Clinical Informed Consent

Last updated: April 1st, 2024

IMPORTANT PATIENT INFORMATION

PLEASE READ IN ENTIRETY 

This document contains important information about our policies and professional services.

If you are having thoughts of suicide or self-harm, please call or text 988, the Suicide and Crisis Lifeline. If you are in immediate danger, please contact 911 or go to the nearest emergency room. Do not attempt to access emergency care through this app. 

Please note that this document is divided into sections which address Psychological Services (i.e. Therapy) and Psychiatric Services (i.e. Psychiatry), as well as general Ginger policies regarding emergencies, communication with providers, and billing and fees. Please read it carefully. 

When you “check” the box and/or click “I Agree,” you affirm your agreement to the policies contained in this document and your consent to receive clinical services. Your consent to treatment is valid until your patient relationship with Ginger is terminated.

PATIENT RESPONSIBILITIES

As a patient, it is your responsibility to:

  • Become actively involved in the treatment goals by having scheduled sessions with your provider and keeping your provider informed as to your progress, in order to assure each other of productivity toward desired outcomes.
  • Notify Member Support via email, phone, or chat no less than 48 hours in advance of any non­ emergency cancellations. Emergency cancellations are at the discretion of the provider, but do NOT include transportation issues, minor illnesses, vacations, ineffective appointment tracking, etc.

If you are being seen for Psychiatric services:

  • It is your responsibility to take medication as prescribed; do not exceed the maximum prescribed dose, and do not make changes to your dose unless doing so has been authorized by your physician.
  • Repeated failure to take medications as prescribed/changing dosages may be grounds for termination and referral of treatment. In the event of going against medical advice and exceeding the prescribed dose, no substitute medication will be provided.

PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods that may be used to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things both during your sessions and between sessions.

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, anxiety, depression and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress and anxiety. Working toward these benefits requires effort on your part. 

Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. You will be asked for your feedback and views on your therapy and its progress. Attempting to resolve issues that brought you into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions to change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick and easy, but more often it can be gradual and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

Your first few sessions will involve an evaluation of your needs. By the end of the evaluation, you will be offered some first impressions of what your therapy will include and a treatment plan to follow if you decide to continue with treatment. The plan will include recommendations to help you achieve your goals. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist. If you have questions about the therapist’s procedures, you should discuss them whenever they arise. If your doubts persist, you can see another mental health professional.

If, after this evaluation period, your therapist does not think he/she can help you, he/she will refer you to others who may be a better fit for your particular issues. Within a reasonable period of time after starting treatment, your therapist will discuss his/her working understanding of your issues, a proposed treatment plan, including the type and frequency of treatment recommended, and therapeutic objectives and possible outcomes of the therapy. If you have questions about any of the procedures used in the course of your therapy, their possible risks, your therapist’s expertise, or about the treatment plan in general, please ask your therapist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your therapist does not provide, your therapist will provide assistance or referral information for obtaining those treatments. 

Deciding when to stop your work with your therapist is meant to be a mutual process. Before treatment  is stopped, you and your therapist will discuss how you will know if or when to come back, or whether a regularly scheduled "check­-in" might work best for you. If it is not possible for you to phase out of therapy, it is recommended that you have closure on the therapy process with at least two termination sessions. 

Noncompliance with treatment recommendations may necessitate early termination of services. Your therapist will look at your issues with you and exercise his/her educated judgment about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved.

If at some point your therapist assesses that he/she is not effective in helping you reach your therapeutic goals, your therapist is obliged to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If you request it and authorize it in writing, your therapist may talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, you have the option to do so. You have the right to terminate treatment at any time. If you choose to do so, your therapist may offer to provide you with names of other qualified professionals whose services you might prefer.

If you commit violence to, verbally or physically threaten or harass your therapist, the therapist’s colleagues or family, Ginger or anyone affiliated with Ginger, your therapist reserves the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. 

PSYCHIATRY SERVICES

Psychiatry is not easily described in general statements. It varies depending on the particular problems you bring forward. There are many different methods that may be used to deal with the problems that you hope to address. Psychiatry calls for a very active effort on your part. In order for it to be most successful, you will have to work on things both during your sessions and at home, including taking your prescribed medication as directed.

Psychiatry can have benefits and risks. Since psychiatry often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, anxiety, depression and helplessness. On the other hand, psychiatry has also been shown to have benefits for people who go through it. Psychiatry often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress and anxiety. Working toward these benefits requires effort on your part.

During your first session, your psychiatrist will assess whether he/she can be of benefit to you. If your psychiatrist does not think he/she can help you, your psychiatrist will let you know and try to refer you to others who work well with your particular issues. Please note that your psychiatrist, in his/her sole discretion, may decide not to start a doctor-­patient relationship with you after reviewing your case during the initial intake process or following your first sessions; similarly your psychiatrist reserves the right to discontinue services at any time. 

If you and your psychiatrist decide to continue, within a reasonable period of time after starting treatment, your psychiatrist will discuss his/her working understanding of your issues, a proposed treatment plan, and therapeutic objectives and possible outcomes of the therapy. If you have questions about any of the procedures used in the course of your treatment, their possible risks, your psychiatrist’s expertise, or about the treatment plan in general, please ask your psychiatrist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your psychiatrist does not provide, your psychiatrist will provide assistance or referral information for obtaining those treatments. 

During the time it takes for your psychiatrist to evaluate you, you or your psychiatrist can decide if the assigned psychiatrist is the best person to provide the services you need in order to meet your treatment goals. If the two of you decide to continue, your psychiatrist will make a recommendation regarding session duration and frequency.  

Medication management sessions typically last 15­ or 30 minutes, are more frequent in the beginning or after any changes are made, and then typically occur every 4­-8 weeks. Duration of treatment varies depending on the nature of the treatment and individual client needs. When medications are used in psychiatry, please be advised that they are frequently used “off-­label” meaning that they are used to control symptoms other than what the FDA originally approved the medication to treat. If you have questions about the procedures your psychiatrist uses, you should discuss them whenever they arise. If your doubts persist, you can see another mental health professional.

Deciding when to stop your work with your psychiatrist is meant to be a mutual process. Before treatment  is stopped, you and your psychiatrist will discuss how you will know if or when to come back, or whether a regularly scheduled "check-in" might work best for you.

Noncompliance with treatment recommendations may necessitate early termination of services. Your psychiatrist will look at your issues with you and exercise his/her educated judgment about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved.

If at some point your psychiatrist assesses that he/she is not effective in helping you reach your goals, your psychiatrist is obliged to discuss this with you and, if appropriate, terminate treatment and try to give you referrals that may be of help to you. If you request it and authorize it in writing, your psychiatrist may talk to the psychotherapist or psychiatrist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another psychiatrist, you have the option of doing so. You have the right to terminate treatment at any time. If you choose to do so, your psychiatrist may offer to provide you with names of other qualified professionals whose services you might prefer.

If you commit violence to, verbally or physically threaten or harass your psychiatrist, the psychiatrist’s colleagues or family, Ginger or anyone affiliated with Ginger, your psychiatrist reserves the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. 

MEDICATION

If medication is prescribed, you agree to abide by your psychiatrist’s directions regarding your medication. Please discuss with your psychiatrist the effects, including any side effects, of your medication.

If your provider has prescribed medication, please contact your pharmacy and ask to have your pharmacy FAX us refill requests.

FAX NUMBER FOR MEDICATION REFILL REQUESTS: 415-891-­0725

Refills of medication are not usually written at the time of your scheduled appointment. Instead they should be handled through your pharmacy. Prescription refills are not normally considered urgent or emergent situations, and must therefore be handled during regular business hours. Refill requests submitted on Fridays or weekends will be turned around the following week. Any controlled or scheduled substances (benzodiazepines, sleep medications, stimulants) will NOT be prescribed by your provider, and we will refer you to an external psychiatrist as appropriate. 

Medications will not be replaced if they are lost, damaged, or stolen without a scheduled appointment. Requests for early refill secondary to lost, damaged or stolen prescriptions will be handled on a case by case basis and an occurrence more than once within a year may be grounds for discharge from the practice. Failure to respond to a trial of medication does not guarantee further medication trials.

DUAL RELATIONSHIPS

Professional mental health services, including therapy and psychiatry, never involve sexual, business, or any other dual relationships that could impair the objectivity, clinical judgment or effectiveness of your provider, or which could be exploitative in nature. Please discuss this with your provider if you have questions or concerns.

TELEPHONE POLICY &
EMERGENCY SITUATIONS 

Your provider is often not immediately available by telephone. If you need to contact your provider between sessions, please contact Member Support or your Ginger coach, who will address your concerns or contact your provider on your behalf. 

Your provider will make every effort to respond within 24 hours of your message, with the exception of weekends and holidays. Please note that cellular, computer, and voicemail technologies are not infallible. It may be more than 24 hours before your provider returns your call to set up an appointment with you. If you are difficult to reach, please inform Member Support or your coach of times when you will be available. If you are unable to reach your provider and feel that you can’t wait for your provider to return your call, contact your family physician or the nearest emergency room. 

Emergency phone consultations of 5 minutes or less are normally free. However, if you and your provider spend more than 5 minutes in a week on the phone, if your provider spends more than five minutes reading and responding to messages from you during a given week, or if your provider spends more than five minutes involved in case management or coordination of care, you may be billed on a prorated basis for that time. If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. If your provider will be unavailable for an extended time, your therapist will provide you with the name of a colleague to contact, if necessary; or, otherwise please contact your coach. Please note that email systems are not entirely secure, and you acknowledge this and consent to use of email if you correspond with your provider by email.

If an urgent situation arises, please indicate it clearly in your message to Member Support  or your coach. If you are having thoughts of suicide or self-harm, please call or text 988, the Suicide and Crisis Lifeline. If you are in immediate danger, please contact 911 or go to the nearest emergency room. Do not attempt to access emergency care through this app.

Urgent situations are conditions that might have severe consequences if not addressed for over a few days, and include (but are not limited to) acute, severe depression, mania, or extremely severe anxiety. In an urgent situation, please contact your coach, who will attempt to contact your provider.

Emergencies include any situations where there is a question of danger to your own life or anyone else’s, or conditions like psychosis, where patients may be incapable of making rational decisions. In emergency situations, you should go directly to the emergency room. In addition, your provider may require you to go to the nearest emergency room. If your provider has any concern of imminent danger to yourself or someone else, your provider will also be required to involve the police or medical authorities to transport you to the nearest medical facility for evaluation, sometimes for an extended time (>24 hours).

Sometimes patients have questions about their medications, side effects, pharmacy problems, or their diagnosis that come up in between appointments. Please do not hesitate to contact Member Support, who will contact your provider to inform him/her of your questions. Your provider will try his/her best to answer you promptly. However, certain important clinical decisions may not be able to be made in­ between appointments. For example, you may need an appointment in order to start a new medication. If your situation is severe enough that you are unable to wait until your next appointment, we recommend that you go to the nearest health care facility/emergency room for attention.

NO SHOW AND LATE CANCEL POLICY

Once an appointment is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation. Late cancellation appointments will be charged $125.  If you are using employer paid therapy and psychiatry sessions, late cancellations and no show appointments will be deducted from the total session count.  Exceptions may be made, on a case by case basis, if your provider agrees that you were unable to attend due to circumstances beyond your control, such as unexpected illness.  If you cancel with less than 48-hour notice or no-show for an appointment, we will contact you to set up another appointment. Three repeated missed appointments or no shows may be grounds for termination of treatment. 

DISABILITY AND MEDICAL
RECORDS REQUESTS

Your provider’s primary role is to provide diagnosis and treatment for your medical condition.  However, we understand that, at times, individuals will request medical input on a variety of matters, including verification of disability status or other work-related concerns. Your provider will determine, on a case by case basis, and in accordance with legal and ethical statutes, whether or not he or she is able to offer such an opinion. At times, providers will not have the training or information necessary to offer detailed assessments about ability to perform certain functions. However, providers are typically able to offer detailed information regarding diagnosis, history, type of treatment, response to treatment, and prognosis, otherwise known as a “Treatment Summary.” You have the right to request disclosure of your records to your primary care provider and we will follow our member records release process to fulfill your request. Please speak with your provider in order to learn more.

VIDEO RECORDING

If you consent to video recording, your provider may record your video session to help you get the best care and ensure you are able to take advantage of the range of interventions that might help you make progress. Video recordings give Ginger information that helps us to better understand what works in treatment, improve and personalize the delivery of care, protect the safety of our members, train and supervise our clinicians, and ensure that we adhere to medical and ethical guidelines.

By participating in video recording, you will not only ensure that your own care is excellent, but also help Ginger to advance the mental health field so that we can provide care to people across the United States.

The following applies to any video recordings of your session:

  • Recordings are confidential and are used to improve the quality and consistency of care
  • Recordings are stored in encrypted format and may only be accessed and reviewed by authorized members of the care team following a strict “need-to-know” and “minimum necessary” protocol pursuant to HIPAA and our Notice of Privacy Practices
  • Ginger uses technology to automate the transcription of video recordings, create personalized recommendations and interventions, and gather and interpret data about our patient population over time. 

With all confidential health information that Ginger maintains, including video recordings, in the unlikely event of a failure of Ginger’s security measures there is a risk that disclosure of your information could cause a loss of your privacy. Ginger has policies and practices in place to minimize the chance of improper access or exposure of your identifiable information and is required to notify you if any such breach were to occur.

Your provider is available to answer your questions regarding the benefits and risks of video recording. By agreeing to this policy, you authorize your provider to record your video sessions with notice. You have the ability and right to “opt-out” of recording at the start of any session. Your provider will provide a reminder at the start of any session that will be recorded. You may request to turn off recording for a particular session or opt-out of future video recording at any time.  

PROFESSIONAL RECORDS

Legal and ethical standards require that your provider keep treatment records. You are entitled to inspect a copy of certain professional records regarding your treatment unless your provider believes that seeing them would be harmful, in which case your provider will be happy to send them to a mental health professional of your choice, or your provider can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them in your provider’s presence so that the contents can be discussed. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

To release medical records to you or other entities, requests need to come in writing. Contact Member Support or talk with your provider for additional information. Please note that these information requests require a substantial amount of time to compose, and thus we ask for 30 days notice, when possible. We are unable to reissue parts of your treatment chart that were submitted by other agencies. You will need to request your records separately from those agencies.

PROFESSIONAL FEES

In addition to scheduled appointments, you will be charged for other professional services you may need on a pro-rated basis per hour.  Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of your provider. If you become involved in legal proceedings that require your provider’s participation, you will be expected to pay for your provider’s professional time, including if your provider is called to testify by another party. Because of the difficulty of legal involvement, your provider may charge more per hour for preparation and attendance at any legal proceeding.

BILLING AND PAYMENTS

Ginger bills for services after each clinical session is completed. Once payment is received from your employer and/or insurance provider, you will be billed for any remaining deductible, coinsurance, or co-pay amounts due. You will receive a billing statement from Ginger's member billing partner via email. You will be able to pay via credit card with the individualized secure payment link included in the statement. Payment plans can be set up by reaching out to the billing team at billing@ginger.io, subject to approval per Ginger’s policy. 

If Ginger is in-network with your insurance plan or has an agreement to provide clinical services sponsored by your employer, this consent authorizes Ginger to send billing claims to your insurance company, health plan, or a third party administrator for reimbursement. You are responsible for payment directly to Ginger any deductible, coinsurance, or co-pay amounts as stipulated by your insurance plan. 

If Ginger raises its fees, you will be provided at least 30 days notice prior to any fee increase.  If you are unable to afford Ginger clinical services or have an outstanding balance, Ginger may discuss payment plans or discuss options for referral to an alternate provider. 

The following includes standard rates (USD) for Ginger services, subject to contractual obligations under customer or partner agreements:

• 90791: CSN Therapy Intake - $149

• 90834: CSN Therapy Follow up - $119

• 90837: CSN Therapy Follow up 60 mins - $119

• 90832: CSN Therapy Follow up 30 mins - $63

If your account has not been paid for more than 30 days, a 3% monthly finance charge may be added to the bill or the maximum amount allowed by law (whichever is less). If your account has not been paid for more than 90 days, and arrangements for payment have not been agreed upon, Ginger has the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If legal action is necessary, any legal costs will be included in the claim. In collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

An Important Note About Credit Card Authorization:

This consent gives Ginger permission to charge your credit card for services rendered. By signing this consent, you authorize Ginger to charge your credit card for any remaining balance after employer and insurance payment amounts are applied. A receipt for payment will be provided, and the charge will appear on your credit card statement. This authorization will remain in effect until you cancel it in writing.

INSURANCE REIMBURSEMENT

Upon request, Ginger can provide you with information about your insurance benefits or a cost estimation. Contacting your insurance company directly is always the best source of information about your specific coverage, benefits, co-pays, deductibles, and out-of-pocket maximums. A quotation of benefits by Ginger is not a guarantee of payment by your insurance. 

Ginger may be considered in-network with your insurance company, or may have a relationship with your employer or benefits provider that may pay all or a portion of the costs of the health care services you receive. You are responsible for payment directly to Ginger any deductible, coinsurance, or co-pay as stipulated by your insurance plan.  You are responsible for payment in-full for all therapy and/or psychiatry fees in the case where your insurance company, employer, or treatment provider does not cover services through Ginger.

If Ginger is not in-network with your insurance company, and you are interested in seeking out-of-network reimbursement, you can request that Ginger provide you with a bill that you may submit to your insurance company directly. When seeking out-of-network reimbursement, you are responsible for paying Ginger payment in-full for the services. For out-of-network claims, any and all dealings with your insurance company will be through you and solely your responsibility.  

MINORS

In order to use the Service, you must be at least 18 years old or between the ages of 13 years old and 18 years old with consent of a parent or guardian. Ginger does not provide treatment to individuals under the age of 13.

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a therapist or psychiatrist is protected by law, and providers can only release information about their work with a patient with the patient’s written permission. But there are a few exceptions:

In most legal proceedings, you have the right to prevent your therapist or psychiatrist from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your provider to testify if the judge determines that the issues demand it.

There are some situations in which a therapist or psychiatrist is legally obligated to take action to protect you or others from harm, even if he/she has to reveal some information about a patient’s treatment. For example, if a psychiatrist believes that a child, an elderly person or disabled person has been abused or neglected, the psychiatrist must file a report with the appropriate agency.

If a therapist or psychiatrist believes that a patient is threatening serious bodily harm to another, that provider is required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, the provider may be obligated to seek hospitalization for the patient or to contact family members or others who can help provide protection.

Your therapist or psychiatrist may occasionally find it helpful to consult other professionals – either as individuals or in a consultation group about a case. The consultant(s) is/are also legally bound to keep the information confidential. If you don’t object, your therapist or psychiatrist will not tell you about these consultations unless they feel that it is important to your treatment. Authorized Ginger clinical professionals may review your records to ensure the quality and consistency of care,  your safety, member safety, and to review provider performance.  This informed consent document  allows your provider to share information and records for the purposes described and with others to facilitate your care and treatment in compliance with state and federal laws (such as HIPAA) and our Notice of Privacy Practices. You will also be informed of your provider’s license and trainee status and supervision requirements, if applicable, at the onset of treatment. 

Ginger will not reveal your identifiable information, your use of Ginger services, or your health records to your employer.  If you are receiving services through an arrangement sponsored by your employer, Ginger is authorized to share minimally necessary information with your health insurance company, employer health plan, or a third party administrator in order to verify benefits, review covered treatment options, and bill for services. 

Please refer to our Ginger Notice of Privacy Practices for more information about the confidentiality of your health information. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you raise to your therapist or psychiatrist any questions or concerns that you may have.

IN THE EVENT OF UNEXPECTED

INTERRUPTION(S) OF PRACTICE

This consent verifies that you release Ginger or its representative to provide someone with your records and your contact information due to your provider’s death or disability or other discontinuance, unless you otherwise advise your provider in writing that you do not wish to provide such information.

ADDITIONAL STATE CONSENT

Depending on the state where you reside, we may provide additional information to you. These additional notifications and consents are incorporated into this Practice Policies and Informed Consent.

MISCELLANEOUS SUBJECTS

Service Animal Requests: We recognize the importance of animals and pets for many people. That said, we are unable to complete service animal designations for psychiatric conditions because of the lack of research and co­ordination of policy guidelines for this indication.

Medical Marijuana: Due to the lack of controlled research on inhaled marijuana for psychiatric conditions and possible harms, we are unable to endorse its use from a medical perspective. However, some people report that the use of marijuana helps with certain psychiatric conditions. Regrettably, we cannot assist in obtaining a medical marijuana card due to conflicts between the state of California’s policy of medical marijuana’s legalization and our prescribing authority, which comes from Federal law.

Termination of Treatment: You have the right to withdraw from treatment at any time. You are advised that there are possible risks that may be associated with withdrawal, such as potential for worsening of psychiatric symptoms. You also have the right to decline treatment, if part or all of the treatment is to be recorded for research or review by another person.

PSYCHIATRY COMPLAINTS

If you are dissatisfied with the psychiatric services you’ve received through Ginger, please contact us through the Ginger App or email help@ginger.io and one of our staff will follow-up with you.  


Ginger is committed to thoughtfully reviewing and researching your concerns and to resolve issues in a timely and satisfactory manner. You have the right to submit complaints in writing to: Ginger, Attn: Member Services, 2417 Michigan Avenue, Santa Monica, CA 90404. 

To facilitate consumers in receiving appropriate psychiatric services, all licensees and registrants are required to post the Notice below in a conspicuous location in their principal psychiatry business office. Since your psychiatrist works in multiple locations, that Notice is in this consent document.

NOTICE: The Department of Consumer Affairs receives questions and complaints regarding the practice of psychiatry. If you have any questions or complaints, you may contact this department by calling (916) 263­-2382, or by writing to the following address:

THE MEDICAL BOARD OF CALIFORNIA
2005 EVERGREEN STREET, SUITE 1200
SACRAMENTO, CA 9581

PSYCHOTHERAPY COMPLAINTS

If you are dissatisfied with the psychological services you’ve received through Ginger, please contact us through the Ginger App or email help@ginger.io and one of our staff will follow-up with you. 

Ginger is committed to thoughtfully reviewing and researching your concerns and to resolve issues in a timely and satisfactory manner. You have the right to submit complaints in writing to: Ginger, Attn: Member Services, 2417 Michigan Avenue, Santa Monica, CA 90404. 

To facilitate consumers in receiving appropriate psychological services, all licensees and registrants are required to post the Notice below in a conspicuous location in their principal psychological business office. Since your therapist works in multiple locations, that Notice is in this consent document.

NOTICE: The Department of Consumer Affairs receives questions and complaints regarding the practice of psychology. If you have any questions or complaints, you may contact this department by calling (916) 263­-2699, or by writing to the following address:

Board of Psychology

1625 N. Market Blvd., Suite N­215

Sacramento, CA 95834

IMPORTANT PATIENT INFORMATION

PLEASE READ IN ENTIRETY 

This document contains important information about the clinical services accessed through Headspace, Inc.’s (“Headspace,” “our,” “we,” or “us”) telehealth platform.  For purposes of clarity, the clinical services are provided by licensed clinicians employed by or contracted with our affiliated medical provider, Ginger.io of California Medical P.C. (the “Providers”). Headspace is not a provider of healthcare or mental health services; rather, Headspace offers a technology platform through which the Providers provide telehealth services. 

If you are having thoughts of suicide or self-harm, please call or text 988, the Suicide and Crisis Lifeline. If you are experiencing a medical or mental health emergency, please contact 911 or go to the nearest emergency room. Do not attempt to access emergency care through this app. 

Please note that this document is divided into sections which address Therapy Services and Psychiatric Services (i.e. Psychiatry) (collectively, the “Clinical Services”), as well as our general policies regarding emergencies, communication with providers, billing and fees, among other topics. Please read it carefully. 

When you check the box and/or click “I Agree,” you affirm your agreement with the policies contained in this document and your consent to receive Clinical Services. Your consent to treatment is valid until your patient relationship with the Providers is terminated.

PATIENT RESPONSIBILITIES

As a patient, it is your responsibility to:

  • Become actively involved in the treatment goals by having scheduled sessions with your Provider and keeping your Provider informed as to your progress, in order to assure each other of productivity toward desired outcomes.
  • Reschedule or cancel your appointment no less than 48 hours in advance of your scheduled appointment. This 48-hour requirement may not apply in the case of emergency cancellations. Emergency cancellations are at the discretion of the provider, but do NOT include transportation issues, minor illnesses, vacations, ineffective appointment tracking, etc.
  • Be in a secure and private location for all sessions.
  • Provide accurate and complete medical information to your Provider(s). Your Provider will rely on such information in the delivery of the Clinical Services to you. The inaccuracy of any information you provide to your provider may impact the efficacy of the Clinical Services.

If you are being seen for Psychiatric services:

  • It is your responsibility to take any medication prescribed to you as directed by your physician; do not exceed the maximum prescribed dose, and do not make changes to your dose unless doing so has been authorized by your physician. You agree to communicate with your Provider if you would like to discontinue taking this medication.
  • Repeated failure to take medications as prescribed/changing dosages may be grounds for termination of Clinical Services and referral of treatment. In the event you repeatedly go against medical advice and exceed the prescribed dose, no further medication will be provided.
  • You understand the Providers will not prescribe controlled substances and there is no guarantee that the Providers will prescribe any medication at all.
  • You understand there may be side effects from certain medications prescribed, and that your Provider will specifically address these risks when prescribing such medications. You further understand you may choose any pharmacy service to fill prescriptions ordered or requested.

OVERVIEW OF CLINICAL SERVICES

Neither psychiatry nor therapy are easily described in general statements. Both services vary depending on the personalities of the clinician and patient, and the particular problems you bring forward. There are many different methods that may be used to deal with the problems that you hope to address. However, success in either service calls for a very active effort on your part. In order for the Clinical Services to be most successful, you will have to work on things both during your sessions and between sessions. For psychiatry services, for example, this includes taking your prescribed medication as directed and/or communicating your experiences with the medication honestly and openly and alerting your Provider if you would like to stop using the medication. 

There are benefits and risks to the Clinical Services. On the one hand, the Clinical Services often involve discussing unpleasant aspects of your life, and you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, anxiety, depression and helplessness. On the other hand, both therapy and psychiatry services have been shown to have benefits for people who go through it. These services often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress and anxiety. However, working toward these benefits requires effort on your part.

THERAPY SERVICES

Therapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. You will be asked for your feedback and views on your therapy and its progress. Attempting to resolve issues that brought you into therapy may result in changes that were not originally intended. Therapy may result in decisions to change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick and easy, but more often it can be gradual and even frustrating. There is no guarantee that therapy will yield positive or intended results.

Your first session will involve an evaluation of your needs. By the end of the evaluation, you will be offered some first impressions of what your therapy will include and a treatment plan to follow if you decide to continue with treatment. The plan will include recommendations to help you achieve your goals. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist.  

If, after this evaluation period, your therapist determines you have needs that they are not best suited to address, they will refer you to others who may be a better fit for your particular needs. Within a reasonable period of time after starting treatment, your therapist will discuss their working understanding of your issues, a proposed treatment plan, including the type and frequency of treatment recommended, and therapeutic objectives and possible outcomes of the therapy. If you have questions about any of the procedures used in the course of your therapy, their possible risks, your therapist’s expertise, or about the treatment plan in general, please ask your therapist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your therapist does not provide, your therapist will provide assistance or referral information for obtaining those treatments. If at any point you have questions about the therapist’s procedures, you should discuss them whenever they arise. If your doubts persist, you can request to see another Provider by contacting Member Support or you can terminate your provider-patient relationship with your Provider and see a third-party clinician.

PSYCHIATRY SERVICES

During your first psychiatry session, your psychiatrist will assess whether they can be of benefit to you. If your psychiatrist does not think they can help you, your psychiatrist will let you know and seek to refer you to others who work well with your particular challenges. Please note that your psychiatrist, in their sole discretion, may decide not to start a doctor patient relationship with you after reviewing your case during the initial intake process or decide to terminate the doctor-patient relationship following your first session(s); similarly your psychiatrist reserves the right to discontinue services at any time. 

During the time it takes for your psychiatrist to evaluate you, you or your psychiatrist can decide if the assigned psychiatrist is the best person to provide the services you need in order to meet your treatment goals. 

If you and your psychiatrist decide to continue, within a reasonable period of time after starting treatment, your psychiatrist will discuss their working understanding of your issues, a proposed treatment plan, and therapeutic objectives and possible outcomes of the services or treatment plan. If you have questions about any of the procedures used in the course of your treatment, their possible risks, your psychiatrist’s expertise, or about the treatment plan in general, please ask your psychiatrist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your psychiatrist does not provide, your psychiatrist will provide assistance or referral information for obtaining those treatments. 

Psychiatry follow up sessions typically last 20 to 30 minutes, are more frequent in the beginning or after any changes are made, and then typically occur every 1-6 month cadence. Duration of treatment varies depending on the nature of the treatment and individual client needs. When medications are used in psychiatry, please be advised that they are frequently used “off label” meaning that they are used to control symptoms other than what the FDA originally approved the medication to treat. If you have questions about the procedures your psychiatrist uses or the medication(s) your psychiatrist prescribes, you should discuss them whenever they arise. If your doubts persist, you can see another mental health professional.

MEDICATION

If medication is prescribed, you agree to abide by your psychiatrist’s directions regarding your medication. Please discuss with your psychiatrist the effects, including any side effects, of your medication. If you have any questions or concerns about your medication between visits, please contact Member Support who will alert your treating psychiatrist on the platform.

If your Provider has prescribed medication, please contact your pharmacy and ask to have your pharmacy FAX us refill requests.

FAX NUMBER FOR MEDICATION REFILL REQUESTS: 415-891-­0725

Refills of medication are not usually written at the time of your scheduled appointment. Instead they should be handled through your pharmacy. Prescription refills are not normally considered urgent or emergent situations, and must therefore be handled during regular business hours. Refill requests submitted on Fridays or weekends will be turned around the following week. Any controlled or scheduled substances (benzodiazepines, sleep medications, stimulants) will NOT be prescribed by your Provider, and your Provider will refer you to an external psychiatrist as appropriate. 

Medications will not be replaced if they are lost, damaged, or stolen without a scheduled appointment. Requests for early refill secondary to lost, damaged or stolen prescriptions will be handled on a case by case basis and an occurrence more than once within a year may be grounds for discharge from the practice. Failure to respond to a trial of medication does not guarantee further medication trials.

TELEHEALTH

The Clinical Services are provided via telehealth. Telehealth involves communication between health care providers at one location with patients at another location for the purpose of providing patient care. Though telehealth services can be provided through various modalities, the Clinical Services occur primarily through video-conferencing and messaging. 

Telehealth has many benefits, including:

  • You do not have to leave the privacy of your home to receive care. 
  • It is easier and more efficient to access health care providers online when you need them.

There are possible risks to using telehealth, though, including: 

  •  It may be more difficult for Providers to diagnose you without seeing you in person. For example, it may be more difficult for a Provider to perform a physical assessment, to check vitals, and/or to perform diagnostic tests.
  • In some instances, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with a local provider.
  • There can be delays in evaluation and treatment in the event of a disruption in communication between you and your Provider if the online connection is interrupted for some reason, or if you or your Provider experience technical difficulties. 
  • While our platform includes security features to protect your information, there is a risk that unauthorized access to your information still can occur. In very rare instances, security protocols could fail, causing a breach of privacy of your personal medical information. 

By agreeing to these terms and/or otherwise accessing the Clinical Services, you acknowledge your understanding of and agreement with the following:

  1. You have read these terms and you have determined that telehealth is a good choice for you.
  2. You understand that there is a risk of technical failures during the telehealth encounter that may be beyond the control of Headspace and your Provider. You agree to hold harmless Headspace and your Provider for any delays in evaluation or for information lost due to such technical failures.
  3. You understand this is a telehealth-based service that is not equipped to handle medical or psychiatric emergencies.
  4. You give your informed consent to telehealth as an acceptable form of delivering health care services to you, and that this consent will cover any and all Clinical Services provided to you through Headspace’s platform.

TERMINATION OF CLINICAL SERVICES

Deciding when to stop your work with your therapist or psychiatrist is meant to be a mutual process. Before treatment is stopped, you and your Provider will discuss how you will know if or when to come back, or whether a regularly scheduled "check-in" might work best for you. If it is not possible for you to phase out of therapy, it is recommended that you have closure on the therapy process with at least two termination sessions. 

Both you and your Provider have the right to terminate treatment at any time. You are advised that there are possible risks that may be associated with withdrawal from treatment, such as potential for worsening of psychiatric symptoms.

There may be circumstances under which your Provider may choose to terminate your treatment unilaterally. These circumstances, include, but are not limited to:

  • Provider determines he/she is not best equipped to meet your needs.  At any point during your Provider-patient relationship, your Provider may determine he or she is no longer able to meet your needs. For example, you may develop a new condition with which your Provider lacks proper experience and/or training. 
  • Your nonadherence with treatment recommendations. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved.
  • Ineffective treatment.  If at some point your Provider assesses that they are not effective in helping you reach your goals, they are obliged to discuss this with you and, if appropriate, terminate treatment and offer you referrals that may be of help to you. If you request it and authorize it in writing, your Provider may talk to the therapist or psychiatrist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another provider, you have the option of doing so. 
  • Violence, harassment, and threats.  If you commit violence to, verbally or physically threaten, or harass your Provider, the Provider’s colleagues or family, your Provider reserves the right to terminate your treatment unilaterally and immediately. 
  • Failure to pay.  Failure or refusal to pay for services after a reasonable time is another condition for which your access to Clinical Services may be terminated. 
  • Missed appointments.  Three repeated missed appointments or no shows may be grounds for termination of treatment. 
  • Repeated requests for early refills.  Requests for early refill secondary to lost, damaged or stolen prescriptions will be handled on a case by case basis and an occurrence more than once within a year may be grounds for discharge from the practice.

Upon termination of treatment for any reason, your Provider may offer to provide you with names of other qualified professionals whose services you might prefer.

DUAL RELATIONSHIPS

Professional mental health services, including therapy and psychiatry, never involve sexual, business, or any other dual relationships that could impair the objectivity, clinical judgment or effectiveness of your Provider, or which could be exploitative in nature. Please discuss this with your Provider or Member Support if you have questions or concerns.

TELEPHONE POLICY & EMERGENCY SITUATIONS 

Your Provider is typically not immediately available by telephone. If you need to contact your Provider between sessions, please contact Member Support or your coach (if you utilize Headspace’s coaching services), who will address your concerns or contact your Provider on your behalf. 

Your Provider will make every effort to respond within 24 hours of your message, with the exception of weekends and holidays. Please note that cellular, computer, and voicemail technologies are not infallible. It may be more than 24 hours before your Provider returns your call to set up an appointment with you. If you are difficult to reach, please inform Member Support or, if applicable, your coach of times when you will be available. If you are unable to reach your Provider and feel that you can’t wait for your Provider to return your call, contact your primary care physician or the nearest emergency room. 

If an urgent situation arises, please indicate it clearly in your message to Member Support or your coach. Urgent situations are conditions that might have severe consequences if not addressed for over a few days, and include (but are not limited to) acute, severe depression, mania, or extremely severe anxiety. In an urgent situation, please contact your coach, who will attempt to contact your Provider.

If you are having thoughts of suicide or self-harm, please call or text 988, the Suicide and Crisis Lifeline. If you are experiencing a medical or mental health emergency, please contact 911 or go to the nearest emergency room. Do not attempt to access emergency care through this app. 

Emergencies include any situations where there is a question of danger to your own life or anyone else’s, or conditions like psychosis, where patients may be incapable of making rational decisions. In emergency situations, you should go directly to the emergency room. If your Provider has any concern of imminent danger to yourself or someone else, your Provider will also be required to involve the police or medical authorities to transport you to the nearest medical facility for evaluation, sometimes for an extended time (>24 hours).

Sometimes patients have questions about their medications, side effects, pharmacy problems, or their diagnosis that come up in between appointments. Please do not hesitate to contact Member Support, who will contact your Provider to inform them of your questions. Your Provider will try his/her best to answer you promptly. However, certain important clinical decisions may not be able to be made in between appointments. For example, you may need an appointment in order to start a new medication. If your situation is severe enough that you are unable to wait until your next appointment, we recommend that you go to the nearest health care facility/emergency room for attention.

NO SHOW AND LATE CANCEL POLICY

Once an appointment is scheduled, you will be expected to pay for it unless you provide at least 48 hours advance notice of cancellation. Late cancellation appointments will be charged $125.00 USD. Insurance cannot be billed for such fees. If you are accessing Headspace’s services under your employee benefits plan, late cancellations and no show appointments may be deducted from the total session count. Exceptions may be made, on a case by case basis, if your Provider agrees that you were unable to attend due to circumstances beyond your control, such as unexpected illness. If you cancel with less than 48-hour notice or no-show for an appointment, we will contact you to set up another appointment. Three repeated missed appointments or no shows may be grounds for termination of treatment.

DISABILITY AND MEDICAL RECORDS REQUESTS

Your Provider’s primary role is to provide diagnosis and treatment for your medical condition. However, we understand that, at times, individuals will request medical input on a variety of matters, including verification of disability status or other work-related concerns. Your Provider will determine, on a case by case basis, and in accordance with legal and ethical statutes, whether or not he or she is able to offer such an opinion. At times, Providers will not have the training or information necessary to offer detailed assessments about ability to perform certain functions. However, Providers are typically able to offer detailed information regarding diagnosis, history, type of treatment, response to treatment, and prognosis, otherwise known as a “Treatment Summary.” You have the right to request disclosure of your records to your primary care provider and we will follow our member records release process to fulfill your request. Please speak with your Provider in order to learn more.

VIDEO RECORDING

If you consent to video recording, your provider may record your video session to help you get the best care and ensure you are able to take advantage of the range of interventions that might help you make progress. Video recordings give us information that helps us to better understand what works in treatment, improve and personalize the delivery of care, protect the safety of our members, train and supervise our clinicians, and ensure that we adhere to medical and ethical guidelines.

By participating in video recording, you will not only ensure that your own care is excellent, but also help us to advance the mental health field so that we can provide care to people across the United States.

The following applies to any video recordings of your session:

  • Recordings are confidential and are used to improve the quality and consistency of care
  • Recordings are stored in encrypted format and may only be accessed and reviewed by authorized members of the care team following a strict “need-to-know” and “minimum necessary” protocol pursuant to HIPAA and our Notice of Privacy Practices
  • We use technology to automate the transcription of video recordings, create personalized recommendations and interventions, and gather and interpret data about our patient population over time. 

With all confidential health information that we maintain, including video recordings, in the unlikely event of a failure of our security measures there is a risk that disclosure of your information could cause a loss of your privacy. We have policies and practices in place to minimize the chance of improper access or exposure of your identifiable information and are required to notify you if any such breach were to occur.

Your provider is available to answer your questions regarding the benefits and risks of video recording. By agreeing to this policy, you consent to being recorded. You have the ability and right to “opt-out” of recording at the start of any session. Your provider will provide a reminder at the start of any session that will be recorded. You may request to turn off recording for a particular session or opt-out of future video recording at any time. 

PROFESSIONAL RECORDS

Legal and ethical standards require that your Provider keep treatment records. You are entitled to inspect a copy of certain professional records regarding your treatment unless your Provider believes that seeing them would be harmful to you, in which case your Provider will be happy to send them to a mental health professional of your choice, or your Provider can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them in your Provider’s presence so that the contents can be discussed. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

To release medical records to you or other entities, requests need to come in writing. Contact Member Support or talk with your Provider for additional information. Please note that these information requests require a substantial amount of time to compose, and thus we ask for 30 days notice, when possible. We are unable to reissue parts of your treatment chart that were submitted by other agencies. You will need to request your records separately from those agencies.

PROFESSIONAL FEES

In addition to scheduled appointments, you may be charged for other professional services you may need on a pro-rated basis per hour. If you become involved in legal proceedings that require your Provider’s participation, you will be expected to pay for your Provider’s professional time, including if your Provider is called to testify by another party. Because of the difficulty of legal involvement, your Provider may charge more per hour for preparation and attendance at any legal proceeding.

BILLING AND PAYMENTS

Headspace bills on behalf of the Providers for the Clinical Services provided.  If Headspace has entered into an agreement with your insurance plan or employer, this consent authorizes us to send billing claims to your insurance company, health plan, or a third party administrator for reimbursement.  If your services are covered by an in-network insurance plan or your employee benefit plan, we will bill for services after each clinical session is completed and once payment is received from your employer and/or insurance provider, you will be billed for, and are solely responsible for, any remaining deductible, coinsurance, or co-pay amounts due. If you are accessing the Clinical services via a subscription, please refer to Headspace’s Terms and Conditions.

If Headspace does not have an agreement in place with your insurance plan or you wish to pay out of pocket for our services, or if the Clinical Services are not covered by your employee benefit plan, you must pay the total amount due prior to each clinical session and you are solely responsible for the entire amounts due for each clinical session. 

You will receive a billing statement from our member billing partner via email. You will be able to pay via credit card with the individualized secure payment link included in the statement. Payment plans can be set up by reaching out to the billing team at carebilling@headspace.com, subject to approval per our policy. 

You are responsible for payment directly to us any deductible, coinsurance, or co-pay amounts as stipulated by your insurance plan. 

If we raise our fees, you will be provided at least 30 days’ notice prior to any fee increase. If you are unable to afford the Clinical Services or have an outstanding balance, we may discuss payment plans or discuss options for referral to an alternate provider. 

The cost for the Clinical Services ranges from $60 to $170 for therapy and $175 to $275 for psychiatry, depending on the type and length/ duration of session provided. Please note that fees may vary based upon the contracted rates negotiated with our customers, partners or direct to consumer offerings. Please contact Member Support if you have questions about the fees which may apply to you. 

If the amount for which you are responsible has not been paid for more than 30 days, a 3% monthly finance charge or the maximum amount allowed by law (whichever is less) may be added to the bill. If the amount for which you are responsible has not been paid for more than 90 days, and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If legal action is necessary, any legal costs will be included in the claim. In collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

An Important Note About Credit Card Authorization:

This consent gives us permission to charge your credit card for services rendered. By signing this consent, you authorize us to charge your credit card for any remaining balance after employer and insurance payment amounts are applied, if applicable. A receipt for payment will be provided, and the charge will appear on your credit card statement. This authorization will remain in effect until you cancel it in writing.


INSURANCE REIMBURSEMENT

Upon request, we can provide you with information about your insurance benefits or a cost estimation. Contacting your insurance company directly is always the best source of information about your specific coverage, benefits, co-pays, deductibles, and out-of-pocket maximums. A quotation of benefits from us is not a guarantee of payment by your insurance. 

We may be considered in-network with your insurance company, or may have a relationship with your employer or benefits provider that may pay all or a portion of the costs of the Clinical Services you receive. You are responsible for payment for any deductible, coinsurance, or co-pay as stipulated by your insurance plan. You are responsible for payment in-full for all fees associated with the Clinical Services in the case where your insurance company, employer, or treatment provider does not cover the Clinical Services. 

If we are not in-network with your insurance company, and you are interested in seeking out-of-network reimbursement, you can request that we provide you with a bill that you may submit to your insurance company directly. When seeking out-of-network reimbursement, you are responsible for making payment in-full for the Clinical Services. For out-of-network claims, any and all dealings with your insurance company will be through you and solely your responsibility. 

Note that the Providers are not Medicare-enrolled providers. Accordingly, if you are a Medicare beneficiary, you will not be reimbursed by Medicare for the Clinical Services. In addition, the Providers are not enrolled in most state Medicaid programs and therefore Medicaid reimbursement will not be available to you. 

MINORS

In order to access the Clinical Services, you must be at least 18 years old or, if you are in the United States, between the ages of 13 years old and 17 years old with consent of a parent or guardian who is a member of a health plan or an employee of employers with which Headspace partners. The Clinical Services are not available to individuals under the age of 13. In the case of minors in the United States between the ages of 13 and 17, the parent or legal guardian of such minor must submit the Headspace Adolescent and Parent Consent form. 

 

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a therapist or psychiatrist is protected by law, and Providers can only release information about their work with a patient with the patient’s written permission. But there are a few exceptions:

In most legal proceedings, you have the right to prevent your therapist or psychiatrist from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your Provider to testify if the judge determines that the issues demand it.

There are some situations in which a therapist or psychiatrist is legally obligated to take action to protect you or others from harm, even if they have to reveal some information about a patient’s treatment. For example, if a psychiatrist believes that a child, an elderly person or disabled person has been abused or neglected, the psychiatrist must file a report with the appropriate agency.

If a therapist or psychiatrist believes that a patient is threatening serious bodily harm to another, that Provider may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm themself, the Provider may be obligated to seek hospitalization for the patient or to contact family members or others who can help provide protection.

Your therapist or psychiatrist may occasionally find it helpful to consult other professionals – either as individuals or in a consultation group about a case. The consultant(s) is/are also legally bound to keep the information confidential. If you don’t object, your therapist or psychiatrist will not tell you about these consultations unless they feel that it is important to your treatment. Authorized clinical professionals may review your records to ensure the quality and consistency of care, your safety, member safety, and to review provider performance. You will also be informed of your Provider’s license and trainee status and supervision requirements, if applicable, at the onset of treatment. 

To the extent you are accessing the Clinical Services through an arrangement between Headspace and your employer Headspace will not reveal your identifiable information, your use of Headspace services, or your health records to your employer. 

Headspace is authorized to share minimally necessary information with your health insurance company, employer health plan, or a third party administrator in order to verify benefits, review covered treatment options, and bill for services. 

Please refer to the Providers’ Notice of Privacy Practices for more information about the confidentiality of your health information. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you raise to your therapist or psychiatrist any questions or concerns that you may have.

ADDITIONAL STATE CONSENT

Depending on the state where you reside, we may provide additional information of relevance to you. These additional notifications and consents are incorporated into this Clinical Informed Consent.

MISCELLANEOUS SUBJECTS

Service Animal Requests: We recognize the importance of animals and pets for many people. That said, the Providers are unable to complete service animal designations for psychiatric conditions because of the lack of research and co­ordination of policy guidelines for this indication.

Medical Marijuana: Due to the lack of controlled research on inhaled marijuana for psychiatric conditions and possible harms, the Providers are unable to endorse its use from a medical perspective. Regrettably, the Providers cannot assist in obtaining a medical marijuana card for states in which such a card is available.