Monika do Valle
Onsight Integrative Psychiatry
San Rafael, CA 94903
Phone: 415.322-8834 ·· Fax: 614.633.3826 ··

 

 

Treatment Policies and Care Agreement

 

Please read the italicized sections carefully, as they represent your agreements in
this care contract. Your initials after each section and signature at the end indicate
acceptance of these policies.
As a patient of Dr. do Valle, you can expect to:
• be treated with consideration and respect
• be viewed as a unique and worthwhile individual with strengths as well as
vulnerabilities
• have your experiences heard with compassion and non--judgment
• receive care in a comfortable and private setting
• receive care that is free from discrimination on any basis
• have appointments that start and end on time
• be educated about your condition and options for its treatment,
including nontreatment, and be involved in all decisions about
your care
• have any concerns and questions addressed in a timely manner
• have every aspect of your care remain strictly confidential, except when the
doctor is required by law to do otherwise
• have any grievances or concerns responded to in a respectful and constructive
manner
• have access to your medical record, if requested
• be fully informed about financial aspects of your care
• be able to designate a health advocate to help you with decision--making in
your care
• be helped to find alternative care if you or the doctor feel that a
different care arrangement is in your best interest

 

 

Office Hours and Appointments

 

Office hours are 12 to 8 pm on Mondays, 10 am to 6 pm on Tuesdays, 11 am to 3 pm
on Thursdays and Saturday appointments may be available between 1 and 4 pm. New
patient appointments are 60 minutes; follow--up visits for medication management
are between 20 and 30 minutes. Psychotherapy sessions are between 45 to 55 minutes. New
patient appointments can proceed only if the requested intake forms are completed
and provided in advance of the appointment.                                                         Initial ______

 

 

Communication

Dr. do Valle manages all scheduling via email, and communicates with patients on other
matters via email or phone. Typically, email is returned within a few business hours.
Email should be used only for non--urgent matters. Routine calls are generally returned
on the next business day. I consent to doctor--patient communication via email. I
understand that even when all reasonable security measures are employed, email cannot
be guaranteed as entirely private and confidential, and that emails I send will be
included as part of my medical chart. Responses to patient emails that require clinical
expertise incur a consult fee as outlined in the Financial Agreement. In an emergency, or
in the case of suicidal or violent thoughts, patients should call 911 or go to their local
emergency room. For urgent but non--life--threatening issues, patients may call Dr. do
Valle and follow instructions for marking their message as urgent. Urgent phone calls
are returned within 12 hours.                                                                                    Initial ______

 

Arrival, Cancellations and Missed Appointments

I will make every effort to arrive on time for my appointments. If I arrive late, I
understand that I will be seen for the time remaining in the appointment but missed
time cannot be made up. If I am ten or minutes late for a 20--minute visit, I understand I
may not be able to be seen that day and will be rescheduled. When possible, if running
late, I will notify my doctor by urgent phone message or email. I will provide 48 hours’
notice of a cancellation or a reschedule request. Without provision of 48 hours’ notice, I
agree to pay the full appointment fee as outlined in the Financial Agreement. Dr. do
Valle makes an exception to this policy only for women in labor or who have been
admitted to the hospital. First--time patients who arrive 15 or more minutes late cannot
be seen that day, and will be rescheduled.                                                 Initial ______

 

Prescription Policies

 

I understand that my doctor will prescribe enough medication to last until the next
recommended visit. I will track my current supply of medication and remaining
refills. I will request prescription refills during my appointments. The responsibility
for making a timely appointment request that ensures an adequate supply of
medication is mine. If I do not meet this responsibility, I agree to pay the fees ($40)
for interim (between--visit) or urgent refills, as indicated on this practice’s website,
if my doctor judges such a refill to be medically necessary. Prescriptions for
controlled substances such as sleep, anti--anxiety or ADD medication will only be
provided during appointments. I understand that while being prescribed a controlled
substance, I will need to be seen monthly for the first several months, and then at
least every 3 months once stable, without exception. Dr. do Valle subscribes to the
California State Prescription Drug Monitoring Program to track patients’ use of
controlled substances. Misrepresentation about or misuse of controlled substances
may be cause for patient discharge. I understand and agree to this office’s policies
regarding prescriptions and controlled substances.                                          Initial ______

​

Confidentiality and Release of Medical Records

​

Your status as a patient and all information related to your care is treated
confidentially. This office will not share or release health information about you to
anyone, including your spouse/partner, without your written consent. There are legal
exceptions to this rule, which you can review with the doctor. I have had any
questions related to confidentiality satisfactorily answered. I agree to keep a
current consent--to--release--information form on file with this office. I will supply
my doctor with all prior mental health records and select physical health records
that she requests. I agree to keep my doctor updated about changes in my health
conditions and about medications being prescribed to me by other doctors. I
understand I have the right not to share my medical records, but that this may
jeopardize my overall care and may be cause for cessation of the doctor--patient
relationship.                                                                                                                  Initial ______

​

Health Habits

 

Being honest with your doctor about your lifestyle habits allows for the best
outcomes. I agree to disclose to my doctor at the onset of care and on an ongoing
basis my habits such as diet, exercise, smoking, internet use, shopping, gambling,
sexuality, alcohol and other drug use, sleep habits, stress management and
relationships. I understand that maximizing healthy habits and self--care is vital to
my treatment.                                                                                                                 Initial ______

 

Alternatives to In--Person Appointments

 

Dr. do Valle offers house calls to patients medically unable to come to the office, and to
patients seeking counseling around parenting a young child. Insurance generally covers
house calls. House calls have geographic and time--of--day restrictions. This office also
offers email-- based care consults, and counseling sessions via telephone, Skype, or Face
Time. Most insurance plans do not as yet reimburse treatment through
these modalities. Using an alternate modality is not always medically appropriate, and
the doctor may decline to provide such a service and recommend an in--person
appointment instead. If I request a phone, Skype, or Face Time, I agree to
pay the full cost of the service. I also understand that even when all reasonable
security measures are employed, these alternate modalities cannot be guaranteed as
entirely secure and confidential.                                                                                     Initial ______

 

 

Social Media and Networking

 

Psychiatric care works best when conducted in a confidential, safe, well--bounded
setting. As a matter of policy, Dr. do Valle does not interact with patients on personal
social media or networking sites.                                                                                      

                                                                                                                                             Initial ______

​

Patient Satisfaction and Grievances

​

Dr. do Valle has an unrestricted medical license (20A11322) from the state of
California, with no history of complaints or actions against it. The doctor and her
staff are strongly committed to patient satisfaction and to working together with
patients to ensure they receive high--quality, compassionate medical care. To that
end, patients are asked to discuss any concerns or dissatisfaction directly with Dr. do
Valle.  I agree that if I am dissatisfied with some aspect of my care, I will a) inform
Dr. do Valle in writing that I have a grievance and b) give her the opportunity to
remediate it. If no such remedy is possible and I choose to terminate my care, I
agree to do so in writing. I also agree that I will follow these steps before posting a
negative review of the doctor or her practice in any public forum, and that if I do
post a negative online review that I will do so in a constructive and respectful
manner.
                                                                                                                                               Initial ______

 

 

Patient Signature                                                                                                                                     Date

 

Printed Name