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«BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ HOSFORD ...»

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U N I V E R S I T Y O F C A L I F O R N I A, S A N TA B A R B A R A

BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ

HOSFORD COUNSELING AND PSYCHOLOGICAL SERVICES CLINIC PHONE (805) 893-8064

DEPARTMENT OF COUNSELING, CLINICAL, AND SCHOOL PSYCHOLOGY Fax: (805) 893-3375 SANTA BARBARA, CA 93106-9490

HOSFORD COUNSELING AND PSYCHOLOGICAL SERVICES CLINIC

Parent/Conservator Consent Form Minor/Dependent Adult Assent Form (rev 8/24/11) Introduction Who We Are: The Hosford Clinic at UCSB provides a variety of mental health care services to individuals, couples, and families. It is a teaching, training, and research center supported by the Department of Counseling, Clinical, & School Psychology (CCSP) and the University. The services are provided by two types of clinicians: 1) Graduate students in the Department of CCSP who are under the supervision of licensed faculty members and mental health professionals, and 2) Faculty members who are either licensed themselves or supervised by a licensed mental health professional. All student and faculty mental health service providers are hereafter referred to as “Clinicians.” It is important to understand that is a training clinic with limited resources. Therefore, we reserve the right to deny treatment to any person who is not deemed appropriate to be seen in this setting. Thus, your minor child or dependent is not considered a client of this Clinic until the intake process is complete, the intake information has been reviewed by a licensed mental health professional and the clinic’s case assignment team, an offer to provide care has been made by the clinic and you, on behalf of your minor child or dependent have agreed to receive the type of care that is being offered. Once accepted as a client, your minor child or dependent and you have an obligation to disclose significant information about the mental and medical status of your minor child or dependent to their clinician, to come to scheduled sessions, to cancel in a timely manner when your minor child or dependent cannot keep an appointment and to cooperate in the diagnosis and treatment being provided. If these conditions are not met, we reserve the right to terminate treatment. If you are attending sessions, the clinician will discuss the possibility of termination with you in an attempt to resolve the issue.

Confidentiality: Your minor child/dependent adult’s contacts with the Clinic will remain confidential. However, Clinicians are required by law to report certain information to other persons/agencies without the client’s permission. Examples of such situations include: if they are ordered to do so by a court of law, if the information must be reported in accordance with the Child Abuse or Elder and Dependent Adult Abuse Reporting Laws or if the minor child/dependent adult threatens to harm themselves or another person. A complete list of circumstances that require the clinician to break confidentiality may be found in the UCSB Notice of Privacy Practices provided to you and your minor child/dependent adult with this Consent Form.

Insurance Reimbursement: Disclosure of confidential information may also be required by your past and present health insurance carriers in order to process claims. Examples of information about you and/or your minor/dependent adult that may be communicated to your insurers are: name and address, social security number and/or student identification number, the client’s diagnosis, treatment plan and type of service received, dates of service, session fee, total amount due, and clinician and licensed supervisor names. In rare instances, insurance companies may require a copy of the entire client record. All of the information provided to insurers will become part of the insurance company files and will probably be stored electronically. Though all insurance companies claim to keep this information confidential, the Hosford Clinic has no control over the information once it is provided to your insurer. Please be aware that submitting a claim carries some risk to client confidentiality and privacy. For example, insurers will use this information to document the client’s condition, which may impact the success of future claims.

Consent: As a client of a student clinician you and your minor child/dependent adult may be observed by the clinic director, supervisors, and graduate students engaged in the study of counseling, clinical, and school psychology. All student clinician sessions are digitally recorded for supervision and training purposes in order to assure a high quality of service. Sessions will be stored on a secure server with controlled access throughout the course of therapy and completely erased at the end of treatment, unless you have provided written authorization to preserve them for another specified period of time. By signing this Consent Form you are consenting to the digital recording all of your minor child/dependent adult’s sessions with student clinicians.

Clinical materials such as digital recordings, documents, and information obtained by observation may be used for program management, research, and training purposes.

Confidentiality is protected by restricting access to these materials. Case records are securely stored and may be accessed only by individuals involved in specific training, research, or treatment activities approved by the Hosford Clinic Policy Committee and by the University Human Subjects Committee. Names and identifying information will be removed from all clinical materials prior to their use in training, research, and/or scientific publication. If a researcher, students, or faculty member knows you on a personal basis, that person will not have access to the materials.





In contrast to student clinicians, faculty clinicians are not required to digitally record.

However, a faculty clinician may request your written permission to record your minor child/dependent adult’s sessions for research and training purposes. Likewise, materials from treatment sessions with faculty clinicians will not be used for research or training purposes without your written permission. If a faculty clinician would like to request permission to record sessions or to use session material for research or training purposes, a separate permission form is required. All case records are securely stored and may be accessed only by Hosford Clinic personnel, which includes student clinicians, faculty clinicians, supervisors, and the clinic director.

Confidentiality of Minors: Our primary aim is to work collaboratively with parents to improve the well-being of a minor who is in treatment. A confidential relationship between a minor and her or his therapist is an essential part of effective treatment.

Therefore, we ask parents to allow their child or adolescent privacy in her or his treatment. The specific context of sessions will remain confidential, between a minor client and her or his clinician, except when the clinician learns that the child is engaging in a lethal activity, is suicidal, or homicidal. According to California law, confidential information discussed in treatment with a minor may be withheld from a parent when it is not in the best interest of the child to disclose it. Even more specifically, the minor’s records may be withheld from the parent if access to those records would have “a detrimental effect on the provider’s professional relationship with the minor patient or the minor’s physical safety or well-being” (California Health & Safety Code, §123115).

Assessments: The purpose of the intake is to evaluate your needs fully. Intakes range from 3-4 hours in duration and include paper-and-pencil psychological assessments.

Several of the intake assessments will be administered periodically throughout the course of treatment.

In order to monitor and enhance the effectiveness of the services we provide, all clients are required to complete weekly assessments that measure well-being and experience of therapy. Please allow 10-15 minutes before and 10 minutes after your scheduled appointment to complete the required forms. By signing this Consent Form, you and your minor child/dependent adult are agreeing to complete these assessments as part of treatment.

Client Rights: We are dedicated to establishing a safe environment that fosters open and honest communication. You are encouraged to discuss any concerns you may have about treatment with your minor/dependent adult’s clinician and/or the clinician’s supervisor. You may terminate services at any time. However, there are conditions, specified in California Law, which permit a minor aged 12 or over or a dependent adult to seek or continue services on their own. If, after consulting with the supervisor, you feel that the minor or dependent adult in your care has received unfair or unethical mental health services, you may submit a formal complaint to the California Medical Board: http://www.medbd.ca.gov/consumer/complaint_info.html or Toll-free line: 1-800Phone: (916) 263-2382, TDD: (916) 263-0935, Fax: (916) 263-2435 or the California Board of Psychology: (866) 503-3221 to request a complaint form or to file a complaint online: http://www.psychboard.ca.gov/consumers/complaints.shtml depending upon the licensure of the clinician providing you with services.

Client Responsibilities: Once accepted as a client, your minor child or dependent adult and you have an obligation to disclose significant information about the mental and medical status of your minor child or dependent to their clinician, to come to scheduled sessions, to cancel in a timely manner when your minor child or dependent cannot keep an appointment and to cooperate in the diagnosis and treatment being provided. If these conditions are not met, we reserve the right to terminate treatment. If you are attending sessions, the clinician will discuss the possibility of termination with you in an attempt to resolve the issue.

If you and/or your minor child or dependent miss two or more sessions in a row, without calling to cancel or reschedule, the clinician will try to contact you by phone. If you do not respond, we will assume that you and your minor child or dependent no longer desire clinic services and we will initiate termination by sending you a letter.

In order to provide a safe environment for our clients and clinicians, we ask that all persons refrain from any violent or aggressive behavior to self, others, or property while in the Clinic. Firearms and other weapons are prohibited on campus. In addition, we request that you and your minor child/dependent adult do not come to the Clinic while under the influence of any drugs or alcohol. Alcohol and illicit drugs may not be brought into the Clinic.

Contacting the Clinic: Our clinicians cannot be reached directly, nor are they available for consultation after hours. If you experience a clinical emergency, please call 9-1-1 or go to your nearest emergency room or contact Emergency Psychiatric Services at Santa Barbara Cottage Hospital at (805) 569-8339. If you or your minor child or dependent adult are a UCSB student, and you experience a clinical emergency, you may call 893-4411. Counseling Center staff members are available to talk to you during business hours and crisis counselors are available by phone when the counseling center is closed.

Records Requests: Laws and standards of the psychology profession require that the Hosford Clinic keep treatment records. Because the records contain information that can be misunderstood by someone who is not a mental health professional, it is our general policy that clients may not review them; however, if you make a written request, and we determine that it is appropriate for you to review your minor child/dependent adult’s record, we will provide a treatment summary free of charge. Additionally, a copy of the client’s full record may be sent to a mental health professional of your choice upon your written request. You will be billed for administrative and shipping/postage costs when you send a full record to another mental health professional or agency.



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