Be a Better Man Course Application

4. It is important to note that the psychoeducation in this course does not constitute clinical treatment. This course is intended to be an adjunct to ongoing therapy or treatment and does not establish a therapist-patient relationship between you and Dr. Minwalla.

All participants are required to have an established therapist-patient relationship with a licensed mental health provider (not Dr. Minwalla) for the duration of participation in the course. Participants agree that, should clinical symptoms arise which require clinical attention, they shall rely upon their designated treatment provider for relevant services.

Dr. Minwalla will not contact your therapist unless there is an emergency. You will be informed if contact is under consideration and a release of information form must be completed prior to any communications with that provider.

I acknowledge I have read, understand, and agree:

6. Dr. Minwalla works with people who voluntarily seek his services. At any time, for any reason whatsoever, if a participant no longer wants to proceed with any type of service being provided by Dr. Minwalla, they have the right to withdraw and terminate participation. Dr. Minwalla also reserves the right to terminate a participant’s participation at any time. In such cases, they will receive a refund for any services that they did not complete.

I acknowledge I have read, understand, and agree:

8. Participation in the Be A Better Man course should always be shared openly and honestly with your spouse or intimate partner. It is recommended that you establish a process for sharing any information from the psychoeducational course with your intimate partner or spouse. The recommended option is processing these issues in the context of couples’ therapy or counseling with a licensed mental health treatment professional. Have you discussed with your partner your plan to participate, and do they support your participation?

9. Have you had a formal professional disclosure as part of your treatment?

10. If you currently have a couple’s therapist, do they support your participation in the Be a Better Man course?

11. Dr. Minwalla and The Institute for Sexual Health will protect all participants’ confidentiality, unless you sign a written release to provide information held by ISH to a clearly identified third party. This policy is in effect with the following exceptions:

• As required by California law: Please be aware that Dr. Minwalla is a mandated reporter of child, elder and dependent adult abuse. He is therefore required to act to protect any threatened third party; action may include notifying the law enforcement and warning the third party directly. Finally, if Dr. Minwalla or any staff member believes a participant is acutely suicidal, ISH may enact to steps which will result in either a voluntary or involuntary hospitalization, determined by designated country providers who will be enlisted.

• Dr. Minwalla shall break confidentiality should you reveal a serious threat of physical harm to a reasonably identified person or persons, which includes Dr. Minwalla, in order to comply with standards of practice in the State of California, and to protect parties involved in the observed threat.

• In cases of emergency, Dr. Minwalla may need to disclose a participant’s protected health care information (PHI) to a participant’s specific health practitioner to facilitate acute treatment.

I acknowledge I have read, understand, and agree:

12. All participants are expected to maintain the confidentiality of other participants. You may not disclose any personal and/or identifying information about any other participants.

I acknowledge I have read, understand, and agree: