Treatment Consent Form (Digital)
Updated 4/30/2019

Dr. Jennifer Dore, MD
Dr. Meredith Bergman, MD
Shannon Dwyer, NP
Marci Gleicher, NP

Instructions: The following document reflects the policies and guidelines for the Helios Psychiatry. Please read carefully, initial on each page, sign and date on the last page. Thank you!

Psychotherapy, or talk-therapy, is a powerful treatment for many mental complaints. It offers benefits of improved interpersonal relationships, stress reduction, and a deeper insight into one’s own life, values, goals, and development. It requires a great deal of motivation, discipline and work on both parties for a therapeutic relationship to be an effective one. Clients will have varying success depending on the severity of their complaints, their capacity for introspection, and their motivation to apply what is learned outside of sessions. Helios Psychiatry's approach to therapy is integrative and client centered with an emphasis on a psychodynamic framework for understanding human complexities.

Clients should be aware that the process of psychotherapy may bring about unpleasant memories, feelings, and sensations such as guilt, anxiety, anger, or sadness, especially in its initial phases. It is not uncommon for these feelings to have an impact on current relationships you may have. If this occurs, it is very important to address these issues in session. Usually these unpleasant sensations are short lived.

At your initial visit, I will conduct a thorough review of your current complaints and of your history. By the end of the first few visits, I will offer my preliminary impressions, and we will discuss your treatment options. However, often it takes much longer to begin to understand what the underlying issues are so evaluation is an ongoing dynamic process. When my thoughts about your diagnosis or treatment change I will share it with you and you are welcome to ask my impression at any point.

Sometimes, psychotherapy alone will suffice. Often times, however, a combination of psychotherapy and medication management is optimal (see below). One of the most important curative aspects of a therapeutic relationship is the “goodness-of-fit between” therapist and client, so, the initial visit is also your opportunity to determine for yourself if I am the right therapist for you and for me to evaluate if I can provide you with the right fit. Thus our first few visits will give us the opportunity to both to get a sense if our psychotherapeutic relationship has the potential for success. If you feel that I am not well matched to your needs, I would be happy to provide you referrals to other mental health professionals.

Medications may be indicated when your mental symptoms require more than psychotherapy. Many mental complaints may have a biological component and respond well to medication. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much needed relief. If it is agreed that medications are indicated, I will discuss with you the medication options that are available to treat your current condition. I will present information in language that you can understand. You will learn how the medication works, its dosage, and frequency, its expected benefits, possible side effects, drug interactions, and any withdrawal effects you may experience if you stop taking the medication abruptly. I use the CURES database that provides me a list of all the controlled medications that you are currently taking to keep track of your prescriptions. It is crucial for you to inform me of all medications you take, both over the counter and prescribed as well as any herbs, or supplements as there may be interactions with the medications I prescribe to you. Importantly, your thoughts about medications and personal beliefs and values are a very important part of deciding on medication treatment and I will work with you to come up with a personalized medication regimen that works for you while also giving you expert advice informed by research and standard of practice. By the end of the discussion you will have the information you need to make a rational decision as to which medication is right for you.

You may already be receiving psychotherapy from another therapist, and are referred to me for medication management. In this case I will make a strong effort to coordinate care with your therapist (with your consent, of course). I believe communication between mental health professionals is key to providing effective care.

Not everyone is a good candidate for medication therapy. Such therapy requires strict adherence to dosage and frequency, close follow-up, and sometimes regular blood tests. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such therapy. Overall, I am a strong proponent of holistic and bio-psycho-social philosophy of psychiatric treatment that considers your biological status, genetics, your psychological development, and social issues. Together considering these factors will yield the best chance for success in achieving your goals.


At your initial visit, we will decide together the structure of your therapy including how frequent and how long your visits should be. Initial visits usually last 90min to 2 hours to provide enough time for a thorough psychiatric and medical history with a focus on the most distressing symptoms/situations. Follow-up sessions are 50 min. Many patients chose to see me more frequently than once per week, up to three times a week at first if they are experiencing intense symptoms or require intensive work. We can decide together what frequency fits best for you.

Patients are charged for each appointment based on my hourly fee. Any other professional services outside your scheduled time that require longer than 10 minutes will be charged for each 10 minute increment, corresponding and prorated to the fee for your office visits.

Examples of professional services typically offered outside of appointment time include report writing, telephone conversations, text messaging on our secure portal, preparation of treatment summaries, communication or coordination of care with family or other providers, or time spent performing any other services on your behalf.

If you must cancel or reschedule an appointment, we require at least 24- hour notice (weekends not included). If your appointment is on a Monday, the cancellation must be made by the same hour on the preceding Friday. Cancellations that occur with less than 24-hour notice or failure to show to an appointment will be charged the full fee for the session.

Time of Service Billing
Helios requires payment at time of service. Patients are asked to leave a valid credit card on file which will be automatically charged if payment is not made at time of service.

For privacy and compliance purposes, invoices and statements are posted to your secure portal. Statements may also be provided directly upon request.

The secure portal (Valant) does not currently provide the ability to pay online. To ensure timely collection for services rendered, you may bring a check or cash to your appointment. Otherwise, we ask that you submit a valid credit card to your provider via the Valant Patient Portal authorizing automatic billing after each appointment.

Rates & Insurance
Appointment rates are determined with your provider. Helios currently does not accept insurance, however patients may directly submit invoices for reimbursement if their plan allows.
Cancellations must take place at least 24 hours before an appointment. All other cancellations are billed at the regular rate.


I do not currently accept insurance. If you are on a PPO plan, I will be considered “out of network.” If you wish to be reimbursed for your sessions, you will need to consult your insurance company to determine their policies regarding mental health benefits for out-of- network providers. I will provide you a paper “super bill” that you can submit to your insurance company for reimbursement.

Many insurance companies have limitations on the number and frequency of visits, and types of medications that will be covered. Occasionally, certain forms of treatment, or large number of sessions require a prior authorization. If this is the case, I may need to provide information about your diagnosis, history, and treatment plan to your insurance company. Once this information is provided, it will be subject to the privacy policies of the insurance provider, and is out of my control.

Helios Psychiatry, Inc./Dr Jennifer Dore and its providers do not participate in Medicare. By law, Medicare-eligible patients are required to enter into a private contract with Helios Psychiatry Inc/Dr Jennifer Dore and its providers and we deliver medical care on a fee-for-service basis, which is NOT reimbursable by Medicare. By accepting the treatment contract with Helios Psychiatry Inc, you agree that you shall not submit a claim or ask Helios Psychiatry, Inc. to submit a claim for payment under Medicare for services rendered, even if such items and services would otherwise be covered by Medicare. This means that you agree not to bill Medicare or ask Helios Psychiatry, Inc. to bill Medicare, for services rendered by our personnel. Please note, the private contract is with Helios Psychiatry, Inc. and applies only to our practitioners. You are not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or healthcare practitioners. This means that Medicare-covered services and payments are still available to you from other physicians or practitioners who have not opted out of Medicare, and therefore you may, if you so choose, use the services of those physicians or practitioners even when you enter into this private contract with Helios Psychiatry, Inc.

I am required by law, to keep complete medical records. Most of my medical records will be electronic on a HIPPA compliant secure server. Any written records including the initial consent forms, letters, outside medical records, will be kept locked in one of my offices. You are entitled to review your medical record at any time, unless I feel that by viewing your records, your emotional or physical well-being will be jeopardized. If you wish to view your records, I recommend that we review them together to minimize any confusion or misinterpretation of medical terms. Time spent collecting, printing, copying, and summarizing the medical record will be charged the appropriate fee.

The security of your sensitive information is of utmost importance to me, and I am bound by law to protect your confidentiality. Any disclosure of your treatment to others will require your explicit consent. As described above, basic information about your treatment may be disclosed to your insurance company for purposes of prior authorization if necessary.

There are exceptions to this confidentiality, where disclosure is mandatory. These include the following:

-If there is a threat to the safety of others I will be required by law to take protective measures including reporting the threat to the potential victim, notifying police, and seeking hospitalization. When there is a threat of harm to yourself, I am required to seek immediate hospitalization, and will likely seek the aid of family members or friends to ensure your safety.

- In legal hearings, you do have the right to refuse my involvement in the hearing. There are rare circumstances, however, in which I will be required by a judge to testify on your emotional, or cognitive condition.

- In situations where a dementing illness, epilepsy or other cognitive dysfunction prevent you from operating a motor vehicle in a safe manner, I will be required to report this to the DMV

-If a mental illness prevents you from providing for your own basic needs such as food, water, shelter, I will be required to disclose information to seek hospitalization.

These situations rarely occur in an outpatient setting. If they do arise, I will do my best to discuss the situation with you before taking action. In rare circumstances I may find it helpful to consult with other professionals specialized in such situations (without disclosing your identity to them)


Medical records at our offices are kept secure, carefully guarded and separate from the records of other professionals sharing the space. Only our medical personnel will have access to your records.

If you do see our wellness providers or another community therapists/physician, we may find it helpful to collaborate and coordinate your care. However, this will not happen without your express prior written consent. Any clinician to whom I refer you will be responsible for the care they provide to you.

Dr. Jennifer Dore’s voicemail can be reached by dialing 650-275-3549 and is the best way to contact her outside the office. Dr. Meredith Bergman’s voicemail can be reached by dialing 650-275-2326. Shannon Dwyer’s voicemail can be reached by dialing 650-690-2757. Unless discussed in advance, please use your primary provider as your first point of contact.

Helios providers carry a cell phone with them most times, and check voicemail regularly. When you leave a message, please state your name clearly, your phone number(s) (even if you think I have it), reason for calling, and let us know when is the best time to contact you. When a message is left the provider will be paged immediately. Please note that your provider may be with a client, but will make every effort to address your issue as soon as possible. For non urgent matters, please allow 24 business hours for a response. If you or someone close to you is in immediate danger, please call 9-1-1 or proceed to the nearest emergency room.

If you choose to contact us via email (,,, please be aware that email is not a secure means of communicating sensitive mental health information. We may not check email regularly so it is not an appropriate way of contacting me in an emergency.

By signing below, you certify that you have read and understand the terms stated in the Treatment Consent Form. You indicate that you understand the scope of my services, session structure, fees, cancellation/no-show policies, payment policy, insurance reimbursement, confidentiality, the nature of our practice, and my contact information, and that you agree to abide by the terms stated above during the course of our therapeutic relationship.

Guidelines and Consent for Intended Use of Electronic Mail (Email) Communication

Email should be used only for non-sensitive and non-urgent matters. Appropriate use of email communication may include, but is not limited to, prescription refill requests and appointment scheduling.

Privacy and Confidentiality:
Generally email communications are not encrypted and therefore are not secure communications.

Secure and HIPAA-compliant email is available as the preferred option, should electronic communication be desired.
Communications from my office will be secure, unless otherwise
requested by the patient.

Email communications may become a part of your patient medical record.

All messages from Dr. Dore, Dr. Bergman and Shannon Dwyer will include the following disclaimers.

The materials in this email are private and may contain Protected Health Information. If you are not the intended recipient be advised that any unauthorized use, disclosure, copying, distribution or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this email in error, please immediately notify the sender via telephone at 650-544-6189 or by return email.

Electronic mail, or email, communications between us are not encrypted and therefore are not secure communications. If you elect to communicate from your workplace computer, you also should be aware that your employer and its agents might have access to email communications between us. Finally, email communications may become a part of your patient medical record. Incoming email communications will be reviewed and answered as soon as possible. If you have not heard from your provider’s office with a response and are concerned that your message was not received, please call the office during regular business hours.

Response time: Email is read daily and most messages are replied to within 24 workday hours. If you have not received a reply after greater than 48 workday hours, please consider that I may not have received your email so contact me directly by telephone.

Ending Email Relationship: Either you or Helios’s providers may request at any time via email or written letter to discontinue using email as a means of communication.

Disclaimer: Dr. Dore, Dr. Bergman and Shannon Dwyer are not responsible for email messages that are lost due to technical failure during composition, transmission and/or storage.

I have been informed of the above, and have had any questions answered to my satisfaction.

I agree to the above guidelines for email communication with Dr. Jennifer Dore, MD, Dr. Meredith Bergman, MD or Shannon Dwyer, NP.

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