This purpose of this consent form is to obtain your permission to perform the evaluation necessary to identify any condition(s) that might require treatment as part of your plan of care. This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment.

*I voluntarily request a provider, or the designees as deemed necessary, to perform reasonable and necessary medical/mental health examination, testing and treatment for the condition which has brought me to seek care at this practice or one that has been identified.

You have the right to be informed about any condition identified and any/all recommended treatments. You may then decide whether or not to undergo any suggested treatment after being informed of the potential risks, benefits, and alternatives involved.

I agree to healthcare communication via phone call, patient portal, and/or secure text messages through the Spruce App. I understand I may opt out of text and or email messaging.

I agree to allow my provider to access my prescription history when appropriate.

I agree to allow my provider to record our sessions via a secure device or a HIPAA compliant, secure documentation platform. Recordings will be stored securely for no more than 90 days. 

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. I understand I am responsible for additional fees that may occur. By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. The consent will remain fully effective until it is revoked in writing.

Also, by signing below you attest that you have been informed of confidentiality and exceptions. That we do not offer any emergency services, and to go to the ER or call 911 should you develop suicidal intent, plan, or dangerous impulsivity.

You are committed to providing your current location at the outset of each video session, both to verify that you, the client is located in a state in which this provider is licensed, as well as for use in case of emergency. You attest that you have been informed of the risks and benefits of using video technology and agree to conduct sessions by video when appropriate. You have been informed that for safety reasons, no session will occur in a vehicle while it is moving.

You have been informed of the payment policies including, but not limited to, your financial responsibility for any session that is not paid for by their health insurance company, as well as standard charges for no shows and late cancellations.

You are aware that you are required to attend at least one in-person appointment per calendar year. If you are taking a controlled substance routinely, you are required to attend at least on in-person appointment every 3 months. Failure to meet these requirements may result in dismissal from the practice. 

You are aware of Marsh Island Psychiatry's no show policy which states that if you have 3 last minute cancellations (within 48 hours) or no show appointments, Marsh Island Psychiatry reserves the right to dismiss you from the practice. In the event that you are dismissed from the practice, you will be provided with a 30 day prescription of your medications. This will not be refilled for any reason. If your medication regimen includes a controlled substance, you will be provided with a taper schedule and enough medication to complete the taper.

You confirm that you understand the above policies and procedures and agree to them. If signing as a parent or guardian, I hereby represent that I am legally empowered to make such decisions.