Informed Consent for Treatment

Please type your initials after each of following statements below in the box provided on the right to indicate that you have read and understand this release.

I understand that as a client of CPI I am eligible to receive a range of services offered. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I understand that all information shared with the clinicians at CPI is confidential and no information will be released without my consent. During the course of treatment at CPI, it may be necessary for my therapist to communicate with providers to determine the best treatment for my particular case. While written authorization will not be requested, prior to any discussion with CPI providers, I understand that my therapist will discuss CPI communications with me. In all other circumstances, consent to release information is given through written authorization. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:

When there is risk of imminent danger to myself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger.
When there is suspicion that a child or elder (65+) is being sexually, physically or emotionally abused or is at risk of such abuse, the clinician is legally required to take steps to protect the child, and to inform the proper authorities. (see Penal Code11166.05).
When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests. Re

I understand that in cases of court ordered services, such as psychological evaluation, bonding studies and attachment assessments, and/or other clinical services, the normal limits of confidentially do not apply. If I have been referred by the Department of Social Services/Department of Children and Family Services/Youth Link, then there may be court ordered free exchange of information between those agencies and all treating agencies, which includes CPI.

I understand that CPI services are provided by a range of mental health professionals, some of whom are in Mental Health Interns who are registered with the Board of Behavioral Sciences. All Mental Health Interns are supervised by licensed staff.

I understand that while psychotherapy and/or medication may provide significant benefits, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. I understand that my symptoms may get worse before they get better and that psychotherapy is not an exact science. Medications may also have unwanted side effects and will need to be monitored during the course of my treatment.

If I have any questions regarding this consent form or about the services offered at CPI discuss them with my therapist. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by CPI. I understand that I may stop treatment at any time.