EMERGENCY AND CRISIS NOTICE
Urban Healthy Minds is an outpatient practice and does not provide 24-hour emergency or crisis services. Do not use email, text messages, voicemail, or TherapyPortal for an emergency. If I or another person may be in immediate danger, I will call 911 or go to the nearest emergency department. For mental health or substance-use crisis support, I may call or text 988.

1. PURPOSE OF THIS CONSENT AND DEFINITIONS
This Consent explains the services Urban Healthy Minds may provide, the possible benefits and risks of participating, the limits of confidentiality, the use of electronic records and technology, financial responsibilities, and my rights and responsibilities. It also records my choices regarding psychiatric and medication-management services, telehealth, TherapyFuel artificial intelligence features, identification photographs, transportation, and communication methods.

IN THIS CONSENT: 

Client or I means the person receiving services. Legal Representative means a parent, legal guardian, personal representative, or other person who has legal authority to consent for the Client. Provider means an Urban Healthy Minds professional or supervised trainee who provides services within that person's education, training, credentials, supervision, and authorized scope of practice. Providers may include therapists, counselors, social workers, psychologists, physicians, Advanced Practice Registered Nurses or nurse practitioners, including APRN, CNP, PMHNP, PMHNP-BC, or CRNP credentials as applicable, interns, trainees, qualified behavioral health professionals, and other authorized clinical or support staff. Prescriber means a Provider who is legally authorized to evaluate, diagnose, prescribe, and manage medications, such as a physician or an appropriately licensed and authorized APRN or nurse practitioner.

By signing this Consent, I request and consent to the services I accept from Urban Healthy Minds. Signing does not require me to accept every optional service listed in this form. My selections in Section 16 control whether Urban Healthy Minds may provide or use the optional services identified there.

2. SERVICES, TREATMENT PROCESS, AND VOLUNTARY PARTICIPATION

Depending on my needs, eligibility, treatment or service plan, and the qualifications of the Provider, services may include:

Intake, screening, behavioral health assessment, diagnosis, and treatment planning; Individual, family, couples, or group psychotherapy or counseling;
Basic Skills Training (BST), Psychosocial Rehabilitation (PSR), case management, care coordination, rehabilitation, and community-based behavioral health support;
Crisis and safety planning within the limits of an outpatient practice; Psychiatric evaluation, diagnosis, medication evaluation, prescribing, medication management, and monitoring by an authorized Prescriber; Referrals and coordination with hospitals, primary-care professionals, pharmacies, laboratories, schools, agencies, and other involved persons when permitted by law; and In-person or telehealth services. Behavioral health care is collaborative. My Provider and I will discuss my concerns, strengths, goals, recommended services, expected frequency and duration, and reasonable alternatives. We may update my treatment or service plan as my needs and goals change. Participation is voluntary unless services are required by a court or another legal authority. I may ask questions, request changes, decline a recommendation, request another Provider when reasonably available, seek a second opinion, or stop services. If I stop services, I am encouraged to discuss follow-up care, medication safety, referrals, and crisis planning with my Provider. Urban Healthy Minds may recommend another Provider or a higher level of care when it cannot safely or appropriately meet my needs. No Provider or service can guarantee a particular outcome.

3. POSSIBLE BENEFITS, RISKS, AND ALTERNATIVES
Possible benefits may include better understanding of thoughts, emotions, behavior, relationships, and symptoms; improved coping, communication, daily functioning, independence, or safety; progress toward personal or family goals; and stronger support systems. Possible risks include temporary emotional discomfort when discussing difficult experiences; changes in symptoms, relationships, or functioning; disagreement among family members; slower progress than expected; side effects from medications; technology or privacy risks; and the possibility that services will not produce the desired result. My Provider will discuss material risks that are specific to a proposed service, medication, or intervention. Alternatives may include choosing no treatment, using a different therapeutic approach, working with another Provider, participating in peer or community support, receiving services in another setting, obtaining a medication evaluation, using non-medication approaches, or seeking a different level of care.

4. PROVIDER CREDENTIALS, INTERNS, SUPERVISION, AND TEAM CONSULTATION
My Provider will identify the Provider's professional role, credentials, license, registration, certification, intern or trainee status, and the type of services the Provider is authorized to provide. A Provider must not perform services outside the Provider's authorized scope or qualifications. If my Provider is an intern, trainee, associate, or another supervised professional, I will be informed of that status and of the supervisor's identity and credentials. Supervisors may review my records, observe services when separately authorized, and discuss my care with the Provider as permitted by law and professional standards. Supervision is intended to support competent, ethical, and high-quality care. Urban Healthy Minds Providers and authorized staff may consult with one another for treatment, medication coordination, supervision, safety, quality improvement, scheduling, billing, and other lawful health care operations. Information will be shared only as permitted by law and the Urban Healthy Minds Notice of Privacy Practices. Except for TherapyFuel Scribe when I specifically consent in Section 16, this form does not authorize audio recording, video recording, livestreaming, observation by an unauthorized person, or use of a session for teaching or marketing. Any other recording or observation requires a specific explanation and permission before it occurs.

5. CONFIDENTIALITY, PRIVACY, AND LIMITS OF CONFIDENTIALITY
Urban Healthy Minds will protect my health information as required by federal and Nevada law. Confidentiality is important, but it is not absolute. The Urban Healthy Minds Notice of Privacy Practices explains how my information may be used and disclosed and describes my privacy rights.

My information may be used or disclosed without a separate authorization when permitted or required by law, including, as applicable:

For treatment, payment, billing, insurance activities, and lawful health care operations; For consultation, supervision, care coordination, quality review, safety activities, and services performed by vendors or business associates that are subject to privacy and security obligations; To report suspected abuse, neglect, exploitation, isolation, abandonment, or other harm involving a child, older person, or vulnerable person when reporting is legally required; To respond to an emergency, a serious or imminent safety threat, or a communicated threat covered by applicable law; To contact emergency services, an emergency contact, a potential victim, law enforcement, or another person when legally permitted or required for safety; To comply with a valid court order, warrant, subpoena, licensing-board requirement, government audit, payer audit, public-health duty, workers' compensation requirement, or other legal obligation; or In other circumstances specifically permitted or required by law. When a disclosure is made, Urban Healthy Minds will limit the information disclosed as required by applicable law. My Provider can explain the limits of confidentiality and answer questions about a particular situation. When disclosure to an outside person or organization requires my written permission, Urban Healthy Minds will ask me to complete an Authorization for Release of Information that identifies the information, recipient, purpose, expiration, and my right to revoke the authorization. If my Provider maintains separate psychotherapy notes as that term is defined by federal law, those notes receive additional protections and are generally not released without a specific authorization except when disclosure is otherwise permitted or required by law. Special confidentiality rules may apply to substance-use-disorder records, HIV-related information, genetic information, services involving minors, couples or families, group services, and court-involved services. My Provider will explain any special rule that applies to my care.

6. ELECTRONIC HEALTH RECORDS, RECORD RETENTION, PHOTOGRAPHS, AND DE-IDENTIFIED INFORMATION
Urban Healthy Minds maintains clinical and administrative records in TherapyNotes, its electronic health record system. Records may include identifying and contact information, consents, assessments, diagnoses, treatment or service plans, progress and medication notes, prescriptions, laboratory or monitoring information, communications, billing and insurance information, telehealth documentation, photographs used for identification, and other information related to services. Authorized Urban Healthy Minds workforce members and contracted technology or service vendors may process protected health information only as permitted by law, the Notice of Privacy Practices, and applicable agreements. No electronic system can be guaranteed to be completely free from risk, but Urban Healthy Minds will use reasonable administrative, technical, and physical safeguards. Health records will be retained for the longest period required by applicable federal or Nevada law, licensing-board rules, payer requirements, and Urban Healthy Minds policy. Nevada law generally requires health records to be retained for at least five years after receipt or production and restricts destruction of records for a person who has not yet reached age 23. Records may be destroyed after the applicable retention period. My rights to request access, copies, amendments, restrictions, confidential communications, or an accounting of certain disclosures are described in the Notice of Privacy Practices. Separate psychotherapy notes may be excluded from the ordinary right of access as permitted by law. Urban Healthy Minds may request a current photograph solely for identity verification, safety, or accurate record matching. An identification photograph becomes part of the health record, will not be used for advertising or social media, and will not be released except as permitted by law or with appropriate authorization. My photograph choice is recorded in Section 16. Urban Healthy Minds may use information that has been de-identified as permitted by law for quality improvement, program evaluation, operations, training, statistics, or reports. De-identified information will not identify me.

7. PSYCHIATRIC EVALUATION AND MEDICATION MANAGEMENT
If I select psychiatric and medication-management services in Section 16, an authorized Prescriber may provide psychiatric assessment, diagnosis, medication recommendations, prescribing, medication changes, monitoring, and coordination with other members of my care team. A nurse practitioner may use APRN, CNP, PMHNP, PMHNP-BC, CRNP, or other credentials depending on the person's license and certification. Medication treatment is an ongoing informed-consent process. Before starting or materially changing a medication, the Prescriber will discuss, as appropriate, the medication's purpose, expected benefits, material risks and side effects, reasonable alternatives, monitoring needs, and the option to decline. This general Consent is not blanket approval for every medication and does not replace medication-specific discussion.

I agree to provide complete and accurate information about my medical and psychiatric history; medications and supplements; allergies; substance use; pregnancy, plans for pregnancy, or breastfeeding; other Prescribers; pharmacies; and significant changes in symptoms or health. I will not stop, increase, decrease, share, or combine prescribed medication contrary to medical advice. I will promptly report significant side effects, allergic reactions, new symptoms, emergency care, hospitalization, or medications prescribed by another professional.

The Prescriber may recommend or require laboratory testing, vital signs, weight, electrocardiograms, pregnancy testing, medication levels, toxicology or drug screening, review of a prescription-monitoring program, or other monitoring when clinically appropriate or legally required. Failure to complete necessary monitoring may affect whether a medication can be safely prescribed or continued.

Refills are not guaranteed outside business hours, after missed appointments, or without required follow-up and monitoring. I will request refills early enough for clinical review and will follow Urban Healthy Minds policies regarding lost, stolen, early, or controlled-substance prescriptions. Additional controlled-substance safety requirements may apply when clinically or legally necessary.

For a severe allergic reaction, overdose, dangerous side effect, serious withdrawal concern, or other medical emergency, I will call 911, contact Poison Control when appropriate, or go to the nearest emergency department rather than waiting for a portal, voicemail, text, or email response.

8. THERAPYFUEL ARTIFICIAL INTELLIGENCE AND SCRIBE
Some Providers may use TherapyFuel, an artificial intelligence feature integrated with TherapyNotes, only for legally permitted administrative or documentation support. My choices are recorded in Section 16. Only an affirmative consent selection authorizes the corresponding TherapyFuel feature.

A. Non-recording TherapyFuel documentation support
With my consent, a Provider may use information already in TherapyNotes, information entered by the Provider, or a Provider-created summary to organize information or create a draft clinical or administrative document. TherapyFuel is not my Provider. It must not provide professional mental or behavioral health care directly to me, independently diagnose me, determine my treatment, conduct a risk assessment, prescribe medication, or replace professional judgment. The Provider remains responsible for my care and must independently review, correct, complete, and approve any AI-generated information before signing it or relying on it. AI-generated content may be inaccurate, incomplete, biased, misleading, or missing important context.

B. TherapyFuel Scribe audio capture and temporary transcription
TherapyFuel Scribe is an optional feature that may capture session audio after the Provider intentionally activates it, create a temporary transcript, and use the transcript to help draft a progress note. Recording does not begin merely because a session or telehealth visit starts. Scribe will not be used unless I have consented in Section 16, the Provider tells participants before audio capture begins, and all adults or legally authorized representatives whose consent is required have agreed. The Provider will confirm consent at the beginning of each session in which Scribe is used. I may ask the Provider to stop Scribe at any time. If any participant declines or withdraws consent, Scribe will not be used or will be stopped. TherapyNotes currently states that TherapyFuel is covered by its Business Associate Agreement with the practice and that participating vendors are restricted to using data to provide the contracted service rather than to train their tools. For Scribe, TherapyNotes currently states that audio is encrypted in transit, audio is deleted after a successful transcript is confirmed, and the encrypted transcript is deleted when the associated note is signed or after 30 days if the note remains unsigned, whichever occurs first. The final signed note remains part of my health record under the applicable retention policy. Possible benefits include reducing Provider documentation burden, supporting timely notes, and allowing the Provider to focus more attention on the session. Risks include inaccurate or incomplete output; capture of unintended speech, background conversations, names, or sensitive information; technology failure; privacy or security incidents, safeguards; and the temporary existence of an audio-derived transcript. I may withdraw consent to a TherapyFuel feature prospectively by telling my Provider or sending a request through TherapyPortal. Withdrawal will not undo lawful processing that occurred before the Provider received the withdrawal and will not remove an accurate final note that is already part of my health record. Declining TherapyFuel will not prevent me from receiving care; Urban Healthy Minds will use another available documentation method and will make reasonable efforts to honor my choice.

9. TELEHEALTH SERVICES
Telehealth uses electronic communication to provide services when the Client and Provider are in different locations. Telehealth may improve convenience, continuity, and access. Risks include technology failure, interruption, reduced ability to observe some nonverbal or physical information, privacy risks, unauthorized access, and limitations on emergency response.

When I use telehealth, I agree to:

Participate from a reasonably private, safe, and stationary location;
Tell my Provider my physical location at the beginning of each session and immediately report any change; Provide an emergency contact and allow the Provider to use that information when reasonably necessary for safety;
Avoid driving, operating equipment, or participating in another unsafe activity during the session; Use a reasonably secure device and internet connection;
Tell the Provider if another person is present or can hear or see the session; and
Not record, photograph, livestream, or permit another person to observe the session without advance permission from everyone involved. My Provider may determine that telehealth is not clinically appropriate and may recommend in-person care, another Provider, or a higher level of care. A session may be limited, rescheduled, or ended if I am physically located in a jurisdiction where the Provider is not authorized to practice or if privacy, safety, identity, or technology concerns cannot be adequately addressed. If technology fails, the Provider may attempt to reconnect through TherapyNotes, call me at the number on file, continue by another approved method when clinically and legally appropriate, or reschedule. Telehealth is authorized only if I select consent in Section 16.

10. COMMUNICATION OUTSIDE SESSIONS
TherapyPortal secure messaging is the preferred method for communicating health information. Ordinary email and text messages may not be secure and should generally be limited to scheduling, reminders, or other non-sensitive administrative matters. I understand that other people may see messages or notifications on my devices, accounts, or phone bill. Messages are not monitored continuously. Urban Healthy Minds will explain its usual response time and after-hours procedures. The portal, email, text messaging, voicemail, social media, and website forms must not be used for emergencies or urgent safety concerns. Providers do not provide clinical services through social media or public review sites and generally do not accept friend or follow requests from current or former Clients. Urban Healthy Minds will not respond publicly to an online review in a manner that confirms whether a person is or was a Client. My authorized communication methods are recorded in Section 16. I may change my communication preferences by notifying Urban Healthy Minds. Urban Healthy Minds may still use a method reasonably necessary for treatment, payment, operations, legal compliance, or an emergency as permitted by law.

11. FEES, INSURANCE, AND FINANCIAL RESPONSIBILITY
Urban Healthy Minds will provide information about applicable fees, payment methods, insurance billing, missed-appointment or late-cancellation charges, administrative services, and collection practices before or at the beginning of services. I may ask for the current fee schedule at any time.

I understand and agree that:

I am responsible for confirming my benefits, network status, deductibles, copayments, coinsurance, visit limits, authorization requirements, and exclusions with my health plan; An estimate or verification of benefits is not a guarantee of payment; I am responsible for copayments, deductibles, coinsurance, non-covered services, denied claims assigned to me, and other amounts I legally owe; If I use insurance or another payer, Urban Healthy Minds may submit diagnoses, service information, treatment information, records, or other information required for eligibility, authorization, medical-necessity review, payment, audit, appeal, or coordination of benefits; Missed appointments and late cancellations may be charged according to the policy communicated to me, and insurance generally does not pay those charges; Administrative work, letters, reports, extensive record review, consultation outside routine care, legal requests, depositions, testimony, court preparation, travel, and court appearances may involve additional charges communicated in advance when possible; A valid payment method may be required to remain on file, but this Consent does not itself collect or display payment-card information; and Unpaid balances may result in payment arrangements, suspension of non-emergency services when clinically and legally appropriate, referral to another resource, or lawful collection activity. Questions about fees should be raised before services are provided whenever possible.

12. ATTENDANCE, TERMINATION, DISCHARGE, AND REFERRAL
Regular attendance, participation, completion of agreed monitoring, and timely communication generally support continuity and safety. I agree to follow scheduling and cancellation procedures and to keep my contact and insurance information current. I may stop services at any time, subject to a court order or other legal requirement. When possible, I am encouraged to discuss ending services with my Provider so that we can review progress, medication safety, follow-up needs, crisis resources, and referrals. Urban Healthy Minds or my Provider may recommend or initiate discharge, transfer, or referral when services are no longer needed; goals have been met; repeated absence prevents effective care; required monitoring is not completed; fees remain unresolved under practice policy; the Provider is unavailable; the service is outside the Provider's competence or scope; safety requires another level of care; or the treatment relationship is no longer effective. When clinically and legally appropriate, reasonable notice, transition planning, and referral information will be provided.

13. MINORS, LEGAL REPRESENTATIVES, COUPLES, FAMILIES, AND GROUPS
A Legal Representative must provide consent when required. Urban Healthy Minds may request custody orders, guardianship papers, powers of attorney, or other documents showing legal authority. The Legal Representative agrees to notify Urban Healthy Minds promptly of any change in custody, guardianship, decision-making authority, or restrictions on access to information. When clinically appropriate, a minor will be included in decisions and asked to provide assent. The Provider will explain, in a developmentally appropriate manner, what information may be shared with a parent or Legal Representative and when confidentiality must be limited for safety or legal reasons. Rights of access to a minor's records depend on applicable law and the circumstances of the services.

For couples, family, or group services, the Provider will clarify who is considered the Client or Clients, the purpose of the service, how records are maintained, who may access information, and the Provider's policy concerning information shared individually. Urban Healthy Minds cannot guarantee that another family member, partner, or group participant will maintain confidentiality, although participants may be asked to respect it. A person who is present in a session but is not the Client does not automatically obtain rights to the Client's record and may be asked to sign an acknowledgment concerning confidentiality, participation, or Scribe consent.

14. COMMUNITY-BASED SERVICES AND TRANSPORTATION
Some services may occur in the Client's home, school, community, or another approved location. These settings may involve additional privacy, safety, travel, and communication risks. The Provider and Client will discuss reasonable steps to protect privacy and safety. Urban Healthy Minds may sometimes help arrange or provide transportation, such as a bus pass, taxi, rideshare, or Provider vehicle, when authorized by practice policy. Transportation is not guaranteed and is not an emergency service. Third-party transportation companies are independent service providers and may have their own terms, privacy practices, and risks. Seat belts and age-appropriate safety restraints must be used, and unsafe behavior may result in termination of a trip.

This Consent does not waive any right or remedy that cannot lawfully be waived. My transportation choice is recorded in Section 16. A Legal Representative must authorize transportation for a minor or other person who cannot legally consent.

15. CLIENT RIGHTS, LANGUAGE ACCESS, ACCOMMODATIONS, AND COMPLAINTS
I have the right to respectful, culturally responsive, and nondiscriminatory care; understandable information; participation in decisions; reasonable privacy; information about my Provider's credentials and supervision; access to records as allowed by law; and the ability to raise concerns without retaliation.

I may request a qualified interpreter, translated information, disability accommodation, large print, or another communication aid. Urban Healthy Minds will take reasonable steps to provide necessary language assistance and accommodations as required by law. Important translated documents should be reviewed by a qualified translator rather than relying only on machine translation.

I may discuss a concern with my Provider or contact Urban Healthy Minds at (702) 661-7436. I may also contact the licensing board that regulates my Provider, my health plan, the Nevada Division of Public and Behavioral Health when applicable, or the U.S. Department of Health and Human Services Office for Civil Rights. Complaints concerning an APRN, CNP, PMHNP, PMHNP-BC, CRNP, or other licensed nurse may be directed to the Nevada State Board of Nursing. Filing a good-faith complaint will not result in retaliation.

16. MY CONSENT CHOICES
My selections below are part of this Consent. Only an affirmative consent selection authorizes an optional service or technology. A selection of "I do not consent," "not at this time," "not applicable," or no affirmative selection does not authorize that option.

I understand that ordinary text and email may not be secure and that messages may be visible to another person with access to my device or account. I will not use any communication method for an emergency.

This Consent remains in effect while I receive services unless it is replaced, expires under law or policy, or is revoked to the extent revocation is legally and clinically permitted. Revocation does not affect services already provided, lawful actions already taken, required record retention, or information already disclosed in reliance on valid consent or other legal authority.

Telehealth services allow clients to receive behavioral health care through secure video or audio communication platforms. By participating in telehealth, you acknowledge and understand the following:

Risks and Benefits:
Telehealth offers increased access to care, reduced travel time, and greater scheduling flexibility. However, risks include potential data security breaches that could result in unauthorized disclosure of personal health information. Technical difficulties such as poor internet connectivity, audio or video disruptions, or software malfunctions may interrupt or delay the session. Telehealth also has limitations, including the inability to conduct a full physical examination or provide immediate in‑person interventions.

Technology Limitations:
Telehealth relies on technology that may not always function as expected. Limitations may include inadequate internet bandwidth for high‑quality video conferencing, outdated or incompatible software or hardware, and potential cybersecurity threats despite reasonable safeguards. Clients are responsible for ensuring they have access to a private, secure location and reliable technology for sessions.

Emergency Procedures:
Because telehealth sessions occur remotely, additional safety measures are required. Clients agree to provide an up‑to‑date emergency contact who may be reached if a safety concern arises during a session. Instructions on how to access local emergency services will be provided. A plan for transferring care or escalating to in‑person services will be implemented if necessary to ensure client safety.

By signing below, you acknowledge that you understand the risks, benefits, and limitations of telehealth services and voluntarily consent to participate. You may withdraw consent at any time without affecting your right to future care. All telehealth sessions will follow HIPAA privacy and confidentiality standards to the extent possible through electronic communication.

By receiving services at Urban Healthy Minds, you acknowledge and agree to the following financial responsibilities:

Insurance Billing:
Urban Healthy Minds will bill your insurance company using the information you provide. You understand that insurance coverage is not a guarantee of payment and that you are responsible for providing accurate and up‑to‑date insurance information at all times. Any services not covered, denied, or applied to your deductible remain your financial responsibility.

Copays and Deductibles:
You agree to pay all required copays, coinsurance amounts, and deductible balances as determined by your insurance plan. These amounts are due at the time of service or upon notification from Urban Healthy Minds.

No‑Show and Cancellation Policy:
Missed appointments or cancellations made with less than 24 hours’ notice may result in a no‑show or late‑cancellation fee. These fees are not billable to insurance and are the client’s responsibility.

Credit Card on File Policy:
Urban Healthy Minds requires a valid credit or debit card to be kept on file for payment of copays, deductibles, no‑show fees, and any outstanding balances. By signing below, you authorize Urban Healthy Minds to charge your card for any patient‑responsibility amounts owed.

By signing below, you acknowledge that you have read, understand, and agree to the financial policies listed above