Consent Form

Nature of Treatment:

• Services may include psychiatric evaluations, medication management, therapy, and other related mental health care services.

• Treatment plans are individualized based on your unique needs and goals.

Confidentiality:

• Your personal information and treatment details are confidential and protected under federal and state laws (e.g., HIPAA).

• Exceptions to confidentiality include:

  • Suspected abuse or neglect of a minor, elder, or vulnerable adult.

  • Threats of harm to yourself or others.

  • Court-ordered disclosures.

Telehealth Services:

• If you choose telehealth, you consent to receive services through secure video or phone platforms.

• You are responsible for ensuring a private, distraction-free environment for your telehealth sessions.

Billing and Insurance:

• You agree to provide accurate insurance information and understand your financial responsibilities for co-pays, deductibles, or uncovered services.

• Payment is required at the time of service unless prior arrangements have been made.

Cancellation Policy:

• We require at least 24 hours’ notice for appointment cancellations. Late cancellations or missed appointments may result in a fee.

Medication Management:

• Medications may be prescribed as part of your treatment plan. It is your responsibility to take medications as directed and report any side effects or concerns to your provider.

Informed Consent:

• You have the right to ask questions, seek clarification, and make decisions about your treatment.

• Participation in treatment is voluntary, and you may withdraw consent at any time.