General Consent to Treat
I voluntarily consent to treatment and/or related services by Psychiatry of SA which may be advised and recommended by the attending physician. I understand that in the event of a medical or psychiatric emergency which may be life threatening, that it may become necessary for Psychiatry of SA to render such emergency treatment and/or transfer myself or my child to a hospital for treatment. In the event of suicidal or homicidal thoughts, I agree to immediately reach out to suicidal hotline or go to the nearest emergency room for treatment.
I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this organization.
I understand that at Psychiatry of SA, patient evaluation and treatment is provided by Mid-level provider (Nurse practitioner or Physician Assistant) under supervision of a physician. My information will be shared with the physician for auditing and treatment planning. I understand that I have a right to refuse care from Mid-level provider at this office. However, I will be responsible for immediately finding another psychiatry practice on my own. This office will hold no responsibility in continuing care during the interim period. I understand that I may not be able to meet with the supervising physician.
I am aware that I may stop my treatment with Psychiatry of SA at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court).
I understand that medication refill request will be addressed only during working business hours and may take as long as 72 hours to be completed. Medical record request, FMLA or any other paperwork may take as long as 4 weeks to be completed and I will be responsible for office charges.
I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s) and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, Psychiatry of SA may stop treatment.
I acknowledge that I have received a copy of Notice of Privacy Practices which summarizes the ways my health information may be used and disclosed by Psychiatry of SA and states my rights with respect to my Protected Health Information (PHI). I understand that Psychiatry of SA has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event Psychiatry of SA changes this Notice, a revised Notice will be posted in the office waiting area and that I may obtain a current Notice of Privacy Practices at any time from the front desk.
Dual Relationships & Social Media
Dual relationships can impair the therapeutic process, your therapist’s objectivity, clinical judgment, or therapeutic effectiveness that could be exploitative in nature. I will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, I will preserve the integrity of our working relationship. For this reason, my social and social media policy is the same distance counseling clients as it is for in-office clients.
Records
The psychiatrist will maintain records of online counseling services. These records can include reference notes, copies of transcripts of chat and internet communications, and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association and the Texas Administrative Code. The client will be asked in advance for permission before recording any audio or video session. When records are requested, the ultimate decision to release them is up to the supervising Psychiatrist.