapy sessions.
• I can change my mind about receiving therapy. If I do, I will tell the therapist as soon as possible.
• The therapist may change during the therapeutic term.
• Give permission to the therapist to gain access to school records, if needed.
• Participate in a diagnostic assessment and creation of treatment goals and/or plan, if needed.

Patient Information

The Notice of Privacy Practices and Patients' Rights and Responsibilities can be found on this webpage. Bookmark or print this information for your records.