15203 NE 72nd Ave, Vancouver, WA 98686

Therapy Treatment Plan Agreement

Welcome to The Villa Health! We're committed to providing compassionate, respectful, and effective therapy services in Washington and Oregon. This agreement explains your rights, responsibilities, and our shared commitments in your care. Please review carefully, and feel free to ask questions at any time.

Supervision Disclosure

Some of our providers are associate-licensed mental health professionals who practice under clinical supervision. Supervision ensures quality care, compliance with state requirements, and professional support for your provider.

Your specific supervision arrangement will be reviewed with you at the start of treatment. Supervision may be provided by:

• Dr. Daniel Roa, DNP, ARNP-PP, AGPCNP-C, PMHNP-BC President & Medical Director, Board-Certified Psychiatric Mental Health Nurse Practitioner; Licensed in Washington & Oregon.
• Other licensed clinical supervisors designated by The Villa Health PLLC.

You will always be informed of your provider's supervisor's name, credentials, and licensure.

1. Purpose of Agreement

This agreement establishes the framework for your therapy treatment at The Villa Health PLLC. It is designed to protect your rights as a patient, outline your responsibilities, and clarify our obligations as your provider.

It complies with:

• Oregon state law (Oregon Revised Statutes and Oregon Health Authority standards)
• Washington State Department of Health requirements.
• Federal privacy and confidentiality laws, including the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2 for substance use disorder records.
• Mandatory reporting laws in both states, including reporting of suspected abuse/neglect and threats of harm.

This agreement applies to all therapy services provided by The Villa Health, whether delivered in- person or via secure telehealth platforms.

2. Informed Consent

You have the right to:

• Participate in developing and updating your treatment plan
• Request changes to your treatment at any time
• Receive clear information about therapeutic approaches, risks, and benefits
• Ask questions and get answers you understand
• Know whether your provider is fully licensed or practicing under supervision
• Expect your information to be protected under federal and state privacy laws

3. Patient Rights

You have the right to:

• Receive respectful, non-discriminatory care
• Access and review your medical records
• Refuse or decline any treatment
• Seek a second opinion
• File a complaint without retaliation, first through The Villa Health, and if unresolved, with:
  • Oregon Board of Licensed Professional Counselors and Therapists
  • Washington State Department of Health
• End treatment at any time
• Be informed of changes in your treatment team
• Understand the licensing status and jurisdiction of your providers Receive information about telehealth and technology use

4. Limits of Confidentiality

Your information is confidential, except when disclosure is legally required:

• Risk of serious harm to yourself or others
• Suspected abuse or neglect of a child, dependent adult, or vulnerable person
• Court order or other legal mandate

Federal law also provides extra protections for substance use disorder treatment records under 42 CFR Part 2. These records cannot be disclosed or redisclosed without your written consent, except as specifically allowed by law. You will be notified if such circumstances arise.

5. Minor Consent (WA & OR Laws)

• Washington: Minors age 13+ may consent to outpatient mental health and reproductive health treatment. Parents/guardians cannot access these records without the youth's written authorization, unless required by law.
• Oregon: Minors age 14+ may consent to outpatient diagnosis or treatment of a mental or emotional disorder or substance use disorder (excluding methadone Providers are expected to involve parents before the end of treatment unless the minor objects or it is clinically inappropriate.

6. Treatment Expectations

As a patient, you agree to:

• Attend scheduled appointments or provide at least 48 hours' notice for cancellations/reschedules. Please see The Villa Health's No-Show and Cancellation Policy for details on fees and care impacts.
• Actively participate in treatment
• Provide accurate information about symptoms and concerns
• Inform your provider of any changes in condition or other treatments you are receiving
• Follow your agreed-upon treatment plan
• Keep contact information up to date
• Notify us if you relocate to another state

7. Provider Commitments

The Villa Health PLLC commits to:

• Provide evidence-based, compassionate care
• Maintain professional boundaries
• Protect your confidentiality within legal limits
• Document treatment appropriately
• Coordinate care with other providers when authorized by you
• Provide crisis resources relevant to your location
• Review treatment progress regularly with you
• Ensure proper supervision of associate-licensed providers
• Maintain licensing in relevant states and adhere to all state-specific requirements

8. Telehealth & Interstate Practice

• Your provider must be licensed in the state where you are physically located during sessions.
• Telehealth is delivered only through secure, HIPAA-compliant platforms.
• Insurance coverage may vary by state and payor.
• Some services may require in-person visits for clinical or safety reasons.
• Email and text may be used for limited, non-urgent communication (e.g., scheduling), but they are not fully secure. By choosing these methods, you accept the risks of unauthorized

9. Crisis & Emergency Protocols Your safety is our highest priority. While The Villa Health PLLC does not provide after-hours emergency coverage, the following resources are available 24/7 for urgent needs:

Emergencies

• Call 911 immediately or go to the nearest emergency department.

Mental Health Crises

• 988 Suicide & Crisis Lifeline: Call or text 988 from anywhere in the United States to connect with crisis support.
• Washington Recovery Help Line: Offers 24/7 help for substance use, gambling, and mental health issues. Call 1-866-789-1511.
• Oregon Crisis Line: Call 988 or chat online: 988lifeline.org
• National Crisis Text Line: Text HOME to 741741 to connect with a trained crisis counselor by text.

Important Note: If you are experiencing a life-threatening emergency or are at immediate risk of harm, call 911 or go to the nearest emergency department.

10. Acknowledgment & Consent

By signing below, I confirm that I have read and understood this agreement, and I consent to therapy under these terms. I understand that this consent is voluntary and may be withdrawn at any time.