I authorize Dr. Stephanie Holland, Ltd., dba Desert Psychological, and all doctors, clinicians and staff (collectively referred to as "Provider"), to provide mental health services which may include, but not be limited to: assessment, reassessment, treatment planning, psychotherapy, rehabilitation services (i.e., BST, PSR), psychological testing, recommendations, referrals, etc., for myself and/or for the above named person if the person named above is a minor or an adult who is legally incompetent. I certify that I am the person named above or the legal guardian of such person and have the legal right to approve of these services. (initials)

Although the client listed above is the identified patient, I understand that the Provider may work with family members of the abovenamed person, including, but not limited to: parents, step-parents, siblings, grandparents, spouses, significant others or children of the above named person. I understand that the Provider may choose to include these individuals in treatment as deemed necessary and that additional consent may be required from such party for such participation. (initials)

I understand that if I am divorced or separated and share joint legal custody with my ex-spouse, she/he must also consent to these services, and such person is entitled to the information obtained during the child's treatment, including, but not limited to, progress notes, assessments, records received, or a summary letter generated by the Provider detailing treatment. (initials)

I understand that the Provider will write progress reports and assessments for the purpose of treatment planning, coordination of care, and authorization for payment of services including for local and state agencies which may be involved in my/my child's/incompetent person's care. _(initials)

I understand that most information disclosed to the Provider is protected by federal and state regulations governing confidentiality and cannot be disclosed to others without my consent. I understand that due to Nevada state regulations, there are legal exceptions in which my consent is not necessary to disclose information to others, including:

In cases of past or present suspected child abuse or neglect, a report must be made to Child Protective Services no later than 24 hours after the information is revealed. In cases of abuse or neglect of a person older than 60 or of a disabled person or legally incompetent person, a report must be made to local law enforcement agencies. In cases where a client is in imminent risk of harming self or others, or when a person with mental illness needs hospitalization, confidentiality may be suspended for the protection of self and/or others and/or treatment of mental illness. In cases when a person appears to have been injured by a knife, firearm or burn, this information must be reported to local law enforcement or local fire department officials respectively._(your initials)

Confidentiality may also be suspended when a client's treatment is part of a legal claim or defense, or when required by federal or state laws; when information about a deceased

person's mental health services is necessary for determining the validity of a will; when a person is court ordered for a psychological evaluation; and in situations where a client's case is investigated by the Board of Examiners as part of an investigation or hearing.

I understand that I will need to sign a Release of Information (ROI) consent form for records to be released to other parties including a spouse, other agency providing services, etc. HIPAA permits the covered entity, Desert Psychological, to communicate with other mental health providers regardless whether a patient and/or legal guardian has signed a release of information. Information obtained during the process, including necessary assessments, treatment plans, progress notes, and/or other documentation, may be released to insurance provider(s) to ensure authorization, continuity of care, etc. via this consent.

I understand my case may be staffed by clinicians within the agency, or as under contract, who are not licensed who may provide treatment services, testing, or other services, review records and provide treatment planning. My provider will be Michael McNamara who will be working under the supervision of Melissa Depa, Ph.D.

I understand recording may occur during therapy sessions with the Provider for use in supervision and treatment planning. I can request the recording be stopped at any time. The recordings will be used solely for training purposes within the office and only shared between the provider and the supervisor. The recording will be stored in a secure location and only accessed by others with my written permission. The recording will be immediately erased once it has been reviewed for training or in no event later than 30 days from collection.

I understand that therapy appointments are scheduled every 45 minutes. My appointment time is set aside for me and if I am late I realize that my session will be shortened, or, after 15 minutes will be considered a "no-show" and the appointment will need to be rescheduled. Private pay clients will be billed for the cost of the full session.

I understand that if I, or my child/incompetent person, misses multiple or excessive appointments as determined by the Provider, services may be terminated and an appropriate referral will be made.

I understand that the relationship with my assigned provider is a professional therapeutic relationship and acknowledge that I do not have any other type of relationship with the provider. I understand that gifts to/from the provider, or bartering or trading services, are not allowed,

I understand there are risks associated with receiving mental health services. I may learn things about myself, or my child/incompetent person, that I do not like. I understand that as I, or my child/incompetent person, experiences and confronts issues it may cause feelings sadness, anxiousness, or other emotional pain. I understand that success depends on the quality of effort I, and/or my child/incompetent person, put forth into treatment and I realize I am responsible for lifestyle choices and changes that may occur.____(initials)

I understand my provider is not available 24 hours a day, 7 days a week, and that there are other options to receiving emergent care. I understand that if I/my child/incompetent person am/is feeling suicidal, homicidal, or otherwise need immediate urgent care I am to call 911 immediately and/or report to the nearest hospital emergency room. I understand I can also access after-hours care by calling the after-hours crisis line as explained to me.____(initials)

I understand that Desert Psychological, under the ownership of Dr. Stephanie Holland, Ltd., has the direct responsibility for the care of my records and treatment. Should my provider not be available to be able to provide services due to unforeseen circumstances including release of services from agency, incapacitation, or death, I authorize to be reassigned to another provider, or, upon my written request and consent, for appropriate records to be provided to another provider/agency of my choosing.

• Dr. Holland does not allow recording by clients of any kind, during live or remote sessions, or on the telephone. Dr. Holland does not consent to recording in any medium. This is a material term in this contract.
• No weapons are allowed on the premises. If found, the police will be called immediately.
• No one under the influence is allowed on the premises.
• Hostile behavior will not be tolerated and may result in permanent exclusion from the office, the police being contacted, cancellation of services and a report made to the Court of the offending behavior.
• Dr. Holland reserves the right to update the Court as to the status of the evaluation including the participation and cooperation of the parties, impressions, test results, interim recommendations, and their account status.
• Dr. Holland reserves the right to cancel the evaluation at any time due to the behavior of party. Fees will be charged and collected for all work performed. If terminated due to behavior there is no guarantee the report will be completed.
• Harassment during or after the evaluation will not be tolerated and will be reported to the proper authorities. Harassment may include excessive emails or calls to the office, appearing at

the office without an appointment, making threats, using rude language, intimidating herself and staff, causing fear, libel or defamation, the use of the courts without a sound legal basis, posting to the internet false and misleading, or other misinformation, contacting clients, peers, associates, employees or contractors with any of the above with the intent to injure the business, reputation, or safety of Dr. Holland.

I voluntarily agree to receive or allow (in the case of a minor/legal incompetent person which I have legal custody), mental health assessment, care, treatment, or services and authorize the Provider and/or Desert Psychological to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree I will participate in the planning of my care, treatment, or services and that I may stop such care, treatment or services at any time. By signing this consent form, I acknowledge that I have both read and understood all the terms and information contained herein and have been provided ample opportunity to ask questions and seek clarification of anything unclear to me.

By signing below I authorize Dr. Stephanie Holland, Ltd. to complete the services stated.

ALL FEES QUOTED ARE VALID FOR 1 YEAR FROM THE DATE CONTRACT IS SIGNED

Rev. 9/1/2024

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