This letter of agreement confirms that CBH has been asked by you to provide mental health services.



We intend to help you get significantly better. There is an expectation, but no guarantee, that you will benefit from treatment. In order for your treatment to be effective, we must work cooperatively. Try to talk as freely as you can about the problems and difficulties that are affecting you at the time of your sessions. That may include thoughts, feelings, memories, comments, and questions. The more openly and freely you talk about yourself, the better. When one talks freely about what comes to mind, the important issues tend to emerge naturally. Thus, regardless of whether what comes to mind seems important or trivial, it will help in the long run if you go ahead and talk about it. Mental health appointments are not like ordinary conversations. We will always be listening to what you are saying, but there are certain times when your questions may or may not be answered. Sometimes questions may be asked which may seem strange. All of this is done in order to facilitate the treatment process. If you have intense emotions or embarrassment or curiosity whencertain questions are asked or when certain topics arise, bring that to the clinician’s attention. You are not obligated to answer all questions, but try to approach the session as open-mindedly as possible.


What is discussed during appointments will not be revealed to anyone outside of CBH without your permission except where disclosure is required by law, such as if there is concern for 1) abuse or neglect of a child, dependent, or elder adult, 2) danger of harm to yourself or others, 3) grave disability to one’s functioning or survival, or 4) pursuant to legal proceedings. I may ask you to sign a “Release of Information” to coordinate care with other health care professionals of yours. Your information will not be disclosed to your health insurance carrier without prior written consent. Please note that this agreement authorizes clinicians of CBH to discuss your confidential information internally with the other staff of CBH.

Risks and Benefits

Medications and psychotherapy each have risks and benefits. Risks of medication will be discussed in appointments before starting new prescriptions. Risks of psychotherapy include experiencing uncomfortable levels of emotion. In the worst case scenario, risks of psychotherapy may include temporary worsening of psychiatric symptoms. Treatment often requires recalling unpleasant aspects of your history as well as the experience of emotional pain in the present. Medications as well as psychotherapy have been shown to have benefits for people who undertake them, often leading to a significant reduction of feelings of distress, reduction of symptoms, better relationships, and resolutions of specific problems.

Limits of Service

In the event of a medical emergency, call 911 or go to an emergency room immediately. Call CBH as soon as is practical and possible. CBH does not provideinsurance, disability, or workman's compensation evaluations. In the event that you intend to apply for medical or life insurance or file a claim for disability or workman's compensation while under the care of CBH, please discuss this first with your clinician because authorization must be provided by your clinician as well as CBH.

Nature of Practice

Coastal Behavioral Health is a California Medical Corporation. Alternative names (or dba’s) include CBH, CBH Newport, and CBH Integrated Behavioral Health. CBH receives no contributions from the pharmaceutical industry.


Cancellation Policy

The scheduling of an appointment involves the reservation of a clinician’s time specifically for you. If you need to cancel or change an appointment, please inform us at least 48 business hours in advance, otherwise you will still be billed and payment is required. For Nursing shifts, cancellation must occur 5 business days in advance, or you will be billed.

Reaching Us

Clinicians or staff at CBH try to answer calls live or return routine phone calls within one business day. Although you may feel free to email CBH, we do not routinely use email for professional communication. Important information should be conveyed to us in person, ideally in appointments.


CBH keepsconfidential records of your treatment that include appointment times, billing records, indications for medication use and response, and certain content of the appointments. You, or a future treating clinician, can request copies of your medical record. Copies for patients are assessed fees which are average for the community. Psychotherapy notes belong to CBH and are not a part of the medical record, therefore they cannot be requested to be viewed. Clinicians at CBH do not give testimony in court. In the unfortunate circumstance that you sue CBH, you thereby waive your confidentiality and CBH is allowed to present your records without your consent.

Professional Fees

CBH generally does not bill for phone calls. However, if phone calls become lengthy in nature (15 minutes or more), they will be scheduled as phone appointments and are billed the same fees as regular office appointments. Additionally, other professional services (for example, report writing, treatment summaries, and correspondence) that require longer than 15 minutes of time are billed the same fees as regular office appointments.

Medication refills

Prescriptions are provided in the office during appointments. Medications are not ordinarily refilled over the telephone, except in the case of emergency. You will receive a prescription valid for a sufficient period of time until your next appointment. You are of course free to call CBH at any time if you have problems with medications. Certain prescriptions, for example stimulants, permit no refills whatsoever and you will be required to have a minimum of one appointment monthly for those prescriptions. It is your responsibility of ensuring that you have an appointment scheduled before your medications run out.


Insurance Reimbursement

Our clinicians do not process payments from health insurance companies; claims may be submitted to your insurance company for them to reimburse you as their policy allows.

CBH is considered an “Out-of-Network” provider. It is your option whether to seek reimbursement from your insurance company for our appointments. CBH provides “superbills” which you can then, in turn, submit to your insurance. These contain sensitive information revealing your diagnoses and diagnostic codes. In order to protect your confidentiality, CBH will not disclose any other information to your health insurance carrier. This may result in the denial of payment from them for services rendered to you.


Payment is due at the time of service. Once service has been rendered, fees are not refundable. Phone appointments are charged the same rates as office appointments. The only form of payment accepted by CBH is credit card. The credit card that is authorized will be used for payment of all services and that this credit card will be used and applied to both card present and not present transactions. Please discuss any billing or payment concerns with your provider as this is an important part of the clinical process. If your account is overdue for more than 30 days, we reserve the right to assess a penalty of a 5% compounding monthly fee, and potentially use legal means to secure payment. This includes charging a credit card on file and/or utilizing a collections agency or a small claims court. In such cases, certain information may be required by these agencies. This can include name, nature of services provided, clinical notes, and amount due. It is always your responsibility to keep the credit card on file up to date with our administrative staff. As such, our clinic policy is to require an active credit card on file in order to keep your chart open. In instances when a credit card charge is disputed, we may need to provide personal and clinical information to your credit card company.


For any services rendered outside of regular business hours (which is 8am-5pm on Mon-Fri) or occurring on nationally observed holidays will be charged at 150% of our usual fees.


I hereby authorize the Coastal Behavioral Health to use telemedicine in the course of my diagnosis and treatment. I understand that telemedicine involves the communication of medical information, both orally and visually, between me as a patient and a physician or other health care provider located remotely in another part of the state or another state altogether.

I understand that I have all of the following rights with respect to telemedicine:

Patient Choice of Care

I have the right to withhold or withdraw my consent to telemedicine at any time without affecting my right to future care or treatment and without risking the loss of my health coverage.

Access to Information

I have the right to inspect all medical information transmitted during a telemedicine consultation; and may receive copies of this information for a reasonable fee.


I understand that the laws which protect the confidentiality of medical information apply to telemedicine; and that no information or images from the telemedicine interaction which identify me will be disclosed to researchers or other entities without my consent.

Potential Risks

I understand that there are risks from telemedicine, including the possibility, despite reasonable and appropriate efforts, that the transmission of medical information could be disrupted or distorted by technical failures in transmission; the transmission of medical information could be interrupted by unauthorized persons; and/or the electronic storage or medical information generated by this telemedicine consultation in one or more databases could be accessed by unauthorized persons. In addition, I understand that telemedical examinations or care may not be as complete as face-to- face examinations or care and that telemedicine does not negate or minimize the risks that may be inherent in a medical illness or condition. Finally, I understand that it is impossible to list every possible risk, that my condition may not be cured or improved, and in rare cases, may get worse.


I understand that by consenting to telemedicine my physician may communicate medical information concerning me in our interaction as well as to physicians and other health care providers located in other parts of the state or outside the state.


I understand that I can expect benefits from telemedicine, but that no results can be guaranteed or assured. Telemedicine provides me with the continuity of care that otherwise would not have been available.

I have read and understand the information provided above, I have discussed it with my physician or my physician’s designee, and all my questions have been answered to my satisfaction.

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