Watch a short video introduction to this agreement.

Practice Policies and Informed Consent

Last Updated: November 1st, 2024

Welcome to Guidepost DBT (formerly the DBT Center of Marin), we look forward to working with you, your child, or a ward for whom you serve as a guardian. Before we begin your therapy you must review, and agree to, our practice policies and provide us with your informed consent to treatment. Your “informed consent” means that you have reviewed the following document, understand it, and agree to its terms and conditions. In this document the terms “we” and “our” refer to Guidepost DBT not individual therapists or staff members. Please read this agreement carefully and contact us with any questions. 

Please be aware that we periodically update this agreement to reflect changes in ethical guidelines, laws, and company policies. We will make reasonable efforts to notify you of such changes and the version published at https://guidepostdbt.com/practice-policy-and-informed-consent will override any previous version that you may have agreed to. You can determine when the agreement was last updated by referring to the "Last updated" notation above. If any of the terms are not acceptable to you, you must contact your therapist immediately to discuss the possibility of continued care.

About Guidepost DBT

Guidepost DBT offers care by psychologists, licensed therapists, and pre-licensed therapists (working under the supervision of a licensed therapist) to provide individual, couples, family, and group therapy to adults and adolescents for a variety of mental health issues. 

Evidence Based Practices

Our practice is guided by research and is focused on treatment modalities that are proven to result in positive outcomes for clients. Our therapists incorporate a range of evidence based practices, but overall Guidepost DBT specializes in Dialectical Behavior Therapy (DBT) and Radically Open Dialectical Behavioral Therapy (RODBT). These modalities combine Cognitive Behavioral Therapies (CBT) with mindfulness practices to modify targeted behaviors that are disruptive to your mental health and to establish new behaviors that promote mental health. 

Therapist Selection

At Guidepost DBT we believe that you should feel comfortable with your therapist(s) and with therapy itself. Evidence has shown that a positive rapport with therapists correlates with improved outcomes. Following this, if you do not feel comfortable with your therapists, or have questions or concerns about their practice, you should discuss these questions and concerns whenever they arise. During your treatment you’ll have a primary therapist who will lead your treatment and you may have secondary therapists that you work with in the context of skills groups or phone coaching. If you feel that any of your therapists are not the ideal fit for you, then our clinical director, or a clinical supervisor, will be available to discuss arranging a meeting with another therapist for a second opinion, assign another therapist, or provide a referral to an outside therapist. For more information about our therapists and their licenses, please visit https://guidepostdbt.com/team-overview.

Therapist Consult Teams

You will engage with a primary therapist during the course of your treatment, however, your overall care will involve a team of therapists who will support your primary therapist through consult meetings. Consult meetings are a standard part of DBT treatment programs and provide your primary therapist with an opportunity to get objective advice and guidance from other Guidepost DBT therapists on your treatment with the goal of improving the quality of your care. 

Informed and Comprehensive Care

Guidepost DBT therapists are committed to DBT as a treatment protocol but not all clients require all aspects of DBT or RO-DBT. Following this, your treatment plan may call for “Comprehensive DBT or RO-DBT” which includes individual therapy, skills group, and phone coaching, or it may call for a subset of these services as part of an “Informed DBT or RO-DBT” plan. 

Benefits of Treatment

Therapy has many benefits including, but not limited to, a positive impact on overall behavior and personal wellness. However everyone’s experience with therapy is unique and it’s impossible to predict how you will respond. There are also potential risks to treatment, including, but not limited to, discussion of sensitive topics can increase discomfort and worsen symptoms before they improve, new symptoms or treatment issues may emerge during the course of treatment, and progress related to mental health symptoms can result in changes that have the potential to disrupt life patterns or interpersonal relationships. 

Starting Treatment

Your first few sessions will be spent with your primary therapist getting to know each other, developing a rapport, and gathering information so that they can evaluate your needs and assess your mental health. Based on this, you will be provided with information on appropriate service options. These include but are not limited to: 1) treatment is not recommended, 2) treatment is recommended but not with the assigned primary therapist, a new primary therapist will be assigned, 3) treatment is recommended but not with Guidepost DBT, referrals will be provided if appropriate, 4) one or some combination of the following: individual therapy, couples therapy, family therapy, group therapy, on-demand skills coaching (referred to as “phone coaching” in the DBT manual), and DBT skills group. If treatment is recommended, your primary therapist will provide you with a treatment plan that you will discuss and agree on. Throughout treatment, your primary therapist will assess your progress toward your goals and make adjustments as needed. 

Ending Treatment

The length of treatment may vary greatly depending on your diagnosis and external factors. Ideally treatment is conducted during a finite period of time after which you’ll no longer require DBT therapy. In some cases, clients do require ongoing support that tends to be at a reduced level after the initial treatment period is complete. In other cases, clients periodically re-engage with a therapist to address challenges that arise after treatment.

The end of treatment typically occurs when your progress goals have been achieved. When ending treatment, it’s ideal to conduct a few sessions focused on transitioning out of therapy with a plan to help guide you moving forward. The appropriate length of the termination depends on the length and intensity of the treatment. However, you may opt to end treatment whenever you want with, or without, such sessions. 

Guidepost DBT may also terminate treatment after appropriate discussion with you and a termination process if you are not benefiting from treatment or are not adhering to  treatment requirements, or for other reasons specified in this document. Prior to the termination of treatment, your primary therapist, our clinical director, or a clinical supervisor, will make every reasonable effort to provide pre-termination counseling and suggest alternative service providers as appropriate. 

Appointments and Cancellation Policy

Treatment at Guidepost DBT involves regularly scheduled, recurring sessions with a therapist. You will set the frequency and the associated schedule of appointments in advance with your primary therapist. Appointments may include both individual, couples, family, and skills group sessions. 

In general, we have a forty-eight (48) hour notice policy for individual therapy appointment types (excluding skills groups).

Individual session appointments can be reviewed via our secure client portal at https://guidepostdbt.clientsecure.me/. Appointment cancellations in particular must be made by email to intake@guidepostdbt.com, or by a voicemail (our phone number is available at: https://guidepostdbt.com/contact-us). Therapists are not directly responsible for managing appointment cancellation.

Skills group sessions are handled differently because it is not feasible to reschedule appointments to accommodate a single participant. Following this, if you miss a skills group session you are still responsible for payment and you are encouraged to schedule an individual make-up session to keep up with the material. Make-up sessions will be billed at the rate of the therapist who provides the make-up session. In order to remain in skills group treatment, you are required to attend individual make-up sessions if you miss more than two sessions in any single skills module (a module is a section of the DBT curriculum).

On-demand skills coaching (phone coaching) can be cancelled at any time. Your request to discontinue use of the service must be provided in writing via email to admin@guidepostdbt.com, or by a voicemail (our phone number is available at: https://guidepostdbt.com/contact-us). Your monthly subscription fee will be adjusted within five (5) business days. 

If you miss four consecutive scheduled appointments Guidepost DBT will consider your absence as non-adherence to treatment and therapy will be terminated effective immediately.

If you decide to discontinue your participation in skills group therapy, thirty (30) days advance notice must be provided in writing via email to admin@guidepostdbt.com, or by a voicemail (our phone number is available at: https://guidepostdbt.com/contact-us). You shall remain responsible for payment of all skills group sessions which occur in the thirty (30) days following notification regardless of whether you attend the skills group. 

Periodically, it is necessary to cancel scheduled therapy appointments due to sickness, vacation, or other reasons. Our policy is that we require a minimum of forty-eight (48) hours notice in order to cancel or reschedule an appointment without charge.  If you cancel or reschedule an appointment with less than forty-eight (48) hours notice but more than twenty-four (24) hours notice, you will be charged a cancellation fee of $30. If you cancel or reschedule an appointment with less than twenty-four (24) hours notice, you will be charged the full session fee. No exceptions will be made to this policy.

Rates, Fees, and Payment Policy

Unless specified in writing otherwise, individual therapy will be delivered at the session rate of your primary therapist as published at https://guidepostdbt.com/rates. If your treatment plan requires on-demand skills coaching sessions, then a monthly subscription fee will charged for this service. The rate for skills-coaching is published at https://guidepostdbt.com/rates. Skills coaching sessions are also available to clients on a prorated basis, in 15 minute increments, based on your primary therapist’s rate. This is more expensive per coaching session but may be more appropriate and affordable for clients that only need occasional skills coaching support. Skills group sessions will be delivered at the rate published at https://guidepostdbt.com/rates.

Fees for all therapy sessions, whether for individual sessions or skills groups, are due on the date of service. If you are unable to make a payment on the date of service we ask that you notify us at your earliest convenience. Payment handling is managed by our administration who can be reached at admin@guidepostdbt.com.

If you are an adult (over 18 years old) and someone else will be responsible for paying for your session, complete the below information. This person who you designate as being financially responsible will be given access to your secure patient portal that provides appointment, invoice, statement, and superbill information. 

Forms of Payment

We prefer to accept payment from a credit or debit card that we securely store in our HIPAA compliant electronic health record platform, as this allows us to process payments in a timely and efficient manner. We do accept payment, in the form of cash or check but request a credit or debit card to be on file as a backup form of payment. If we do not receive payment from you for two consecutive appointments, we will charge your credit card for the outstanding appointment fees. There is a thirty five dollar ($35.00) processing fee on returned checks.

Refunds

In the event that a refund is appropriate, as judged solely at the discretion of Guidepost DBT, and you are an active client, a credit will be applied to your account. If you are no longer an active client, we will issue a refund to the credit card on file. If that fails, a check will be mailed to the address we have on file for you. In the former case, such credit will be applied to your account within ten (10) business days; in the latter case, a refund should appear on your credit card statement within ten (10) business days; however, you agree to hold Guidepost DBT harmless if it has undertaken good faith action to credit your credit card on file and through inaction, fault, negligence, or any other mistake on your part or the part of your credit card provider such credit does not appear within ten (10) business days. If a refund to your credit card is not possible, a check will be mailed within an additional ten (10) business days.

Missed Payments

If payment is not made on the date of service, we’ll reach out to you to arrange payment before your next scheduled session. If payment is not made on the next date of service, we will cancel all scheduled appointments until payment is received. Additionally, if you have not paid for two, or more sessions and payment is more than thirty (30) days late, then Guidepost DBT reserves the right to terminate treatment, unless other arrangements have been made in writing with our administrative staff (therapists are not part of our administrative staff). 

If payment is past due by 90 days, unless payment arrangements have been made with our administrative staff, it may be sent to collections. As a courtesy to clients, a collections warning notice will be sent and you will be given ten (10) working days to respond to this notice before action is taken. If you discontinue treatment at any time and your account is delinquent or assigned to collections, you will not be allowed to re-engage in therapy until your balance has been paid in full.

Rate Changes

Guidepost DBT adjusts our therapist’s rates annually at the end of the calendar year and as their credentials change. When this happens we will provide at least thirty (30) days notice before any rate change becomes effective. 

Fees for Consultation

During treatment it may be necessary to consult with a third party about your treatment. Such meetings include in-person or remote verbal and written communication with you, your family members, other mental health professionals, insurance providers, or other relevant parties. Meetings of this type are generally done with your knowledge after a release of information has been completed, though in some cases we may be compelled to participate in such meetings by a third party. Guidepost DBT does not charge for meetings with other professionals regarding your treatment that are less than fifteen (15) minutes. Meetings that are longer than fifteen (15) minutes will be charged on a prorated basis, in fifteen (15) minute increments, based on your primary therapist’s session rate. 

If you become involved in a legal or administrative proceeding with a third party, even if Guidepost DBT is compelled to testify by such a third party, about our relationship then you will be responsible to pay your primary therapist’s session rate on a prorated basis, in fifteen (15) minute increments for any and all time. 

Insurance Policy

Guidepost DBT does not contract with any insurance carriers or bill insurance companies directly, following this you are personally responsible for payment of all fees. As a courtesy, for you to obtain reimbursement from your insurance carrier, Guidepost DBT will provide you with an itemized statement of your sessions (also known as a Superbill) at the end of each month, which you can use as your receipt in submitting to your insurance carrier. It is your responsibility to verify the specifics of your coverage and benefits before treatment begins. 

Communication Policy

Guidepost DBT provides clients with access to a secure, HIPAA compliant, client portal at  https://guidepostdbt.clientsecure.me/ that is intended to be the primary interface for communication that includes clinical information. With the exception of skills coaching requests (referred to as phone coaching in the DBT manual) our therapists generally respond to communications via our client portal within twenty-four (24) hours, with the exception of weekends, holidays, and vacations. If your primary therapist is on vacation, or absent for another reason, you may request access to another therapist who will cover for your primary therapist while they are unavailable. Guidepost DBT will make every reasonable effort to provide coverage or a referral who can cover during absences. 

If you do not use our client portal for communications, we cannot guarantee, or be held responsible for, the security and privacy of your communications. Nor can we be held responsible for any harm resulting from breaches of confidentiality, security, privacy, or disclosure. Following this, we strongly recommend that you limit communications outside of our client portal to non-clinical administrative matters. 

Any communication, electronic or otherwise, may become part of your clinical record and will be legally treated as any other written, or recorded, health record.

Emergency Communication

Guidepost DBT therapists are not available to respond to emergency communications. In the case of an emergency, you should contact emergency services by dialing 911 on your phone, or proceed to the nearest hospital emergency room. 

On-Demand Skills Coaching (Phone Coaching)

During your treatment you may request on-demand skills coaching during the hours specified in your treatment plan. Requests for skills coaching should be made via our client portal if at all possible and will be responded to as quickly as possible by a Guidepost DBT therapist. We do not guarantee response times, however, we strive to respond as quickly as possible without infringing on other commitments such as therapy appointments with other clients. To achieve the quickest possible response, the responding therapist may not be your primary therapist. 

Skills coaching requests should include a genuine request for skills coaching along with information about what skills you have already tried. If your request does not meet these criteria, your primary therapist may not reply to your request at his/her discretion. You may also request support in two additional situations: 1) you are imminently considering ending treatment and feel you may not attend your next scheduled session, 2) you feel that there is a pressing issue related to your relationship with your therapist that cannot wait until your next scheduled session to address. 

Phone coaching is intended to be an occasional but important intervention. If you use the service inappropriately or too frequently, your primary therapist reserves the right to withhold the service. Additionally, if you have engaged in self-harming behaviors, on-demand skills coaching will be withheld for twenty-four (24) hours. 

Direct Electronic Communication

If we communicate by email, text messaging services, video messages, or other direct communication medium, you accept the risks associated with these mediums and recognize that they may not be HIPAA compliant. 

Therapists are not required to check their work email or personal email accounts, text messaging services, or other communication services regarding clinical issues. We encourage therapists to use password protected cellular phones, but they do so at their discretion whereas our client portal requires password protection regardless of device. 

Social Media Communication

Guidepost DBT and therapists may have “social media” accounts that are accessible to the general public, you should not connect with your therapists through these accounts. You agree to refrain from beginning, continuing, or maintaining, any communication or “relationship” through “social media” with therapists at Guidepost DBT. Additionally, we request that our therapists not connect with active or past clients via these platforms. If social media services present “suggest connections” with our therapists, you should not act on such suggestions or invitations. With some services it is not possible to readily identify who the actual account owner is, so we rely on your discretion to avoid improper connections via anonymous accounts. 

Our therapists are instructed not to search or view your online activities without your consent and without our explicit agreement to do so for the specific clinical purpose to preserve the boundaries of our professional relationship. If you wish to share aspects of your online life, please bring them into sessions for discussion. 

If you obtain concerning information about our therapists via social media, or more generally on the internet, you should raise your concerns in the context of your next session. Alternatively, our clinical director or a clinical supervisor will be available to discuss such concerns with you. 

You should not attempt to obtain private information about our therapists. Doing so may make your professional relationship with our therapists uncomfortable. This constitutes non-adherence with treatment requirements and may lead to the need to change therapists or terminate care. 

At Guidepost DBT, it is our priority to provide a positive experience to all of our clients. If there is something that we can be doing better, we ask that you arrange a time to connect with your primary therapist and/or our administrative assistant at admin@dbtmarin.com so we can understand your situation and attempt to directly resolve it. If you post a negative review or comment about Guidepost DBT, or a specific therapist, online via a social platform (e.g. Yelp, etc.) we reserve the right to respond to your review or comment if the service allows us to do so. We will never respond in a way that reveals personally identifiable information, details about your treatment, or that goes beyond the information contained in your original review or comment. 

Telehealth Policy

You may opt to receive treatment via telehealth which includes both audio and video sessions delivered via a HIPAA compliant service. You should understand that these services have unique affordances that are different than in-person sessions.

Telehealth sessions have potential benefits including, but not limited to, easier access to care and the convenience of meeting from a location of your choosing. There are also potential risks to this technology, including, but not limited to, interruptions due to internet outages, unauthorized access, and other technical difficulties. 

When using telehealth we recommend that you find a quiet, and private, location with a secure internet connection. If you’re using video, a well lit location is preferred. These steps will help ensure a high quality experience. You, or your therapist, however, can discontinue a telehealth session at any time if it is felt that the telehealth service is hindering treatment and/or if your therapist finds that the location of your session is not private and puts confidentiality at risk. You will still be responsible for the full session fee. Additionally, you can request information about our telehealth platform at any time to assess potential risks and to address potential concerns.

Guidepost DBT provides telehealth through SimplePractice for individual therapy sessions (https://simplepractice.com/) and Zoom for skills groups (https://zoom.us/). These services are only available for scheduled sessions and should not be used for any other communication. Neither SimplePractice or Zoom provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. SimplePractice and Zoom facilitate online audio and video sessions and they are not responsible for the delivery of any healthcare, medical advice or care.

Guidepost DBT subscribes to these services and is not responsible for their technical functioning or security. Following this, you agree not to hold Guidepost DBT responsible for any issue, security, privacy, or otherwise, relating to the functionality of these services.

To ensure your confidentiality you should not share appointment links or other details with anyone who is unauthorized to attend your session.

Session Recording Policy

Recording therapy sessions can be useful and valuable for you and your therapists. Therapy sessions can be intense and rich experiences that are hard to fully process in real-time. Some clients find it valuable to review recorded sessions to more fully unpack, understand, and integrate insights. Recordings can also be used effectively in the context of individual sessions for a range of purposes including, but not limited to, exploring triggering moments, and reviewing skills use. 

For therapists, recordings can be used to enhance clinical supervision, which therapists engage in to further develop their skills. Recordings can also be used in the context of consult groups at which your primary therapist can obtain advice and guidance on your care from colleagues. As with supervision, this practice is ultimately focused on optimizing the quality of care we provide. The recording of therapy sessions is a standard practice associated with training and supervision for therapists. 

Our policy is to obtain your authorization at the beginning of any recorded session such that your permission is part of the recording itself. No recordings will ever be made without your authorization at the time of the recording.

The above pertains to recordings that are facilitated by Guidepost DBT and not to recordings that are facilitated by you. If you choose to record a session using your own recording device, then you’ve inherently authorized the recording. You are required to inform your therapist, and obtain their consent, if you plan to record a session. 

Safety Policy

Guidepost DBT staff and client safety are of utmost importance. As such, any act of aggression to yourself, others, or property while at our Center or in a telehealth setting will be reported to our clinical director or a supervisor. A corrective action plan will be implemented to address the incident which may involve a written apology, compensation for damages, taking legal action, and/or immediate termination of Guidepost DBT services. 

You should not come to sessions under the influence of drugs or alcohol. If drugs or alcohol have already been used, you may only come to sessions if you are able to act and appear clean and sober. 

HIPAA

This document contains important information about the professional services and business policies at Guidepost DBT. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides protections and client rights with regards to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with Guidepost DBT Practices Policies and Informed Consent that includes the use and disclosure of PHI for treatment, payment, and health care operations. This Agreement explains HIPAA and its application to your PHI in greater detail. Guidepost DBT is legally required to follow the Practice Policies and Informed Consent described in this Agreement. Please note that we reserve the right to change the terms of this Agreement at any time as permitted by law. We are happy to discuss any of these rights with you. 

Records Policy

Guidepost DBT is required by law (CA HLTH & S § 123100 et seq.; 45 C.F.R. § 164.524) and professional standards to keep appropriate treatment records. You have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances, or when it is assessed that releasing such information might be harmful (see above legal citation). In such cases, Guidepost DBT will provide the records to an appropriate and legitimate mental health professional of your choice unless otherwise prohibited by law. At your request, Guidepost DBT will release information to any agency/person you specify unless it is assessed that releasing such information might be harmful or such disclosure is prohibited by law. Legal guardians, as well as any parent whose parental rights have not been terminated, are legally entitled to the medical records of their child, including psychotherapy records. Note, requests to share records are subject to separate agreement for the release of information which can be provided by our administrative staff. 

Confidentiality and Privacy Policy 

Your confidentiality is protected by California and Federal Law (45 C.F.R. §§ 164.500 et seq.; CA WEL & INST § 5328), and by professional, ethical rules. For your convenience, a summary of situations in which confidentiality will not apply are listed below, this list is illustrative, not exhaustive, and in the case that any listed situation is in conflict with law, the law will prevail over what’s listed here:

  • When there is reasonable suspicion of any child abuse (under the age of 18) or abuse to a dependent adult or elder adult (over the age of 65);

  • When the client is suicidal;

  • When the client communicates a threat of bodily injury to others;

  • Certain legal and administrative proceedings;

  • In furtherance of your treatment with other Guidepost DBT therapists or professionals;

  • Emergencies.

In the event that one of the above occurs, as judged by Guidepost DBT, or as otherwise required by law, Guidepost DBT will do whatever it can within the limits of law to prevent you from injuring yourself or others and to ensure that you receive the proper medical support and care. For this purpose, Guidepost DBT may also contact someone whose name you have provided and consented to for us in the case of an emergency.

Consultation Team Policy

Related to the consultation team model at Guidepost DBT, therapists are required to participate in a regular consultation group with other DBT therapists. In this small group, we respect clients’ confidentiality as much as possible; however, certain aspects of your treatment may be discussed and your records will be available to all Guidepost DBT therapists that are engaged with your care including your primary therapist, therapists leading or co-leading skills groups which you attend, therapists who provide phone coaching, and therapists who review your care in the context of supervision or consultation. 

Skills Group Policy 

While DBT skills group members are strongly encouraged to respect one another’s privacy, ultimately, confidentiality cannot be guaranteed because other clients are not held to the same ethical and legal requirements as therapists. It’s important that you understand that there is an increased risk to confidentiality and privacy when participating in skills groups. 

Family, Couples, and Minor Policy

Confidentiality and privilege exist between Guidepost DBT and our clients but does not apply between family members. In the case of child and adolescent therapy, however, maintaining confidentiality and privacy can be essential to treatment and all clients are encouraged to respect confidentiality and privilege whether legally required or not. 

Parent or Guardian 

If you are signing this document on behalf of a child, or ward, be aware that their therapist will review the terms of this agreement with them. As the legal authority, and per our records policy, you have the right to request their treatment records. In general, however, we recommend that you respect your child’s, or your ward’s, confidentiality with their therapist as this supports that therapeutic alliance between a therapist and client.

If you share joint custody with another parent or guardian, we will request that the other parent or guardian complete this form as well. Please check the box below if you hold joint custody with another parent or guardian:

[CHECKBOX]  I share joint legal custody 

Please include the following Co-Parent information: 

Full Name and Email of Co-Parent: REFER TO INFORMATION ON FILE

Last Name of Co-Parent: REFER TO INFORMATION ON FILE

Email of Co-Parent: REFER TO INFORMATION ON FILE

Phone Number of Co-Parent: REFER TO INFORMATION ON FILE

Please enter your child or ward’s full name and date of birth below:

Child’s First Name:: REFER TO INFORMATION ON FILE

Child’s Last Name:: REFER TO INFORMATION ON FILE

Child’s Date of Birth: : REFER TO INFORMATION ON FILE

The DBT Center of Marin has a quarterly newsletter that is emailed to clients. Please indicate below if you would like to be added to our newsletter communication.  

[CHECKBOX]  Yes/No : REFER TO INFORMATION ON FILE

Instant Agreement Consent

You and Guidepost DBT agree that this agreement is to be governed by the laws of California and when applicable Federal Law. Further, in the event of any controversy, legal or administrative action of any kind, or disagreement, relating to or arising from this agreement, or any other agreement between you and Guidepost DBT, will be brought only before the Marin County Superior Court located in Marin County California, whether brought directly by you, Guidepost DBT, or by heirs or assigns.

You and Guidepost DBT further agree that if any portion, provision, or section of this agreement, or any other agreement, past or future, is found to be unconscionable, unenforceable, or contrary to the public policy of the State of California that such provision, portion, or section, is to be severable and the agreement absent such severed portion is to remain fully intact, binding, and enforceable.

No modification of this agreement shall be valid or enforceable unless in writing.

By clicking here I am agreeing that: 

  • That I have read or had this form read and/or had this form explained to me.

  • That I have had the opportunity to consult with an attorney. 

  • That I fully understand its contents including the risks and benefits of the procedure(s).

  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

  • That I am voluntarily entering into this agreement.

DATE: REFER TO INFORMATION ON FILE

Include the below information for the person completing this form: 

First Name: REFER TO INFORMATION ON FILE

Last Name: REFER TO INFORMATION ON FILE

Email: REFER TO INFORMATION ON FILE

Phone Number: REFER TO INFORMATION ON FILE

Date of Birth: REFER TO INFORMATION ON FILE