We Are Open: MON, WED, FRI - 8am-5pm | TUE, THR - 8am-7pm | SAT – 9am-3pm

Business & After Hours: (323) 987-1200 | For emergencies: Call 911

Informed Consent for Behavioral Health Services

Confidentiality: You have the absolute right to the confidentiality of your services. We cannot and will not tell anyone else what you have told us without your prior permission. Everything you share is confidential, however if you report danger to yourself, others or report child abuse, elder abuse or dependent abuse, it is our legal duty to keep everyone safe.

The following are legal exemptions to your right to confidentiality:

  1. If there is good reason to believe that you will harm another person, we must attempt to contact that person and warn or inform them of your intentions. We must also contact the police and ask them to protect your intended victim.
  2. If there is good reason to believe that you are abusing or neglecting a child or vulnerable adult or if you give me information about someone else who is doing so, ,    we must inform Child Protective Services or Adult Protective Services immediately.
  3. If we believe that you are in danger of harming yourself (wanting to commit suicide) we may have to request assistance to get you hospitalized. We would explore all other options with you prior to taking this step.

HIPPA: You are protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law ensures the confidentiality of all electronic transmission of information about you. Whenever a Behavioral Health Clinician transmits information about you electronically for example, by faxing information, it will be sent using special safeguards to ensure confidentiality is maintained. If you elect to communicate by email at some point in our work together, please be aware that email is not completely confidential.

Record-Keeping: Each time you meet with a Behavioral Health Clinician, notes are entered into your electronic medical record. Your records cannot be accessed by anyone else except your primary care provider. You may request your records at any time by completing a request form.

Other Patient Rights:
1. If you would like us to contact someone outside of WMCHC we will need a signed Authorization for Release of Protected Health Information.
2. It is illegal for a health care provider to pursue or engage in a social or sexual relationship with patients or former patients.
3. You may contact the Los Angeles County Department of Mental Health’s Patients’ Rights Office at 1- 800-700- 9996 or 213-738-4949 or Protection and Advocacy Inc. in Los Angeles at 1-800-776-5746 for help with complaints about your rights as a patient.

Appointments: We expect you to be on time for your appointments and notify us at least 24 hours in advance if you need to cancel or reschedule.

Please note: White Memorial Community Health Center Behavioral Health Services does not provide psychiatry or emergency mental health services after hours. For emergencies, please go to the nearest emergency room or call 911.

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors. You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

Teletherapy: I understand that during tele therapy, I agree to be treated via [telehealth or telephone] and provide verbal consent. The plan for dealing with an emergency during the session is that the clinician will call 911, depending on the nature of the situation. I am aware of this plan.