Informed Consent Form
Welcome to UCSF Student Mental Health and Wellbeing (SMHW). Below are the general guidelines for counseling and psychiatry appointments. We will be happy to discuss any questions or concerns you may have about these guidelines.
SERVICES AND STAFF
UCSF Student Mental Health and Wellbeing (SMHW) offers a range of mental health services provided by licensed clinicians. Supervised psychiatry residents may also provide services. In addition to providing direct counseling services, SMHW provides training, consultation, and outreach.
SHORT TERM COUNSELING
Counseling and Psychological Services (CS) provides confidential, brief counseling and psychological services to UCSF students & learners who are in California at the time of treatment. CS does not provide assessment or treatment for legal purposes. Based on CS resources, your individual therapeutic goals, and your counseling needs, you may be referred to individual counseling, group counseling, or to a community provider for ongoing treatment.
SMHW follows a brief counseling model. Your therapist will work with you to develop an appropriate treatment plan based on your needs. If longer term care is indicated, your therapist will connect you with a community mental health provider.
SMHW does not accept insurance for longer term therapy at SMHW. The school-sponsored Student Health Insurance Plan (SHIP) covers mental health services outside of SMHW. Students enrolled in SHIP can find benefit details on the "Student and Covered Dependent(s) Benefits Summary" available at SMHW, from your therapist, or on the SMHW website. Visits to mental health providers outside SMHW must be pre-approved by SMHW for the SHIP plan to pay.
AFTER HOURS EMERGENCIES
In case of an emergency, students can call the main clinic phone number at (415) 476-1281 and listen to the instructions to speak with a mental health provider (will be instructed to push option 2). If you are in immediate danger, please call 911 or go to the nearest emergency room. Please notify SMHW after any emergency room visits.
CANCELLATION POLICY
If you need to cancel or re-schedule, please contact SMHW and/or your provider as soon as possible. All cancellations less than 24 hours in advance of your appointment time will count as a No Show appointment, and you will be charged the $15 No Show fee.
INSURANCE BILLING
SMHW will bill your insurance for counseling and psychiatry visits. No copay or coinsurance is expected from you. If your insurance company does not pay the claim, SMHW will not seek any additional payment from you. Insurance companies will routinely send you an Explanation of Benefits (EOB) when a bill is processed. If you wish to receive this statement electronically, as opposed to in the mail, please contact your insurance company.
BENEFITS AND RISKS OF COUNSELING
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits, including better relationships, solutions to specific problems, and significant reductions in feelings of distress. Results of treatment cannot be guaranteed.
CONFIDENTIALITY
Each client will have a confidential electronic treatment record. Access to your records is restricted to SMHW staff on a need-to-know basis for the purpose of treatment and coordination of care. Medical Students only: Medical Student Well Being Program (MSWB) licensed mental health providers also have access to medical student records. All information you provide will be kept confidential unless:
- You request a release of your clinical records or a summary or your records to any person or agency you specify.
- You sign a release form requesting that your clinician consult with a specific person.
- Your clinician is legally mandated to disclose information when there is an imminent risk that you may harm yourself or others; when there is reasonable suspicion of abuse of children (including viewing child pornography online), dependent adults, or the elderly; if you lack the capacity to care for yourself; or when there is a valid court order for the disclosure of your files.
- If you are taking psychiatric medications, the prescription information will be placed in your primary care medical chart to assist your PCP in making appropriate clinical decisions. Primary care clinicians may also access your psychiatry records as needed for treatment and coordination of care.
- Information may be accessed by other health care providers in SMHW for purposes of coordinating your treatment.
- SMHW staff may discuss your care with community health care providers for referral purposes or to coordinate care if you are ever hospitalized.
RECORD ACCESSIBILITY AND COMMUNICATION
SMHW is legally required to make your relevant clinical notes available to you through the secure health record. Potential benefits of accessing your clinical notes may include, but are not limited to, more immediate access to your records, the opportunity to track your progress in treatment, and the ability to view your record for accuracy. While most clients respond positively to this option, some do not. When determining whether you want portal access to your records, it is important to consider implications regarding confidentiality. For example, if you have given a parent or partner your ID and password, they would be able to see your clinical notes. Please know that you are able to opt out of having access to these notes on the portal. If you would like to opt out, please discuss that with your treating provider.
E-MAIL
With respect to electronic mail (e-mail), e-mail is generally not a confidential means of communication. SMHW cannot ensure that e-mail messages will be received or responded to if your therapist is not available. Thus, e-mail is not an appropriate way to communicate confidential, urgent, or emergency information. Please come to SMHW or phone at (415) 476-1281 during open hours if your need is more urgent. If you have urgent needs after hours, please follow the above protocol, under "After Hours Emergencies". Your signature below indicates that you have read and understand this document, discussed any questions or concerns you may have with your therapist, and voluntarily consent to psychotherapy.
SECURE COMMUNICATION WITH YOUR PROVIDER
If you wish to message your provider, please use the secure online messaging system found at https://MyHealthRecord.ucsf.edu. Do not use email, as it may not be secure/confidential. Examples of appropriate reasons to send a secure message to your provider include: scheduling/rescheduling and following up on referrals. Secure messaging is not to be used as a replacement for an appointment, nor as a means of online psychotherapy. There may be a delay responding to messages sent through the secure portal if your provider is away, therefore do not use the message system for urgent communications. For urgent needs: Please come to SMHW in person or phone SMHW at (415) 476-1281 during business hours. If you have urgent needs after hours, please follow the above protocol, under "After Hours Emergencies".
TREATMENT AUTHORIZATION
I understand that Counseling Services is a department of the Student Mental Health and Wellbeing (SMHW) and that counseling and medical providers work collaboratively to provide services to students. I understand that my CS provider will collaborate with other SMHW providers involved in my care, which may include consulting and sharing my treatment record, including psychotherapy notes. I have read this information about CS and SMHW and give my consent to be treated by CS and for information to be shared for the purpose described above. If I have questions or concerns about this consent, I am able to discuss them with my CS provider prior to signing this form.
Your acknowledgment of this form indicates that you have read and understand this document and voluntarily consent to treatment. Feel free to discuss any questions or concerns you may have with your provider.