I do hereby seek and consent to take part in the treatment and/or Psychiatric Evaluation with NovaHealth Clinic LLC, and other providers.This is a fill in the field. Please add appropriate.

If the patient is a minor, I hereby give my consent as a parent/legal guardian for my child to participate in Psychotherapy and/or complete Psychiatric Evaluation by   *   I understand that it is my sole responsibility to notify my child’s other parent of these Psychiatric Services. I also understand that no promises have been made to me as to the results of treatment, evaluation or of any other procedures provided by this clinician, as treatment benefits, while likely, cannot be guaranteed. I have the right to inquire fully about the credentials, education, and experience of   *   _ and to have my questions answered to my satisfaction.

I am aware that I may discontinue services with   *   _ at any time. My only obligation will be to pay all outstanding fees for the services I have already received. I understand that under certain circumstances I may lose other services or may face other consequences if I stop treatment. I am aware that the procedures utilized for diagnosing psychiatrist disorders; selecting and implementing therapeutic interventions; and in maintaining my privacy will be carried out in accord with the rules and guidelines of the American Psychiatric Association and other professional organizations with adherence to diagnostic criteria in the Diagnostic and Statistical Manual (DSM). All interventions and assessment measures that are chosen will be suitable for purposes described above.

Historically, mental health services have been associated with absolute confidentiality between the family and clinician. Currently, Federal and Florida laws and regulations and professional ethics require clinicians to maintain complete confidentiality of information and communications revealed during treatment. In these cases, the clinician cannot release any information about my family without my expressed and informed permission. There are some exceptional circumstances where clinicians are required or permitted to communicate information about mental health services to persons outside the family. I am aware that an agent of my insurance company may be given information about the type(s),cost(s), date(s), and providers of any services or treatments I receive. Other exceptions include the following situations:

-The patient presents a clear and present danger to himself or herself and refuses to accept appropriate treatment or communicates to the clinician an imminent threat of physical violence against a clearly identified or reasonably identifiable victim, or the clinician has a reasonable basis to believe there is a clear and present danger of psychical violence against such a victim.

-The patient introduces his or her mental conditions as a defense in a legal proceeding.

-In child custody or adoption cases, the judge determines that the clinician has information bearing significantly on the patient’s ability to provide suitable care or custody effecting the welfare of the child.

-The patient initiates legal action against the clinician, and client information is necessary or relevant to the clinician’s defense or a Judge orders a clinical to release patient information.

-The clinical has grounds to believe a child under the age of 18, and elderly person (over age 60), or a handicapped adult, has been or is at risk of being or neglected.

I acknowledge that I have read, understand, and agree with the terms of Office Policies and Procedures.