Consent for Mental Health Evaluation and/or Treatment
1. Consent to Evaluate/Treat: I voluntarily consent that I will participate in a mental health evaluation and/or treatment by staff from Vicki Paulus LLC. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:
a. The benefits of the proposed treatment
b. Alternative treatment modes and services, including "off-label" use of medications
c. The manner in which treatment will be administered
d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable)
e. Probable consequences of not receiving treatment The evaluation or treatment will be conducted by a Psychiatric Nurse Practitioner.Treatment will be conducted within the boundaries of Washington or Oregon Law. It is my responsibility to update my provider regarding insurance or medical/medication changes, including the use of over the counter medications and supplements.
2. Benefits to ivaluation/Treatment: Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.
3. Charges: Fees are based on the length or type of the evaluation or treatment, which are determined by The nature of the service. I will be responsible for any charges not covered by insurance, including co- payments and deductibles, and know I am ultimately responsible for the balance of my account for any professional services rendered. I have been provided a fee schedule with the Policies & Procedures.
4. Confidentiality, Harm, and Inquiry: Information from my evaluation and/or treatment is containedina confidential medical record at Vicki Paulus LLC, and I consent to disclosure for use by Vicki Paulus LLC's staff for the purpose of continuity of my care. Per Washington mental health law, information provided will be kept confidential with the following exceptions:
1) if am deemed to present a danger to myself or others;
2) if concerns about possible abuse or neglect arise;
3) if a court order is issued to obtain records; or
4) pertinent information is needed to make an emergent decision.
5. Appointment Cancellations: I understand I am responsible for charges accrued for missed appointments and appointment cancellations without 48-hour advanced notice, unless it is a verifiable emergency.I understand my insurance company will not reimburse for missed sessions.
6.Termination of Treatment: Termination of treatment is usually a mutually agreed upon ending of the therapeutic relationship, but some circumstances may result in premature termination or closing of my case. Circumstances include (2) or more unexcused missed appointments within one rotating calendar year, no office appointments scheduled within (30) days of a missed appointment, undisclosed substance use, physical threat to providersor staff, on-compliance with treatment guidelines, or no payment received on my balance over (60) days.
7. Prescription Refills: I agree to contact my provider for refill requests 7-10 days before the refill is needed.
8. Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician.
9. Expiration of Consent: This consent to treat will expire with termination of services.
10. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based mental health services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care acility in my immediate area.
11. I understand that different states have different regulations for the use of telehealth and that such services offered by Vicki Paulus LLC may be temporary based on urgent and unprescedented global circumstances.