The PHQ-9 is a commonly used screening tool for assessing the severity of depression. It consists of nine questions that are designed to evaluate the frequency and severity of depressive symptoms experienced by individuals.

Instructions:
Please read each statement carefully and select the response that best describes how often you have experienced each symptom over the past two weeks.

The GAD-7 (Generalized Anxiety Disorder-7) is a widely used questionnaire for assessing the severity of generalized anxiety disorder symptoms. It consists of seven questions that measure the frequency and severity of anxiety symptoms experienced by individuals. Here is the GAD-7 questionnaire:

Atlanta Telehealth is committed to providing high-quality mental health services to our clients. Before initiating treatment, it is important that you understand and provide your informed consent for the therapeutic process. This consent to treat policy outlines the expectations, rights, and responsibilities associated with receiving services from our agency. Please read and sign this form to indicate your understanding and agreement.

1. Purpose and Nature of Services

• You acknowledge that you have sought services from Atlanta Telehealth for mental health support, counseling, therapy, or related services.
• You understand that the purpose of treatment is to address mental health concerns, enhance well-being, and promote personal growth and development.

2. Therapist Qualifications

• You have been informed of the qualifications, credentials, and experience of your assigned therapist or mental health professional.
• You have the right to request information about your therapist's qualifications or seek a change of therapist if desired.

3. Confidentiality

• You understand that all information shared during sessions is confidential, except for specific legal and ethical exceptions, which will be explained to you.
• You give consent for your therapist to consult with other professionals within Atlanta Telehealth for treatment purposes.

4. Limits to Confidentiality

• You have been informed of the circumstances in which your therapist may be legally or ethically required to breach confidentiality, including situations involving imminent danger to yourself or others.
• You understand that your therapist is obligated to report suspected abuse or neglect of children, elderly individuals, or vulnerable populations.

5. Benefits and Risks

• You have been informed of the potential benefits, limitations, and risks associated with mental health treatment.
• You understand that therapy outcomes may vary and cannot be guaranteed.

6. Treatment Plan

• You agree to actively participate in the treatment process, including collaborating with your therapist to develop a mutually agreed-upon treatment plan.
• You understand that treatment goals, interventions, and duration may be reviewed and modified throughout the course of therapy.

7. Cancellations and Missed Appointments

• You acknowledge that it is your responsibility to provide at least 24 hours notice for appointment cancellations or rescheduling.
• You acknowledge that Atlanta Telehealth reserves the right to discontinue treatment/services if you miss three (3) consecutive appointments without contacting us.  
• You understand that missed appointments or late cancellations may be subject to a fee, as specified in the agency's financial agreement, if applicable.

8. Termination of Services

• You have the right to terminate therapy at any time, and your therapist retains the right to recommend or terminate services when deemed appropriate.
• You understand that a termination process will be discussed and implemented collaboratively to ensure continuity of care.

9. Emergency Situations

• You acknowledge that therapy sessions are not designed to address immediate crises or emergencies.
• You understand that in case of an emergency, you should contact emergency services or your designated emergency contact.

By signing below, you confirm that you have read and understood this consent to treat policy, and you voluntarily consent to receive mental health services from Atlanta Telehealth. You also acknowledge that you have had an opportunity to ask questions and clarify any concerns.

Patient Information

Emergency Contact Information

Primary Physician Information

In case of an emergency, Atlanta Telehealth may need to contact your designated emergency contact or primary physician. Please provide the information requested above.

Please note that by providing this information, you consent to our mental health agency contacting the individuals listed in case of an emergency or if we determine it is necessary for your safety or well-being. We will make reasonable efforts to maintain the confidentiality of this information and use it solely for emergency purposes.

It is your responsibility to notify us of any changes to your emergency contact or primary physician information promptly. If there are any changes, please inform us as soon as possible.

By signing below, you acknowledge that the information provided is accurate and up to date.

Atlanta Telehealth strives to provide comprehensive and personalized mental health services. As part of your treatment journey, it may be necessary to conduct specific evaluations or assessments to better understand your needs, develop an appropriate treatment plan, or monitor your progress. This Consent for Evaluation or Assessment Policy outlines the purpose, procedures, and potential outcomes of these assessments. Please read and sign this form to indicate your understanding and agreement.

1. Purpose and Nature of Evaluation/Assessment

• You acknowledge that evaluations or assessments may be conducted to gather comprehensive information about your mental health, symptoms, functioning, and any relevant contextual factors.
• The purpose of these evaluations/assessments is to aid in diagnosis, treatment planning, and monitoring progress over time.

2. Assessment Procedures

• You understand that assessments may involve interviews, questionnaires, standardized tests, self-report measures, or other data collection methods deemed appropriate by your mental health professional.
• Your therapist or mental health professional will explain the purpose, duration, and expected procedures of each assessment prior to its administration.

3. Benefits and Limitations

• You acknowledge that evaluations or assessments can provide valuable insights into your mental health, strengths, and areas of concern.
• However, you understand that assessments have limitations and cannot provide definitive answers or predict specific outcomes.

4. Confidentiality and Privacy

• You acknowledge that evaluation or assessment results will be handled with the same level of confidentiality as your other mental health records, as outlined in our agency's privacy policies.
• Your assessment information may be shared within our agency on a need-to-know basis for treatment purposes, but external sharing will require separate informed consent.

5. Potential Outcomes

• You understand that the results of evaluations or assessments may contribute to diagnostic impressions, treatment recommendations, and other therapeutic interventions.
• You acknowledge that assessment findings may help to inform your therapeutic goals and enhance the effectiveness of treatment.

6. Right to Decline or Request Clarification

• You have the right to decline participation in specific evaluations or assessments if you find them uncomfortable or have concerns about their appropriateness.
• You may request additional information, clarification, or ask any questions about the evaluation or assessment process before providing your consent.

7. Use of Assessment Results

• You acknowledge that assessment results will be used for clinical purposes only and will not be shared without your consent, unless required by law or ethical guidelines.
• Your therapist may use the assessment results to inform treatment planning, track progress, and communicate relevant information with other healthcare providers, with your express permission.

By signing below, you confirm that you have read and understood this Consent for Evaluation or Assessment Policy, and you voluntarily provide your consent to participate in evaluations or assessments as recommended by your mental health professional.

This Treatment Agreement outlines the expectations, rights, and responsibilities associated with receiving mental health services at Atlanta Telehealth. It serves as a collaborative agreement between you, the patient, and your therapist or mental health professional. Please read and sign this form to indicate your understanding and agreement.

1. Purpose of Treatment

• You acknowledge that the purpose of treatment is to address mental health concerns, promote well-being, and support personal growth and development.
• You understand that therapy aims to provide a safe and supportive space for exploration, insight, and the development of coping strategies.

2. Therapist Qualifications

• You have been informed of the qualifications, credentials, and experience of your assigned therapist or mental health professional.
• You have the right to request information about your therapist's qualifications or seek a change of therapist if desired.

3. Collaborative Nature of Treatment

• You agree to actively participate in the treatment process, including open and honest communication with your therapist.
• Your therapist will listen attentively, provide support, and collaborate with you to set goals, identify interventions, and evaluate progress.

4. Session Duration and Frequency

• You and your therapist will mutually agree upon the duration and frequency of therapy sessions.
• Sessions typically last 40-60 minutes and will be scheduled on a regular basis, unless otherwise agreed upon.

5. Confidentiality

• You understand that all information shared during therapy sessions is confidential, except for specific legal and ethical exceptions, which will be explained to you.
• You give consent for your therapist to consult with other professionals within Atlanta Telehealth for treatment purposes.

6. Limits to Confidentiality

• You have been informed of the circumstances in which your therapist may be legally or ethically required to breach confidentiality, including situations involving imminent danger to yourself or others.
• You understand that your therapist is obligated to report suspected abuse or neglect of children, elderly individuals, or vulnerable populations.

7. Treatment Plan

• You and your therapist will collaboratively develop a treatment plan that outlines your therapeutic goals, objectives, and strategies.
• The treatment plan may be reviewed, modified, or updated throughout the course of therapy based on your progress and evolving needs.

8. Termination of Services

• You have the right to terminate therapy at any time, and your therapist retains the right to recommend or terminate services when deemed appropriate.
• A termination process will be discussed and implemented collaboratively to ensure continuity of care.

9. Fees and Payment

• You acknowledge that you are responsible for the payment of fees associated with the mental health services provided, as outlined in the agency's financial agreement.
• You agree to make timely payments for services rendered and to discuss any financial concerns or questions with the agency's billing department.

10. Communication

• You and your therapist will establish agreed-upon methods and availability for communication outside of scheduled therapy sessions, if necessary.
• You understand that urgent or crisis situations should be addressed by contacting emergency services or utilizing appropriate crisis resources.

By signing below, you confirm that you have read and understood this Treatment Agreement, and you voluntarily agree to participate in therapy at Atlanta Telehealth. You also acknowledge that you have had an opportunity to ask questions and clarify any concerns.

At Atlanta Telehealth we are committed to maintaining the privacy and confidentiality of your personal health information. This Notice of Privacy Practices explains how we handle and protect your information, your rights regarding your health information, and our legal responsibilities. Please review this notice carefully.

1. Uses and Disclosures of Health Information

• We may use and disclose your health information for treatment purposes, payment activities, and healthcare operations as permitted by law.
• Examples include sharing information with your healthcare providers involved in your care, submitting insurance claims, and conducting quality assessments.

2. Your Rights

• You have the right to request restrictions on how we use and disclose your health information, as well as the right to access, amend, and receive an accounting of disclosures of your health information.
• You have the right to request confidential communications and opt-out of certain communications.
• To exercise your rights, please contact our Privacy Officer as indicated below.

3. Privacy and Security Safeguards

• We maintain administrative, technical, and physical safeguards to protect the privacy and security of your health information.
• Our staff is trained on privacy policies and procedures, and we have implemented measures to prevent unauthorized access, use, or disclosure of your information.

4. Notice of Breach

• In the event of a breach of your unsecured health information, we will provide you with notification as required by law.

5. Complaints

• If you believe your privacy rights have been violated, you have the right to file a complaint with our Privacy Officer or with the appropriate regulatory authorities.
• We will not retaliate against you for filing a complaint.

6. Changes to This Notice

• We reserve the right to change our privacy practices and update this Notice of Privacy Practices accordingly.
• Updated notices will be available on our website, and we will provide a revised copy upon request.

7. Contact Information

By signing below, you acknowledge that you have received and read our Notice of Privacy Practices and understand your rights and our practices regarding your health information.

Please retain a copy of this signed Notice of Privacy Practices for your records. If you have any questions or concerns about our privacy practices, please contact our Privacy Officer using the provided contact information.

 

Atlanta Telehealth is committed to protecting your privacy and maintaining the confidentiality of your health information in accordance with applicable laws and regulations.

Telehealth involves the use of secure videoconferencing or other electronic means to provide mental health services remotely. This Informed Consent for Telehealth outlines the benefits, limitations, and potential risks associated with receiving mental health services through telehealth. Please read this document carefully and indicate your understanding and agreement by signing below.

1. Definition of Telehealth

Telehealth refers to the delivery of mental health services using interactive audio, video, or other electronic communications technologies between you and your mental health professional, without being physically present in the same location.

2. Benefits of Telehealth

• Telehealth allows for convenient access to mental health services, particularly in situations where in-person visits may be challenging or not feasible.
• It reduces travel time, eliminates geographical barriers, and provides flexibility in scheduling appointments.

3. Limitations and Risks

• You understand that there are potential risks and limitations associated with telehealth services, including technical issues, interruptions, and the potential for unauthorized access or interception of your health information.
• Although reasonable security measures are in place, there is a slight risk of technology failures or breaches compromising the confidentiality of your information.
• You acknowledge that telehealth services may not be suitable for all mental health concerns, and your therapist will determine the appropriateness of telehealth for your specific needs.

4. Confidentiality and Privacy

• Your mental health professional will make every effort to ensure the privacy and confidentiality of your telehealth sessions.
• You are responsible for ensuring that you are in a private and secure location during telehealth sessions to maintain the confidentiality of your discussions.

5. Technological Requirements

• You are responsible for ensuring that you have access to the necessary technology and a stable internet connection to participate in telehealth sessions.
• You understand that you may need to download and install specific software or applications to facilitate telehealth sessions, and you agree to comply with any instructions provided by your mental health professional.

6. Emergency Situations

• Telehealth sessions may not be appropriate for emergencies or crisis situations.
• You understand that it is your responsibility to seek immediate assistance in case of an emergency or when your mental health is at risk.

7. Termination or Modification of Telehealth Services

• Either you or your mental health professional may decide to terminate or modify telehealth services at any time.
• Alternative options for in-person sessions may be discussed if deemed necessary or appropriate.

8. Billing and Insurance

• You understand that telehealth services may be subject to the same billing and insurance processes as in-person services.
• It is your responsibility to verify coverage and reimbursement with your insurance provider.

By signing below, you acknowledge that you have read and understood this Informed Consent for Telehealth and voluntarily consent to receive mental health services through telehealth as deemed appropriate by your mental health professional.

Please retain a copy of this signed Informed Consent for Telehealth for your records. If you have any questions or concerns regarding telehealth services, please discuss them with your mental health professional before proceeding.

1. Purpose of Telephone Therapy: I understand that the purpose of telephone therapy is to receive professional counseling and mental health services remotely, which may include individual or group therapy, psychotherapy, consultation, or any other mental health-related services deemed appropriate.

2. Confidentiality: I acknowledge that all the standard confidentiality and privacy protections that apply to in-person therapy sessions also apply to telephone therapy. [Provider’s Full Legal Name] will make every effort to ensure the privacy and confidentiality of our telephone sessions.

3. Technological Considerations: I understand that participating in telephone therapy requires a reliable and secure telephone or telecommunications system. I am responsible for ensuring that I have access to a private and secure space for our telephone sessions, free from potential interruptions or privacy breaches.

4. Risks and Limitations: I acknowledge that telephone therapy may have some limitations compared to in-person therapy, such as potential difficulties in non-verbal communication and challenges in ensuring complete privacy or compared to a HIPAA-compliant video call. I understand and accept these limitations and agree to participate in telephone therapy with full awareness of these considerations.

5. Emergency Situations: I understand that in the event of a crisis or an emergency, I am responsible for contacting the appropriate emergency services or crisis resources. I understand that telephone therapy is not a suitable option for crisis intervention.

6. Cancellation and Rescheduling: I agree to adhere to Atlanta Telehealth, LLC cancellation and rescheduling policy for telephone therapy sessions, which may include providing a minimum notice period for changes to appointments.

7. Termination and Discontinuation: I acknowledge that either party may choose to terminate or discontinue telephone therapy sessions at any time. Atlanta Telehealth, LLC reserves the right to terminate therapy if they believe it is in the best interest of the client, or if the client is non-compliant with therapy policies.

9. Agreement to Participate: By signing this waiver, I affirm that I have read, understood, and agree to comply with the terms and conditions outlined in this waiver for telephone therapy sessions.

Nature of Communication:
I understand that the text messages may include, but are not limited to:

• Appointment reminders
• General health information
• Administrative messages

Scope of Consent:
This consent covers text messages sent by members of Atlanta Telehealth to the provided phone number. I acknowledge that standard text messaging rates may apply according to my mobile carrier plan.

Frequency and Timing:
I understand that text messages may be sent periodically, and the timing of these messages may vary based on the nature of the communication. Atlanta Telehealth will make reasonable efforts to minimize any inconvenience.

Privacy and Security:
Atlanta Telehealth is committed to protecting the privacy and security of my personal information. I understand that text messages may contain sensitive healthcare information, and I consent to receive such messages with this understanding.

1. Notice of Privacy Practices: I have received and read the Notice of Privacy Practices, which explains how my health information will be used, disclosed, and protected by Atlanta Telehealth.

2. Consent to Treat Policy: I have received and read the Consent to Treat Policy, which outlines the expectations, rights, and responsibilities associated with receiving services at Atlanta Telehealth..

3. Treatment Agreement: I have received and read the Treatment Agreement, which outlines the purpose of treatment, therapist qualifications, session duration and frequency, confidentiality, fees and payment, and other important aspects of our therapeutic relationship.

4. Emergency Contact Form: I have received and provided the necessary information on the Emergency Contact Form, which includes emergency contact details and primary physician information.

5. Consent for Evaluation or Assessment Policy: I have received and read the Consent for Evaluation or Assessment Policy, which explains the purpose, procedures, and potential outcomes of evaluations or assessments that may be conducted as part of my treatment.

I confirm that I have had the opportunity to ask questions, seek clarification, and discuss any concerns regarding the above documents. I understand the content and implications of the information provided in these documents, and I voluntarily agree to comply with the policies, procedures, and terms outlined therein.

Please retain a copy of this signed Acknowledgment of Receipt for your records. If you have any further questions or require additional information, please do not hesitate to reach out to the appropriate staff member at Atlanta Telehealth.