COMPREHENSIVE PATIENT INTAKE & POLICY PACKET

SECTION 1: CONSENT TO TREATMENT & GENERAL POLICIES

INFORMED CONSENT FOR PSYCHIATRIC EVALUATION AND TREATMENT

1. CONSENT TO EVALUATION AND TREATMENT

I voluntarily consent to receive psychiatric evaluation, diagnosis, and treatment from [PRACTICE NAME] (hereafter referred to as “the Practice”). I understand and acknowledge that:

• Psychiatric care involves clinical assessment, diagnosis, and treatment based on current medical standards and professional judgment.
• No guarantees or promises have been made regarding outcomes, improvement, or cure. Treatment outcomes vary and may require adjustments over time.
• All medical and psychiatric treatments carry inherent risks, including those that may not be fully predictable or explained in advance.
• I am responsible for providing accurate and complete information regarding my medical, psychiatric, and medication history.
• In the event of a medical or psychiatric emergency, I must call 911 or go to the nearest emergency department.

2. NATURE OF PSYCHIATRIC TREATMENT

Psychiatric treatment may include, but is not limited to:

• Psychiatric evaluation and diagnosis
• Medication management
• Brief therapeutic interventions and psychoeducation
• Care coordination with other providers
• Recommendations for additional services such as psychotherapy, higher levels of care, or specialized testing.

3. POTENTIAL BENEFITS OF TREATMENT

Potential benefits may include improvement in mental health and emotional well-being, reduction in symptoms, development of coping strategies, increased self-awareness, and improved functioning in daily life.

4. RISKS OF PSYCHIATRIC TREATMENT

I understand that psychiatric treatment carries risks, including but not limited to:

• Medication-Related Risks: Side effects (e.g., nausea, sedation, dizziness), allergic reactions, and possible interactions with other medications, supplements, or substances.
• Dependency and Withdrawal: Certain medications may carry a risk of dependence, tolerance, or withdrawal.
• Worsening Symptoms: Symptoms may temporarily worsen before improving.
• Treatment Resistance: Some individuals may not respond fully or at all to treatment.
• Emotional Discomfort: Discussing difficult topics may lead to temporary emotional discomfort.

5. PATIENT RESPONSIBILITIES

I agree to:

• Provide accurate and complete information.
• Inform my provider of all medications and substances I am using.
• Report side effects, allergic reactions, or worsening symptoms promptly.
• Follow prescribed treatment recommendations and attend scheduled appointments.
• Complete recommended testing when required.

Failure to follow recommendations may impact treatment outcomes and may result in modification or discontinuation of care.

6. LABORATORY AND DIAGNOSTIC TESTING

I understand that laboratory or diagnostic testing (e.g., blood tests, urine testing) may be required before or during treatment to ensure safe and effective care. I acknowledge that I am responsible for any associated costs unless otherwise covered.

7. MEDICATION CONSENT

If medication is recommended, I understand that the purpose, potential benefits, and risks will be discussed. I may accept or decline treatment. I must follow prescribed instructions and should not stop medications abruptly without medical guidance.

8. TELEHEALTH ACKNOWLEDGMENT

I understand that some services may be provided via telehealth when appropriate. I agree to participate from a private and secure location, use appropriate technology, and maintain confidentiality. I understand that telehealth is not appropriate for emergencies.

9. VOLUNTARY CONSENT

I confirm that I have read and understand this document, have had the opportunity to ask questions, and voluntarily agree to receive psychiatric evaluation and treatment.

CONSENT TO TREAT A MINOR

(To be completed if the patient is under 18)

1. PURPOSE OF THIS CONSENT

This document authorizes the Practice to provide psychiatric evaluation and treatment to the above-named minor. Consent for treatment is typically required from a parent or legal guardian.

2. AUTHORITY TO CONSENT

I certify that I have legal authority to consent to treatment as:

☐ Biological parent    ☐ Adoptive parent    ☐ Legal guardian (court-appointed)    ☐ Other (specify): __________________________

3. LEGAL CUSTODY AND DECISION-MAKING AUTHORITY

I understand that legal custody (not physical custody) determines the authority to make healthcare decisions. The Practice relies on the information provided by the parent/guardian unless legal documentation states otherwise.

Custody status: ☐ Joint legal custody    ☐ Sole legal custody    ☐ Legal guardianship    ☐ Foster care / state custody    ☐ Other: _________

Required Documentation (if applicable): ☐ Court order    ☐ Divorce decree    ☐ Custody agreement    ☐ Guardianship documentation    ☐ Foster placement documentation

Good Faith Representation: I certify that I am providing accurate and complete information and will provide documentation upon request.

4. CONSENT FOR TREATMENT

I authorize the Practice to provide psychiatric services including psychiatric evaluation, diagnosis, medication management, psychotherapy or counseling, care coordination, and referrals.

5. MINOR ASSENT

I understand that the provider will seek the minor’s assent when developmentally appropriate and that the minor may participate in treatment decisions.

6. CONFIDENTIALITY AND PARENTAL ACCESS

I understand that parents/guardians generally have access to the minor’s medical records. However, certain services may be confidential depending on state law, the type of service, or clinical judgment.

7. MINOR CONSENT EXCEPTIONS

I understand that minors may consent to certain services under state law (e.g., emancipated minor status, specific services like reproductive care).

8. DIVORCE, SEPARATION, AND MULTIPLE GUARDIANS

I understand that one parent may consent unless restricted by court order. I agree to notify the Practice of any custody changes.

9. VOLUNTARY CONSENT

By signing, I acknowledge that I have legal authority to consent, have provided accurate information, understand the risks and benefits of treatment, and have had the opportunity to ask questions.

PRACTICE POLICIES AND PATIENT RESPONSIBILITIES AGREEMENT

1. PURPOSE OF THIS AGREEMENT

This document outlines the policies, expectations, and responsibilities required to receive care from the Practice. These policies are designed to support safe, effective, and evidence-informed psychiatric care.

2. GENERAL PATIENT RESPONSIBILITIES

I agree to:

• Provide accurate, complete, and current medical, psychiatric, and medication history.
• Inform the Practice of any changes in symptoms, medications, contact information, insurance, or major health events.
• Attend scheduled appointments on time and follow treatment recommendations or discuss concerns openly.
• Complete requested labs, screenings, or other monitoring.
• Communicate respectfully with providers and staff.

Failure to meet these responsibilities may affect treatment, refill decisions, and continuation of care.

3. APPOINTMENTS AND FOLLOW-UP REQUIREMENTS

I understand that psychiatric care requires ongoing follow-up for safe monitoring. Follow-up visit timing is determined by the provider based on clinical needs. Stable patients are generally seen every [TIMEFRAME, E.G., 1–3 MONTHS]. Failure to maintain follow-up may result in denial of refills, plan modifications, or discharge.

4. MEDICATION REFILL POLICY

• Requests: Must be submitted at least [TIMEFRAME, E.G., 48–72 BUSINESS HOURS] in advance through approved channels (e.g., patient portal, pharmacy request).
• Requirements: Refills may require a recent appointment, up-to-date monitoring, and stable clinical status.
• Controlled Substances: Subject to additional legal and safety requirements. Early refills are generally not provided.
• Denials: Refills may be delayed or denied if the patient is overdue for follow-up, monitoring is incomplete, or there are safety concerns.

5. PAPERWORK, FORMS, AND ADMINISTRATIVE REQUESTS

Completion of forms (e.g., disability, FMLA, school letters) requires provider time and may not be included in the visit fee.

• Fees: Standard forms: [AMOUNT OR HOURLY RATE].
• Processing Time: Typically [TIMEFRAME, E.G., 5–10 BUSINESS DAYS].

6. COMMUNICATION POLICY

• Clinical communication must occur through approved channels only (e.g., patient portal).
• Response times for non-urgent messages are [TIMEFRAME, E.G., 1–2 BUSINESS DAYS].
• Complex issues may require an appointment. The Practice may charge fees for extended calls or clinical messaging that requires substantial professional time.

7. AFTER-HOURS AND EMERGENCY POLICY

The Practice does not provide 24/7 emergency services. In case of emergency, call 911, go to the nearest emergency room, or call/text 988 for a suicidal crisis.

8. TERMINATION OF CARE

The Practice may terminate the patient-provider relationship for reasons including non-compliance, repeated missed appointments, unsafe or inappropriate behavior, violation of policies, or non-payment. The Practice will provide notice and transition support as appropriate.

9. FINANCIAL RESPONSIBILITY

I am responsible for charges not covered by insurance. Insurance verification is not a guarantee of payment. Unpaid balances may lead to collection activity, scheduling restrictions, or discharge.

10. VOLUNTARY AGREEMENT

I have read, understood, and agree to follow these policies.

NO-SHOW & LATE CANCELLATION POLICY AGREEMENT

1. PURPOSE

This policy supports timely access to care, maintains provider availability, and supports continuity of treatment. Missed appointments delay care and limit access for other patients.

2. DEFINITIONS

• No-Show: Failure to attend a scheduled appointment without required notice.
• Late Cancellation: Canceling or rescheduling with less than [24–48 BUSINESS HOURS] notice.
• Business Hours: Defined as [PRACTICE BUSINESS HOURS].

3. CANCELLATION REQUIREMENTS

I must provide at least [24–48 BUSINESS HOURS] notice through the patient portal or a phone call. Failure to do so will result in a late cancellation fee.

4. NO-SHOW AND LATE CANCELLATION FEES

These fees are not covered by insurance and are my responsibility.

• Follow-up visit: $[AMOUNT]
• Initial evaluation: $[AMOUNT]
• Therapy session: $[AMOUNT]

5. LATE ARRIVALS

Arriving more than [10–15 minutes] late may result in a shortened visit, rescheduling, or classification as a no-show, and the full fee may apply.

6. PAYMENT FOR MISSED APPOINTMENTS

Fees may be automatically charged to the card on file. Outstanding balances must be paid before scheduling future appointments and may lead to collection or discharge.

7. EXCEPTIONS AND WAIVERS

Fees may be waived at the Practice’s discretion for medical emergencies, severe illness, or extreme weather.

8. REPEATED NO-SHOWS

Repeated missed appointments (e.g., [2–3] within [6–12 MONTHS]) may result in scheduling limitations, deposit requirements, or termination of care.

9. IMPACT ON TREATMENT AND MEDICATIONS

Missed appointments may delay care, and medication refills may be denied without appropriate follow-up.

10. APPOINTMENT REMINDERS

Reminders are a courtesy, but I am responsible for tracking my own appointments. Failure to receive a reminder does not waive fees.

11. VOLUNTARY AGREEMENT

I understand cancellation timelines, fees, and my financial responsibility.

FINANCIAL POLICY (CREDIT CARD ON FILE AUTHORIZATION AGREEMENT)

1. PURPOSE

This agreement explains how the Practice may keep a secure payment method on file to charge authorized amounts related to services rendered.

2. CARD-ON-FILE REQUIREMENT

A valid credit or debit card is required to be kept on file. The Practice uses a secure third-party processor and does not store full card details directly.

3. AUTHORIZATION TO CHARGE CARD

By signing, I authorize the Practice to charge the card for:

• Time-of-Service Charges: Copayments, coinsurance, deductibles, self-pay fees.
• Post-Insurance Balances: Remaining balances after insurance claim adjudication.
• Missed Appointment and Late Cancellation Fees.
• Additional Authorized Charges: Fees for forms, returned payments, and other administrative services.

4. PAYMENT PROCESSING TIMELINE

Charges may be processed on the date of service, after insurance claim adjudication, or after a missed appointment.

5. DECLINED, REVERSED, OR FAILED PAYMENTS

If a transaction is unsuccessful, the Practice may make follow-up attempts. The patient remains responsible for valid balances owed.

6. SECURITY AND DATA PROTECTION

The Practice uses reasonable safeguards to protect payment information and may use tokenization to reduce risk.

7. DISPUTES AND CHARGEBACKS

If I believe a charge is incorrect, I agree to contact the Practice before initiating a charge dispute with my card issuer. Improper chargebacks may result in scheduling restrictions.

8. AUTHORIZATION DURATION AND REVOCATION

This authorization remains in effect until revoked in writing to [BILLING DEPARTMENT CONTACT INFO]. Revocation does not apply to charges already incurred.

9. UPDATED PAYMENT INFORMATION

I agree to provide updated card information upon expiration or change. Failure to maintain a valid payment method may affect non-urgent scheduling.

10. VOLUNTARY AGREEMENT

I understand and agree to these terms.

SECTION 2: COMMUNICATION & PRIVACY

COMMUNICATION CONSENT AND ELECTRONIC COMMUNICATION POLICY

1. PURPOSE

This policy explains how the Practice may communicate with patients, the benefits and risks of available methods, and the patient’s responsibilities.

2. COMMUNICATION METHODS USED

The Practice may communicate through the patient portal, telephone, voicemail, text message (SMS), email, and mail. The Practice uses reasonable safeguards to protect my information.

3. SECURE AND NON-SECURE COMMUNICATION

• Secure: The patient portal and other encrypted systems are preferred for protected health information.
• Non-Secure: Standard text messaging, email, and voicemail involve greater privacy risks, including unauthorized access, misdelivery, and delayed transmission.

4. AUTHORIZATION FOR TEXT AND EMAIL COMMUNICATION

If I choose text/email, I authorize the Practice to contact me for appointment reminders, scheduling, and limited health-related information. I understand the risks and may revoke this consent in writing at any time.

5. PATIENT PORTAL COMMUNICATION

The portal is the preferred method for non-urgent clinical communication. Messages may become part of my medical record. Response time is within [TIMEFRAME, SUCH AS 1–2 BUSINESS DAYS].

6. LIMITATIONS OF ELECTRONIC COMMUNICATION

Electronic communication is not appropriate for emergencies. Messages may be delayed, and the Practice may require an appointment for complex issues.

7. EMERGENCIES AND CRISIS SITUATIONS

In an emergency, I will not rely on electronic communication. I will call 911, go to the nearest emergency department, or call/text 988.

8. PHONE COMMUNICATION AND VOICEMAIL

I authorize the Practice to leave voicemail messages according to my selected preference above.

9. PATIENT RESPONSIBILITIES

I agree to provide accurate contact information, protect my devices and accounts, and use communication methods appropriately.

10. VOLUNTARY CONSENT

I understand and voluntarily consent to these communication policies.

NOTICE OF PRIVACY PRACTICES (NPP)

[PRACTICE NAME] is required by law to maintain the privacy of your health information and to provide you with this Notice of our legal duties and privacy practices.

1. HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use and disclose your Protected Health Information (PHI) without your written authorization for the following purposes:

• Treatment: To provide, coordinate, or manage your healthcare.
• Payment: To obtain payment for services (e.g., billing insurance).
• Healthcare Operations: For quality improvement, staff training, and administrative functions.
• Appointment Reminders: To contact you with reminders and health-related information.
• Individuals Involved in Your Care: To disclose relevant PHI to a family member or friend involved in your care if you agree or do not object.

2. USES AND DISCLOSURES REQUIRING AUTHORIZATION

We will obtain your written authorization before using or disclosing your PHI for purposes such as psychotherapy notes, marketing, or selling your PHI. You may revoke this authorization at any time.

3. SPECIAL CONSIDERATIONS FOR PSYCHIATRIC PRACTICES

• Psychotherapy Notes: These are kept separate from the medical record and have special protection. Their release generally requires specific written authorization.
• Sensitive Information: Additional protections apply to substance use treatment records (42 CFR Part 2), HIV/AIDS, and genetic information.

4. DISCLOSURES WITHOUT YOUR AUTHORIZATION

We may disclose your PHI without authorization when required or permitted by law, such as for public health activities, abuse or neglect reporting, serious threats to health or safety, health oversight activities, legal proceedings, and law enforcement.

5. YOUR RIGHTS REGARDING YOUR PHI

You have the right to:

• Inspect and Copy: Request to access your PHI.
• Request Amendment: Request corrections to inaccurate information.
• Request Restrictions: Request limits on certain uses or disclosures (we are not required to agree).
• Confidential Communications: Request communication by alternative means or locations.
• Accounting of Disclosures: Request a list of certain disclosures.
• File a Complaint: File a complaint with our Privacy Officer or the U.S. Department of Health and Human Services without retaliation.

Contact:
Privacy Officer: [NAME]
Phone: [PHONE]
Email: [EMAIL]
Address: [ADDRESS]

6. SECURITY OF YOUR INFORMATION

We implement administrative, physical, and technical safeguards to protect your PHI.

7. CHANGES TO THIS NOTICE

We reserve the right to change this Notice. Changes will be posted in the office, on our website, and available upon request.

PATIENT ACKNOWLEDGMENT OF RECEIPT: I acknowledge that I have received or have been given the opportunity to receive a copy of the Notice of Privacy Practices.

SOCIAL MEDIA AND PROFESSIONAL BOUNDARIES CONSENT POLICY

1. PURPOSE

This policy explains how the Practice maintains professional boundaries and protects patient privacy online.

2. NO PERSONAL SOCIAL MEDIA CONNECTIONS

Providers and staff will not accept or initiate personal social media connections (e.g., friend requests, follows) with current patients.

3. NO DIRECT MESSAGES FOR CLINICAL CARE

I should not use social media for clinical, urgent, or personal matters. Providers will generally not respond to such messages.

4. APPROVED COMMUNICATION METHODS

Approved methods are the patient portal, secure messaging, office phone, and scheduled visits.

5. PROFESSIONAL SOCIAL MEDIA ACCOUNTS

The Practice may maintain professional social media accounts for educational or business purposes. Interactions there are not individualized medical advice.

6. PUBLIC INTERACTIONS AND CONFIDENTIALITY

To protect privacy, providers may choose not to acknowledge me first in public. Online, they will avoid discussing my treatment.

7. ONLINE REVIEWS AND TESTIMONIALS

I understand that posting an online review may reveal my identity as a patient. The Practice will not confirm I am a patient in responses.

8. DUAL RELATIONSHIPS AND PROFESSIONAL BOUNDARIES

Providers are ethically required to avoid dual relationships (e.g., personal friendships, business relationships) that could impair judgment or exploit the therapeutic relationship.

9. PATIENT RESPONSIBILITIES

I agree to use only approved channels for treatment-related matters and to respect professional boundaries.

10. VOLUNTARY ACKNOWLEDGMENT

I have read and understand this policy and agree to follow it.

TELEHEALTH INFORMED CONSENT AGREEMENT

1. DEFINITION

Telehealth is the use of electronic communication technologies to provide healthcare services remotely, including live video, audio-only (if permitted), and secure messaging.

2. PURPOSE AND SCOPE

Telehealth services may include psychiatric evaluations, medication management, follow-up visits, and care coordination.

3. BENEFITS OF TELEHEALTH

Benefits include improved access to care, reduced travel, convenience, and continuity of care.

4. LIMITATIONS OF TELEHEALTH

Limitations include the inability to perform a full physical exam, reduced observation of non-verbal cues, and dependence on technology.

5. TECHNOLOGY RISKS

Risks include connectivity failures, software malfunctions, and data transmission interruptions.

6. PRIVACY AND SECURITY RISKS

The Practice uses reasonable safeguards, but no system is completely secure. I accept the risk of unauthorized access.

7. PATIENT RESPONSIBILITIES FOR PRIVACY

I agree to participate from a private location, use a secure device, and ensure others cannot view the session.

8. CONFIDENTIALITY AND LIMITS

Telehealth sessions are confidential, with the same legal limits (e.g., harm to self/others, abuse reporting).

9. EMERGENCY AND SAFETY PROCEDURES

Telehealth is not for emergencies. In an emergency, I will call 911, go to the nearest emergency room, or call/text 988.

10. RECORDING POLICY

Sessions will not be recorded without explicit consent, and unauthorized recording is not permitted.

11. VOLUNTARY CONSENT

I have read, understood, and voluntarily agree to participate in telehealth services.

SECTION 3: SPECIFIC MEDICATION POLICIES & AGREEMENTS

CONTROLLED SUBSTANCE TREATMENT AGREEMENT

(This agreement applies to all controlled substances, including stimulants and benzodiazepines.)

1. PURPOSE

This agreement explains the expectations and safety requirements when the Practice initiates or continues treatment with a controlled substance (e.g., stimulants, benzodiazepines).

2. INFORMED CONSENT AND RISKS

I understand that controlled substances carry significant risks, including misuse, addiction, tolerance, sedation, impaired coordination, and interactions with other substances. The provider may decide not to prescribe or may discontinue treatment if risks outweigh benefits.

3. PRESCRIBING STANDARDS

Controlled substances will be prescribed only when medically appropriate. Prescribing is not guaranteed. Prescriptions may be limited in quantity and duration.

4. ONE PRESCRIBER / ONE PHARMACY POLICY

To reduce errors and diversion, I agree to use one designated pharmacy. I will notify the Practice before changing pharmacies.

5. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP) REVIEW

I consent to the provider’s review of my controlled substance prescription history in the state PDMP.

6. REFILL POLICY

Refills are addressed during appointments and must be requested at least [TIMEFRAME, E.G., 48–72 BUSINESS HOURS] in advance. Early refills are not provided. No refill is guaranteed.

7. LOST, STOLEN, OR DAMAGED MEDICATION

Lost medication will not routinely be replaced. The provider may consider exceptions with documentation (e.g., police report).

8. URINE DRUG SCREENING AND OTHER MONITORING

I agree to complete requested urine drug screening, pill counts, or other monitoring. Refusal or unexplained results may result in reassessment or discontinuation of treatment.

9. MEDICATION USE REQUIREMENTS

I agree to take medication only as prescribed, not share it, and store it securely.

10. OTHER PRESCRIBERS AND CONTROLLED MEDICATIONS

I agree not to obtain controlled substances from another clinician without informing the Practice.

11. SUBSTANCE USE DISCLOSURE

I agree to be honest about my use of alcohol, cannabis, illicit substances, and other medications.

12. TELEHEALTH AND CONTROLLED SUBSTANCES

Prescribing through telehealth is governed by law. The provider may require an in-person visit.

13. REASONS CONTROLLED SUBSTANCES MAY BE REDUCED OR DISCONTINUED

The provider may reduce or discontinue medications if risks outweigh benefits, the medication is ineffective, there is suspected misuse, or I violate this agreement.

14. VOLUNTARY ACKNOWLEDGMENT

I have read, understood, and agree to the terms of this agreement. I understand signing does not guarantee a prescription.

BENZODIAZEPINE AND OPIOID MEDICATION POLICY

(This policy is specific to these high-risk medication classes.)

1. PURPOSE

This policy outlines safety requirements for patients prescribed benzodiazepines (e.g., alprazolam, clonazepam) and/or opioids.

2. CLINICAL APPROACH TO PRESCRIBING

These medications are prescribed only when clinically appropriate and are not first-line treatments. Prescribing is not guaranteed.

3. RISKS OF BENZODIAZEPINES AND OPIOIDS

• Benzodiazepines: Sedation, cognitive/memory impairment, dependence/withdrawal, increased fall risk.
• Opioids: Respiratory depression (slowed/stopped breathing), sedation, constipation, tolerance, addiction, overdose, and death.
• Combined Use Risk: The combination significantly increases the risk of respiratory depression, overdose, and death. Co-prescribing is generally avoided unless clinically justified and closely monitored.

4. ALCOHOL, CANNABIS, AND OTHER SUBSTANCES

• Alcohol: Use with benzodiazepines/opioids is strongly discouraged due to increased risk of sedation, respiratory depression, and overdose.
• Cannabis: Cannabis may increase sedation, cognitive impairment, and interfere with treatment assessment.
• Practice Policy: I will disclose all substance use. The provider may recommend reduction or discontinuation of substances if they create safety concerns.

5. PRESCRIBING REQUIREMENTS

I understand that prescriptions may be limited in dose, quantity, and duration. Early refills are not provided.

6. PDMP AND MONITORING

I consent to PDMP review and may be subject to monitoring (e.g., urine drug screening, pill counts).

7. ONE PROVIDER / ONE PHARMACY POLICY

I agree to use one provider and one designated pharmacy for these medications.

8. VOLUNTARY AGREEMENT

I understand the risks and agree to comply with this policy.

STIMULANT MEDICATION POLICY

(This policy is specific to stimulant medications.)

1. PURPOSE

This policy explains expectations, responsibilities, and safety requirements for patients prescribed stimulant medications (e.g., amphetamine-based, methylphenidate-based).

2. CLINICAL APPROACH TO PRESCRIBING

Stimulants are prescribed only after a comprehensive evaluation determines they are clinically appropriate. Prescribing is at the provider’s discretion.

3. POTENTIAL BENEFITS AND RISKS

• Benefits: May improve attention, concentration, and executive functioning.
• Risks: Increased heart rate/blood pressure, decreased appetite, insomnia, anxiety, mood changes, risk of misuse and diversion.

4. CANNABIS (MARIJUANA) USE AND STIMULANT TREATMENT

• Clinical Rationale: Cannabis use can impair attention, working memory, and cognitive function, interfering with accurate ADHD assessment and treatment response.
• Practice Policy: The Practice does not recommend ongoing cannabis use during stimulant treatment. I agree to disclose all cannabis use. The provider may require reduction, cessation, or sustained abstinence before initiating or continuing stimulant treatment. This applies regardless of whether cannabis use is recreational or authorized under state law.

5. PRESCRIBING STANDARDS

Prescriptions will be limited in quantity and duration. The provider may require additional records or formal testing.

6. MONITORING REQUIREMENTS

I understand that monitoring may include symptom reviews, blood pressure/pulse checks, PDMP review, and urine drug screening.

7. REFILL POLICY

Refills are addressed during appointments and must be requested in advance. Early refills are not provided.

8. LOST, STOLEN, OR DAMAGED MEDICATION

Lost medication will not routinely be replaced. Repeated reports may be treated as a safety concern.

9. MEDICATION USE EXPECTATIONS

I agree to take medication as prescribed, not share it, and store it securely.

10. VOLUNTARY AGREEMENT

I have read and understood this policy, including the Practice’s position on cannabis use during stimulant treatment, and agree to comply.

SECTION 4: PSYCHOTHERAPY-SPECIFIC CONSENT

INFORMED CONSENT FOR PSYCHOTHERAPY

(This form is for psychotherapy services.)

1. WHAT PSYCHOTHERAPY IS

Psychotherapy is a collaborative treatment process between a patient and a licensed/ supervised mental health provider to help understand and cope with emotions, thoughts, behaviors, and mental health symptoms. Approaches may include CBT, supportive therapy, and psychodynamic therapy.

2. GOALS OF TREATMENT

Treatment goals are developed collaboratively and may address issues like anxiety, depression, trauma, grief, and life transitions.

3. EXPECTED BENEFITS

Potential benefits include reduced distress, improved coping skills, increased self-awareness, and better relationships. No specific result can be guaranteed.

4. RISKS AND DISCOMFORTS

Psychotherapy may involve temporary increases in sadness, anxiety, or emotional discomfort when discussing difficult topics.

5. PATIENT RESPONSIBILITIES

I agree to attend sessions, participate honestly, and practice coping strategies. Progress may be limited if attendance is inconsistent.

6. CONFIDENTIALITY

Information shared in psychotherapy is generally confidential. Limits include risk of harm to self/others, abuse/neglect reporting, and legal requirements. Psychotherapy notes receive special protection under HIPAA.

7. TELEHEALTH PSYCHOTHERAPY

Telehealth sessions use secure video platforms. They carry risks like interruptions, technical failures, and privacy concerns. I should participate from a private location.

8. EMERGENCY AND CRISIS CARE

Psychotherapy is not a substitute for emergency services. In an emergency, I will call 911, go to the nearest emergency room, or call/text 988.

9. BETWEEN SESSION CONTACT

The Practice may offer limited between-session communication. Messages are not monitored continuously and are not appropriate for emergencies.

10. FEES, MISSED APPOINTMENTS, AND CANCELLATIONS

I understand that fees apply and missed/late-canceled appointments may incur charges.

11. SOCIAL MEDIA AND PROFESSIONAL BOUNDARIES

The provider will not engage in personal friendships or dual relationships with patients. Social media contact is limited.

12. PATIENT RIGHTS

I have the right to ask questions, participate in treatment planning, decline treatment, and request records (subject to limitations).

13. VOLUNTARY CONSENT

I have read, understood, and voluntarily consent to participate in psychotherapy.

SECTION 5: ADVANCED NOTICE

VIRTUAL SCRIBE NOTICE

To ensure I can fully focus on you during our sessions, a virtual scribe is used to generate necessary documents, eliminating note-taking throughout the session. The documents are derived from session recordings that are not stored and are automatically deleted after processing. The scribe complies with HIPAA regulations, and all data is encrypted. Choosing not to utilize this service will not have any negative impact on the therapeutic process. Your comfort and autonomy are our top priority.