choicetherapy psychological services, Inc. Monthly Group Consultation Agreement
Ideal for therapists that have had training in and utilize ERP and ACT and would like support with more challenging cases. 

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This document contains important information about the educational consultation services and business policies of Marisa T. Mazza, Psy.D. Please read it carefully and discuss any questions you have with Dr. Mazza.

CONSULTATION: Dr. Mazza will provide educational case consultation for experienced therapists, in individual and/or group formats, with the scheduling of sessions to be mutually agreed upon by participants. The aim of educational consultation is to teach the consultee theory and skills in areas that Dr. Mazza specializes (ERP, ACT, OCD and Anxiety Disorders) as it pertains to the consultees' general practice, not to specific individuals (unless it is otherwise allowed by your state).

Dates and Time (Pacific): ***6 month commitment required***
Meetings will be held virtually on the last Thursday of the month from 8:00am - 8:50am (Pacific) 
1/25/2024
2/29/2024
3/28/2024
4/25/2024
5/23/2024 ***Not the last Thursday of the month
6/27/2024

*this schedule may change

RESPONSIBILITY: It is agreed that Dr. Mazza assumes no legal, ethical, or professional responsibility for treatment you provide based on the consultation she provides.

CONFIDENTIALITY: In the event that group consultation services are provided, you are expected to keep all communications regarding patients discussed in the group confidential. It is acknowledged that Dr. Mazza cannot be held responsible for a breach of confidentiality on the part of group members.

RESEARCH, WRITING, TEACHING: Dr. Mazza conducts training, and supervision, and writes for professional and lay audiences. Your signature below gives Dr. Mazza and Choicetherapy Psychological Services, Inc. permission to use information about you and your consultation in any of these ways, provided that they do not reveal any personal information that would identify you.

PAYMENT: $600 for all 6 meetings. Once this form is signed and payment is made your spot will be reserved. Dr. Mazza will send you a text from IVY Pay with payment information. Please complete payment within 24 hours of receiving the text. Payment will be automatically charged monthly. 

CANCELLATION: If you or I can't attend a group meeting we will try to reschedule it to a time that works for everyone. If we are unable to reschedule it, you would not receive a refund unless I was the one that needed to cancel. Since this is a closed group we would not be able to offer your spot to someone else therefore you would be charged when you miss a meeting. There are no refunds for the group. 
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Name *
Phone Number (must be a number that receives text messages)
 *
Email *
In the service of everyone being able to access evidence based therapy we offer a sliding scale to professionals in the BIPOC community and to those with a limited income. If you identify as either please indicate what you can contribute financially below. If you do not identify as either please write NA.  
I have read and understood this policy statement and I have had my questions answered to my satisfaction. I accept, understand, and agree to abide by the contents and terms of this agreement and further, consent to participate in consultation sessions. I understand that I may withdraw from consultation at any time. *
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Today's Date *
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Once this form is complete you will receive a text with billing information. Once we receive payment you will be sent an introductory email that will include the zoom information. ***Payment must be received 24 hours before the start of the group.
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