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TREATMENT AGREEMENT AND INFORMED CONSENT Pheonix Collective, Inc. 7456 Mission Gorge Road #165 San Diego, CA 92120 Phone: (619) 649-6649 Client Treatment Agreement and Informed Consent Form Date of Form: 1-24-2025 1. MY TRAINING AND LICENSURE: I hold a master’s degree in Social Work (MSW) from the University of Minnesota-Twin Cities (2003) and I am a Doctor of Social Work student at Tulane University. My California registration number is 113278. My clinical supervisor is Patricia Bruce, DBH, LCSW, California license number 62698. 2. FEES: To make counseling accessible, I offer sliding-scale payments based on your ability to pay. My sliding scale fees are subject to change, and I am open to discussion at any point. My current fees are up to $50 per hour based on a client’s ability to pay. However, some clients who would otherwise be unable to receive treatment do not pay any fee. Sessions are between 53-60 minutes. There is no fee for phone calls up to less than 15 minutes. Calls with a duration of 1637 minutes are prorated at one-third of your usual fee; 38-52 minutes’ duration are two-thirds your usual fee; and calls longer than 53 minutes or longer are at your usual session fee. Paperwork that takes more than 15 minutes can be completed in a session, or it will be billed at a rate of $10 for 16-37 minutes, $20 for 38-52 minutes, and $30 for more than 53 minutes. Total payments or copays are expected on or before the date of services. Late cancellation or no-show fee is $25 for all clients, including those who are being treated pro bono. 2. INSURANCE: I only accept Medicaid under my clinical supervisor, Dr. Patricia Bruce. If you are using insurance, you should be aware that processing insurance for payment can be timeconsuming and complicated. During treatment, you may learn that you have a deductible or copay, or you may learn that your insurance will not cover your sessions for some reason. Phoenix Collective will do our due diligence to determine these situations beforehand and help navigate them if they arise. If your insurance does not cover your care, you will not pay a fee. Also, billing insurance puts more of your PHI (Protected Health Information) at risk. We accept insurance because we want to serve you. You may also consider paying out of pocket and then getting reimbursed by your insurance company. This is possible if you have ‘out of network benefits even if we do not usually take your insurance. We can provide a Superbill for you for this purpose. 3. APPOINTMENT SCHEDULING & CANCELLATION: Appointments can be scheduled for your Phoenix Collective, Inc. portal or with your therapist. If you schedule an appointment, we expect you to keep it. Please give us 24 hours' notice if you need to cancel or change it; otherwise, you may be charged $25. In some cases, we may waive the fee, but you may be warned that further cancellations may cause us to terminate therapy. Please let us know about illnesses and emergencies; we usually understand. We appreciate your understanding if an emergency arises, and your clinician also needs to cancel. We may need to stop seeing you for therapy if there are more than three no-shows or late cancellations. You can discuss this policy with your clinician. 4. CONFIDENTIALITY: All our discussions are confidential. You must sign a release of information for us to communicate with others. We may sometimes ask if students or new Associates observe your sessions. We will always allow you to refuse. In certain situations, we may be required to discuss confidential information, such as in the clinic for treatment planning and consultation, when a court order is received, when we have reason to believe that you or someone else is in imminent danger, or when we have reason to believe that you or someone else may be abusing a child, elder, or disabled person; if you were to file a complaint or lawsuit against us. Please review our Notice of Privacy Practices, which contains additional information on how your Protected Health Information may be used. By signing this document, you give consent for me and my staff to use and disclose your protected health information for the purposes of treatment, payment, and healthcare operations. 5. EMERGENCIES and COMMUNICATION: If you have a mental health crisis, please call 988. This number can also connect you to the San Diego Crisis Line at 1-888-724-7240 or Veterans Crisis Line at 1-800-273-8255 (press option 1). If you feel you are at imminent risk for self-harm or harm to others, go immediately to your nearest Emergency Room for evaluation. If you believe you are unable to go to the Emergency Room with or without assistance, call 911 immediately. My voicemail and text line are (619) 535-0773. ALWAYS leave a message and I will return your call as soon as possible. Communication by e-mail is also feasible. Voicemail, texts, and emails are usually feasible and can be discussed, but it should never be used for emergencies as I can never be sure of being available 24/7. There are additional risks and limits of confidentiality associated with email and text that you should be aware of before using these methods to communicate with me (see Telehealth Policy). Please use your Therapy Portal to send messages to our staff or your clinician whenever possible. 6. TREATMENT & THERAPY PROCESS: We will complete an assessment on our first 1-2 sessions. We will then develop a treatment plan together. There is no guarantee that treatment will improve your symptoms, problems, or issues. In fact, they may become worse as we uncover complex material. I invite you to be a part of the whole therapy process. Please use your portal to schedule, cancel, and sign documents. Please communicate openly with me about your treatment and process. I promise to do my best not to be defensive if you bring me a concern of any kind. 7. THERAPIST RELATIONSHIP: My professional policy is that I do not connect with my clients via social media. This may create a fuzzy boundary that could make therapy more challenging. If we run into each other in the community or on social media, I may say hello, but I will never introduce myself as your therapist and ask that you do not introduce yourself as my client or me as your therapist. To me, my relationship with my clients is sacred and private. We both must practice good boundaries to ensure that it is not damaged so that you can expect the best results, and I can optimize the quality of professional services provided to you. If our relationship is damaged for any reason, we may need to terminate therapy. Please bring any concerns to my attention as soon as possible. I will do my best to help you find an alternative if that is the only solution. If you learn that I am seeing one of your friends or family members, or if they are being treated at our clinic, please do your best to keep good boundaries and refrain from sharing information about our therapeutic relationship with them. 8. DISCLOSURES: We are a 501(c)(3) public benefit corporation. This organization exists to provide people who would otherwise be unable to receive therapy with free or low-cost treatment. When I am unavailable (e.g., vacations), I will ensure your needs are met as best as possible during this time. 9. VIDEO and/or AUDIO THERAPY (Telehealth): I can conduct sessions via video platforms for our convenience. I can use Therapyportal.com, Google Meet, and Zoom. I prefer Zoom. These platforms are HIPPA compliant. All services provided are via telemental health and are recorded to ensure fidelity with evidence-based treatment protocols and obtain feedback from clinical supervisors as appropriate. You may request a copy of this recording at any time. I do not have sessions by text as it limits my ability to observe nonverbal communication, an important aspect of effective therapy. I limit access to audio-only sessions (e.g., phone calls) for the same reason, generally for crisis calls. Phoenix Collective Inc. provides all clinical services via telehealth. Our address is strictly for mail. 10. RECORD KEEPING: Your Provider is required to keep records of your treatment. These records help ensure the quality and continuity of your care and provide evidence that the services you receive meet the appropriate standards of care. A clinical supervisor will review and sign all notes created by Associates. Your records are maintained in an electronic health record (Therapy Notes). Therapy Notes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information challenging to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all logins and actions within the system. All phone calls are HIPAA-compliant and recorded to protect both of us by ensuring our interactions are documented accurately. You will receive a copy of the phone call upon request. 11. COMPLAINTS: If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, myself, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services. The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of a registered Associate Clinical Social Worker. You may contact the Board online at www.bbs.ca.gov, or by calling 916-574-7830. Thank you for taking the time to review my Informed Consent. If you have questions or concerns about any of these policies and procedures, please bring them to my attention, or talk to my clinical supervisor (Dr. Patricia Bruce at drpatriciabruce@gmail.com or (520) 980-1975 so we can address them. ACKNOWLEDGMENT: Providing my name and email on the Acknowledgement Form and checking the designated box represents my attestation that I have received the Treatment Agreement and Informed Consent and that I understand all the information included in the document. If I do not understand any part of this document or the information contained therein, I will report this to Robin Mathy at (619) 535-0773 or robin.mathy@phoenixcolectiveinc.org and refrain from signing it. There will be no adverse consequences for refusing to sign this document. However, California laws and regulations preclude Phoenix Collective, Inc. clinicians from providing services to clients who do not sign it.

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