Professional Disclosure Statement and Consent for Treatment
Effective Date: April 2025
Brightline, Inc., Brightline Medical Associates, P.A., and their affiliated professional corporations (collectively “Brightline” or “we,” “us,” or “our”) offers healthcare services both in person and through telehealth technologies, such as interactive audio, video, and messaging, using Brightline’s virtual care platform for children and teens ages 2 to 18 years and their families. These services include psychiatry and medication support, psychotherapy, comprehensive testing, and other behavioral health services.
Brightline offers in-person locations in selected states and can be found online at hellobrightline.com or via our mobile app. Our phone number for support is 888-224-7332. All calls are returned within 24 business hours. The email address for clinical support is [email protected]. If you would like to write to us, our corporate address is:
Brightline, Inc.
400 Concar Drive
San Mateo, CA 94402
When you seek services from Brightline, you will be connected with a personalized Brightline Medical Associates, P.A. healthcare professional (“BMA clinician”) and be able to view a bio of professional qualifications that will include the following:
Your therapist’s name, credentials, education/training
Your therapist’s license and state registration number and the type of license or registration
Your therapist’s area of speciality
Treatment and Process
Your BMA Clinician is here to help you with problems in your life that are bothering you or that are keeping you from being successful in school, sports, hobbies, friendships, relationships or other important areas of your life. When you communicate with your clinician, they will discuss these concerns. The first couple of sessions will involve an evaluation of your needs. Your clinician will ask you questions, listen to you and decide with you on a plan for care. If it is determined that therapy is appropriate, your child’s therapist will work with you to create a treatment plan that includes shared goals.
Therapy is a dynamic, fluid process between therapist and patient. There are many different therapy methods your therapist may use to deal with the concerns that you hope to address. Therapy requires an active effort and commitment on your part. In order for therapy to be most successful, you will have to work on things discussed both during sessions and in between your sessions.
Our Therapy consultations begin with an initial 60-90 minute intake appointment and subsequent sessions can vary between 30 minutes to 60 minutes in length depending on your care plan needs, the type of appointment, and the attendance of you, your child or both.
Risks of Therapy:
Therapy can have benefits and risks. There are no guarantees of what you will experience. You may accept or reject any suggested clinical intervention. Your refusal will not jeopardize your ability to access care in the future. You have the right to ask for a referral to a different clinician or to terminate treatment at any time. You have the right to choose a therapist that best suits your needs and purpose. If you would like to terminate for any reason, your care team will support you in your decision.
It is important that you feel comfortable talking with your therapist. For many people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their doctors and therapists. Privacy, also called confidentiality, is an important and necessary part of treatment.
Our Therapists:
BMA licensed therapists are not physicians and cannot prescribe medication.
BMA therapists are employed or contracted licensed professionals who practice within independently owned and operated professional practices. For patients in New Jersey, this is known as "Brightline Medical Associates of NJ, PA." For patients in all other states, this is known as “Brightline Medical Associates, PA". Brightline, Inc. does not itself provide any physician, behavioral health professional, or other healthcare provider services.
Licensed professionals practicing therapy for a fee must be credentialed with the state licensing board for the protection of the public health and safety. Credentialing of an individual with the state licensing board does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.
Your Rights under HIPAA
Your rights to privacy of your protected health information are further explained in our Notice of Privacy Practices.
Information you disclose to your BMA clinician is kept confidential within the limits of state and federal law. Communications between therapists and clients are typically confidential, unless the law requires their disclosure. Your therapist will inform you of the legal exceptions to confidentiality, and should such an exception arise, will share only such information as required by law. Examples of such exceptions include but are not limited to:
abuse of a child;
abuse of an incapacitated adult;
Health Information Portability and Accountability Act (HIPAA) regulation compliance;
certain rights you may have waived when contracting for third party financial coverage;
orders of the court; and
significant threats to self, others or property.
Except for situations such as those mentioned above or when required by law, we will not share specific details for what occurs in sessions with parents or caregivers. We will share general information (e.g., treatment approach, recommended ways that caregivers support their youth in care) with parents or caregivers so that you can support your child's experience with Brightline. This may include information such as scheduling details, your child’s treatment plan, and general progress that you should know about. You should also know that in certain states, like California, a parent/guardian has the right to see any written records we keep about our sessions. We only put information into the written record that is relevant to your child's treatment.
Electronic Communications
You acknowledge that email and text messages may not be completely secure means of communication and your BMA clinician cannot guarantee confidentiality in this form of communication. Please do not email personal health information.
Contacting Your Provider
If you are experiencing an emergency, please contact emergency resources and do not contact your clinician for emergency needs. Outside of emergency needs, if you need to reach your clinician in between appointments, you can contact them using methods they provide to you and/or by contacting Support at 1-888-224-7332. Office hours are 8 am - 7 pm, Monday through Friday and 9 am to 1 pm Saturdays, local time. Phone messages will be checked daily (M-F), and phone calls will be returned within 24 business hours.
Please note that clinicians do not respond to and are not able to receive text messages.
Social media: BMA clinicians do not communicate with patients via social media, nor do they accept “friend requests” or “follow” current or former patients.
Code of Ethics
Your BMA clinician follows the Code of Ethics of the following organization(s):
The individual state licensing Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists
American Counseling Association 2014 Code of Ethics
The individual state licensing Board of Social Worker Examiners
The National Association of Social Workers
RIGHTS AND RESPONSIBILITIES REGARDING MENTAL HEALTH SERVICES
Your Rights
Brightline is committed to providing services that ensure competent and considerate care, including supporting your rights as a client under federal and state law.
You have the right to:
Be treated in a professional, respectful, competent and ethical manner consistent with all applicable state laws and the following professional ethical Standards:
for psychologists, the American Psychological Association;
for independent clinical social workers; the National Association of Social Workers;
for pastoral psychotherapists; the American Association of Pastoral Counselors;
for clinical mental health counselors; the American Mental Health Counselors Association; and
for marriage and family therapists; the American Association for Marriage and Family Therapists.
Have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected.
Receive full information about your treatment provider's knowledge, skills, experience and credentials.
A safe setting and to know that the services provided are elective and of a quality consistent with the standard of care within each profession and to know that sexual relations between a clinician and a client or former client are a violation of the law. Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned. Violations of a professional relationship should be reported to the state board that licenses, registers, or certifies the licensee, registrant, or certificate holder;
Obtain information, as allowed by law, pertaining to your therapist’s assessment, assessment procedures and mental health diagnoses.
Participate meaningfully in the planning, implementation, and termination or referral of your treatment.
Be informed of the risks and benefits of the proposed treatment, the risks and benefits of alternative treatments and the risks and benefits of no treatment.
Obtain information regarding the provision(s) for emergency coverage.
Be informed of the cost of professional services before receiving the services. You have a right to know the cost of services, receive an itemized bill for the services you receive, and to inquire about financial assistance for services.
Know that your BMA clinician is licensed in the state where you maintain legal residence in order to provide care to you.
Obtain information about our Brightline practice in your state. Please refer to the Appendix of this consent for each individual state board that regulates the licensee, registrant and certificate holder, to include address and telephone number.
Discuss questions or concerns about the care you receive with your therapist.
File a complaint with the Board of Mental Health Practice. Please refer to the Appendix of this consent for each individual state board that regulates the licensee, registrant and certificate holder, to include address and telephone number.
Mental Health Consent
Prior to the start of any therapy session(s), you were given a copy of our Brightline Mental Health Consent to review and sign. You may refer to this consent for more detail on the following:
Our services and BMA clinicians
Session Procedure and Duration
Technology
Attendance and Cancellations
Informed Consent:
Risks and benefits of Telehealth through two-way audio, video-conferencing technology, or other electronic communication
Risk and benefits of mental health treatment
Minors, Parental involvement and communication
Provisions of emergency coverage
Financial responsibility and assignment of benefits
Fees and billing structure
Your signature verifies you have been given this document, you have read and understand, and that you consent to treatment. Please be aware of the following:
Treatment isn’t always successful and may open unexpected emotionally sensitive areas.
Therapists are not physicians and cannot prescribe medications.
Therapists may need to consult with your physician, attorney, or other provider with whom you are working pursuant to your consent to such disclosure
Brightline is not available 24 hours a day and does not provide urgent or emergent services. If you believe your child or teen is at risk of harming themselves or someone else, please call 9-1-1 or take them to the nearest emergency room. Nothing is more important than keeping your child/teen safe.
You are not liable for any fees for services rendered prior to receipt of the Telehealth Informed Consents/ Clinical Service Agreement.
Brightline has tried to anticipate any risks you may face as a result of being in therapy. If you have any questions regarding the documents you have received, please feel free to discuss them with me.
I have read the preceding information and understand my rights as a patient or as the patient’s responsible party.
Patient or Legal Guardian’s Signature
___________________________________________________________________________________________
Date
__________________________________________________________________________________________
If signed by Legal Guardian, please state relationship to client and authority to consent
Appendix
Individual state boards that regulate the licensee, registrant and certificate holder, to include address and telephone number. Complaints to a state board must be provided in writing either through mail or through electronic form on their website (if applicable).
Connecticut
Connecticut Department of Public Health
Professional Counselor Licensure
410 Capitol Ave., MS# 12HSR, Hartford, CT 06134-0308
Phone: (860) 509-7552 Fax: (860) 707-1916 or (860) 509-7535/ Email: [email protected]
Credential Title(s):
-Psychiatrist (MD)
-Psychologist (PhD, PsyD EdD)
-Licensed Professional Counselor (LPC)
-Licensed Clinical Social Worker (LCSW)
-Master’s Level Social Worker
Massachusetts
Consumer Protection Coordinator
Board of Registration in Medicine
178 Albion Street, Suite 330, Wakefield, MA 01880
Phone: 781-876-8200 / Fax: 781-876-8381
Credential Title(s): Psychiatrist (MD, DO)
Department of Public Health
Bureau of Health Professions Licensure
Attn: Office of Public Protection
250 Washington St., Boston, MA 02108
Phone: 617-973-0800 / Fax: 617-973-0988
Credential Title(s): Psychologist (PhD, PsyD)
Board of Registration of Allied Mental Health and Human Services Professions
1000 Washington Street, Suite 710, Boston, MA 02118
Phone: 617-727-3080 / Fax: 617-727-1627
Credential Title(s):
-Licensed Mental Health Counselor (LMHC)
-Licensed Marriage and Family Therapist (LMFT)
-Licensed Certified Social Worker
-Licensed Independent Clinical Social Worker
-Licensed Social Worker
New Jersey
Board of Medical Examiners
P.O. Box 183, Trenton, New Jersey 08625
Attn: Antonia Winstead, Executive Director
Phone: (609) 826-7100 / Email: [email protected]
Credential Title(s): Psychiatrist (MD, DO)
State Board of Psychological Examiners
P.O. Box 45017, Newark, New Jersey 07101
Attn: Edie Nugent, Executive Director
Phone: (973) 504-6470 / Fax: (973) 792-4269 / Email: [email protected]
Credential Title(s): Psychologist (PhD, PsyD)
Professional Counselor Examiners Committee
P.O. Box 45044, Newark, New Jersey 07101
Attn: Milagros B. Collazo, Executive Director
Phone: (973) 504-6582 / Email: [email protected]
Credential Title(s):
-Licensed Professional Counselor (LPC)
-Licensed Marriage and Family Therapist (LMFT)
State Board of Social Workers
P.O. Box 45033, Newark, New Jersey 07101
Attn: Edie Nugent, Executive Director
Phone: (973) 504-6495 / Fax: (973) 792-4267 / Email: [email protected]
Credential Title(s):
-Licensed Clinical Social Worker (LCWS)
New York
New York State Education Department, Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov / Phone: 1-800-442-8106 / Email: [email protected]@nysed.gov,
https://www.op.nysed.gov/sites/op/files/2022-08/opd-complaint.pdf
Credential Title(s):
-Psychiatrist (MD, DO)
-Psychologist (PhD, PsyD)
-Licensed Mental Health Counselor (LMHC)
-Licensed Marriage and Family Therapist (LMFT)
-Licensed Clinical Social Worker (LCSW)
Washington
Washington Medical Commission
P.O Box 47866, Olympia, Washington 98504-7866
Phone: 360-236-2750
Credential Title(s): Psychiatrist (MD, DO)
Washington State Department of Health
Town Center 2
111 Israel Rd. S.E. Tumwater, WA 98501
Phone: 360-236-4700 / Fax: 360-236-4818 / Email: [email protected]
Credential Title(s):
-Psychologist (PhD, PsyD)
-Licensed Mental Health Counselor (LMHC)
-Licensed Marriage and Family Therapist (LMFT)
-Licensed Independent Clinical Social Worker (LICSW)
*Certified counselors or certified advisers are not credentialed to diagnose mental disorders or to conduct psychotherapy as defined in WAC 246-810-010(14).
*The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.
*Acts of unprofessional conduct - RCW 18.130.180