Informed Consent for Assessment and Treatment

Psychiatric treatment involves diagnosing, treating, and managing mental health conditions. It often includes medication management, therapy, and regular consultations with your provider. The goal of treatment is to help improve your mental health and well-being.

It is important to establish trust between the patient and provider to achieve optimal outcomes. This form outlines the scope, limitations, and expectations of treatment, as well as your rights and responsibilities throughout the process.

If you have any questions, please feel free to ask, and we will be happy to provide clarification.

Your provider is a Licensed Psychiatric Mental Health Nurse Practitioner (PMHNP). Specializing in diagnosing and treating mental health disorders, your provider is experienced in medication management and psychotherapy for conditions such as depression, anxiety, bipolar disorder, and more. With extensive experience, your provider is committed to providing evidence-based care tailored to your mental health needs.

Sessions are scheduled by appointment, Monday through Friday from 9:00 AM to 5:00 PM. If you need to cancel or reschedule your appointment, please notify us at least 24 hours in advance. Your provider also reserves the right to reschedule appointments when necessary.

Psychiatric treatment involves open communication about your thoughts, emotions, and behaviors. This may include prescribing medications, conducting psychotherapy, and creating a treatment plan tailored to your needs.

During treatment, you may experience discomfort, including side effects from medications or emotional distress as sensitive topics are discussed. It is normal for symptoms to fluctuate during the course of treatment. Please communicate any concerns with your provider so adjustments can be made.

Medications may be prescribed as part of your treatment plan. Your provider will explain the benefits, risks, and potential side effects of any prescribed medications. It is important to follow your medication regimen as prescribed and report any side effects or concerns. Never stop or change your medication dosage without consulting your provider.

HIPAA is a federal law that regulates the use and disclosure of your personal health information (PHI) by healthcare providers. PHI includes your medical records, treatment plans, and any other information related to your health and healthcare services.

Your PHI will remain confidential and cannot be shared without your written consent, except in specific circumstances outlined in this form. For more details about HIPAA, you can visit HIPAA Website

Your privacy is a top priority, and all information shared during treatment is confidential. However, there are certain situations where confidentiality may be broken:

• If your provider believes there is a risk of harm to yourself or others.
• If there is suspicion of abuse or neglect of a child, elder, or vulnerable adult.
• If you disclose involvement in criminal activity or sexual abuse.
• If a court order mandates the release of your medical records.
• Your provider will make every effort to discuss any need to break confidentiality with you before taking action when possible.

As a patient, you have the right to:

• Be informed about your diagnosis and treatment options.
• Ask questions and receive clear explanations.
• Consent to or refuse any treatment plan or medication.
• Receive confidential care in compliance with HIPAA regulations.

As a patient, you are responsible for:

• Being open and honest with your provider about your health, history, and any current concerns.
• Following the treatment plan and medication regimen prescribed by your provider.
• Notifying your provider of any changes in your condition, including side effects or adverse reactions to medications.
• Attending scheduled appointments and notifying the office of cancellations in a timely manner.

• I have read and understood the terms and information provided in this Informed Consent to Treatment Form regarding psychiatric treatment. Ample opportunity has been offered for me to ask questions and seek clarification of anything unclear. All of my questions have been answered to my satisfaction.
• I understand my rights and responsibilities as a patient, including the right to ask questions throughout the course of treatment and request an outside consultation if necessary. My provider may offer additional information about specific treatment issues or methods as needed, and I have the right to consent to or refuse such treatment.
• I understand the information about HIPAA and the confidentiality agreement outlined in this form.
• I further understand that I may stop treatment at any time but will discuss this decision first with my provider.
• I am aware that I must authorize my provider, in writing, to release information about my treatment, though confidentiality may be broken under certain circumstances, such as danger to myself or others. Once information is released to insurance companies or third parties, my provider cannot guarantee its confidentiality.
• I give my informed consent to participate in psychiatric treatment with my provider and voluntarily request and consent to behavioral health assessment, care, and treatment as necessary and advisable.
• I understand that psychiatric treatment is not an exact science, and no guarantees or promises have been made about the results of this treatment or any procedures.
• I agree to use electronic records and signatures and acknowledge that I have read the related consumer disclosure.
• Electronic Signatures: The parties acknowledge and agree that this informed consent form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature.
• I voluntarily sign this Informed Consent to Treatment Form, confirming that I have full legal authority and accept the risks, conditions, and terms outlined in this document.