By checking this box, I acknowledge and agree to the following:
I confirm that I am a licensed mental health professional, associate, resident, intern, or post-master’s clinician seeking clinical consultation, supervision, peer supervision, and/or mentorship for professional development and/or licensure purposes.
I understand that services provided by Tranquillium are educational, consultative, and professional in nature and are not a substitute for personal psychotherapy, mental health treatment, crisis intervention, or medical care.
I verify that I am eligible to receive clinical supervision or consultation and that my professional practice and licensure pursuit are based in Washington, DC; Maryland; Virginia; Arizona; Oregon; Nevada; or Washington, and that I am practicing in accordance with the laws and regulations governing my jurisdiction.
I understand that consultation and supervision services may be conducted in individual, dyadic, or group formats and may include the discussion of de-identified clinical case material, professional challenges, ethical considerations, leadership development, and systems-level practice issues for educational and professional development purposes.
I agree to present clinical material ethically and accurately and to maintain client confidentiality in full compliance with HIPAA, applicable state and federal laws, and the ethical standards of my licensing board and professional discipline. I understand that no identifying client information will be disclosed during consultation or supervision.
I acknowledge that I am solely responsible for ensuring that supervision hours, documentation, and supervisory relationships meet the requirements of my licensing board, credentialing body, employer, or regulatory authority. I understand that it is my responsibility to verify that services provided through Tranquillium satisfy applicable licensure requirements.
I understand that consultation, mentoring, and peer supervision are intended to support clinical skill development, ethical decision-making, leadership capacity, self-of-the-therapist awareness, and professional growth, and do not guarantee licensure, certification, board approval, employment, promotion, or specific professional outcomes.
I agree to adhere to all Tranquillium policies regarding scheduling, payment, attendance, cancellations, technology use (if applicable), professional boundaries, and standards of conduct.
I understand that professional conduct consistent with ethical and legal standards is required at all times. I acknowledge that failure to comply with ethical, legal, financial, or professional standards, or misrepresentation of clinical material, may result in immediate suspension or termination of consultation or supervision services without refund, where permitted by law.
