Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

May we call you at work?Yes No May we leave a message?YesNo

In Case of Emergency: other than Parent/Guardian

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

In signing this document, I am stating that I have read and agree to the following conditions regarding services rendered by Evolve Yourself LLC I consent to and authorize treatment through Evolve Yourself Behavioral Health 1. I authorize the collection of necessary administrative dates regarding me. I understand that such data shall be computerized for statistical, programming, and billing purposes. 2. I understand information regarding me shall be collect responsibility and maintained in a confidential clinical record. Any such records or information shall remain confidential except in the following incidents: a) Information required by third-party payers and parties giving EVOLVE YOURSELF authorization to provide said services shall be forwarded to them. b) Records shall be open to Evolve Yourself LLC staff as needed and to appropriate state mental health officials. c) Information may be exchanged if I sign a written release form indicating the nature of information to be released. d) Information, which indicates a severe threat to the life or safety or another person or to self, shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety. e) Information will be released if required under a court subpoena. f) Suspected abuse or neglect shall be reported to Protective Services as mandated by the Code of Texas and Federal Law. g) State and Federal law prohibit the disclosure of any information identifying a Recipient as receiving alcohol/drug services unless the Recipient consents in writing, the disclosure is allowed by court order, or disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations. h) Federal Law does not protect any information about a crime committed by a Recipient either at the program or against any person who works for the program or about any threat to commit such a crime. 3. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, or level of disability. 4. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf. 5. Evolve Yourself LLC staff may share information with my consent with other associated facilities such as group homes, Dept. of Social Services, Court Services, and Area Programs if a Recipient is seen in two or more of these agencies. 6. I agree to satisfy my financial obligation with Evolve Yourself Behavioral Health. I understand payment is due at the time services are rendered unless payment arrangements are made. 7. You have the right to accept or refuse any medication, procedure, test, or treatment. Exception to this right is when there is an emergency, court order or if the recipient is under 18 years old and his/her parent or guardian has given permission. I understand the following services:

Medication Training and Support; Skill Development & Training;Intensive Case Mgmt Individual/Family Intervention Counseling Group Other:

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Evolve Yourself LLC's policy is to protect the rights of each client. During the intake process, the client's rights are reviewed in a manner that is understandable. The Corporate Compliance Officer responds to questions and grievances pertaining to the client's rights and ensures compliance with Texas administrative code. Rule $404.154. The client's rights and responsibilities are reviewed annually as listed below.

1. To be informed of the client's rights and responsibilities at the time of admission or within 24 hours of admission; 2. To have a family member, chosen representative and/or his or her own physician notified of admission to the BHS provider at the request of the client; 3. To receive treatment and medical services without discrimination based on race, age, religion, national origin, gender, sexual orientation, or disability; 4. To maintain the personal dignity of each client; 5. To be free from abuse, neglect, exploitation and harassment; 6. To receive care in a safe setting; 7. To receive the services of a translator or interpreter, if applicable, to facilitate communication between the client and the staff 8. To be informed of the client's own health status and to participate in the development, implementation and updating of the client's treatment plan; 9. To make informed decisions regarding the client's care by the client or the client's parent or guardian, if applicable, in accordance with federal and state laws and regulations; 10. To participate or refuse to participate in experimental research when the client gives informed, written consent to such participation, or when a client's parent or legal guardian provides such consent, when applicable, in accordance with federal and state laws and regulations; 11. To be informed, in writing, of the policies and procedures for filing a grievance and their review and resolution; 12. To submit complaints or grievances without fear of reprisal; 13. To have the client's information and medical records, including all computerized medical information, kept confidential in accordance with federal and state statutes and rules/regulations; 14. To be given a copy of the program's rules and regulations upon admission; 15. To receive treatment in the least restrictive environment that meets the client's needs; 16. To not be restrained or secluded in violation of federal and state laws, rules and regulations; 17. To be informed in advance of all estimated charges and any limitations on the length of services at the time of admission or within 72 hours (There are no out-of-pocket fees associated with services provided to Medicaid recipient's) 18. To receive an explanation of treatment or rights while in treatment;

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

a. nature and purpose of any services rendered; b. the title of personnel providing that service; C. the risks, benefits, and side effects of all proposed treatment and medications; d. the probable health and mental health consequences of refusing treatment; and e. other available treatments which may be appropriate;

20. To accept or refuse all or part of treatment, unless prohibited by court order or a physician deems the client to be a danger to self or others or gravely disabled; 21. To have a copy of these rights, which includes the information to contact Evolve Yourself

EVOLVE YOURSELF, LLC 1980 Bissonnet, STE

To make your mental health treatment successful, we need to work together. The agency asks that all clients provide clear, complete, and truthful information always. We do our part by providing you with information concerning your rights and the services we offer. Your part is to take responsibility for the following:

1. Follow agency rules, policies, and procedures. 2. Follow the steps described in this handbook if you wish to file a grievance or appeal with our agency. 3. Keep scheduled appointments and call to cancel or reschedule if you cannot make your scheduled appointment. 4. Ask questions when you do not understand or when you want more information. 5. Provide any information to your worker that is necessary for your treatment. 6. Participate actively to create goals that will help you in your recovery. 7. Follow the treatment plans that you and your providers have agreed upon. 8. Take medications as they are prescribed for you. 9. Tell your doctor if you are having unpleasant side effects from your medications, or if your medications do not seem to be working to help you feel better. 10. Seek out additional support services in the community. 11. Invite the people (family, friends, etc who will be helpful and supportive to you to be included in your treatment. 12. Understand your rights and the grievance process. 13. Treat staff, as you would expect to be treated.

NOTIFICATION OF RECEIPT OF RECIPIENT RIGHTS

I understand its contents regarding the recipient's rights and responsibilities. I have received a copy of the confidentiality notice, Recipient Handbook (which includes a summary of my rights), and Program Rules. I have also been explained the services, including the benefits and risks, the program rules, and the grievance procedure. I also understand that I may withdraw from Evolve Yourself LLC any time I feel

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

treatment/services are not beneficial to me. Staff has answered my questions regarding Recipient rights. I also understand that specific programs may have additional policies and procedures pertaining to Recipient rights and that those will be explained to me upon entry into the program.

I have received the following information:

1. Protections regarding disclosure of confidentiality; 2. Procedure for obtaining a copy of my treatment plan; 3. Policies addressing fee assessment and collection practices for my treatment rehabilitation; 4. Grievance policy/procedure; 5. Suspension and expulsion policy notification 6. Search and seizure policy notification;

Evolve Yourself LLC will implement the use of the least restrictive intervention and the most appropriate setting and methods as a last resort. Evolve Yourself LLC prohibits the contingent use of painful body contact, or substances administered to induce painful bodily reactions

I acknowledge that I have been provided a copy of the Notice of Privacy Practices for Evolve Yourself Behavioral Health. I understand that the Notice of Privacy Practices discusses how my personal health care information may be used and/or disclosed, my rights with respect to health care information, and how and where I may file a privacy-related complaint.

I may review a copy of the Notice from Evolve Yourself LLC office. I may obtain a copy of this from Evolve Yourself LLC.

I understand that the terms of this Notice may be changed in the future, and these changes will be posted in the Evolve Yourself LLC office. I may also request a copy of the new Notice by contacting the Privacy Officer.

If you are dissatisfied with the services being provided by Evolve Yourself LLC or if you wish to file a grievance against perceived unfair treatment, the follow procedures can be followed:

Begin by explaining your concern, complaint, or grievance to the Professional providing the service. The treating professional will attempt to resolve the problem by scheduling a meeting to come to a joint decision. If the contact with the professional does not resolve the problem, put your concern/grievance in writing and ask for it to be reviewed in the Client Rights Committee for resolution. This can be done so by completing a grievance form. Please feel free to ask a Evolve Yourself staff for the form. An appeal process will take place and a representative of the company will get back with you. If the management and client rights committee is unable to resolve the issue to your satisfaction, you can seek legal advice as necessary at you own expense. You can also contact the Office of Consumer Services and Rights Protection at 1800- 252-8154

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

I have been informed that Evolve Yourself LLC has a crisis response line (877-997-2625) available 24 hours a day/7 days a week, 365 days a year for the Recipient to use in crisis situations. A designated on-call qualified professional will be responsible for responding to all crisis calls during and after regular business hours. The on-call qualified professional will be responsible for the implementation of the Crisis Plan via phone and face-to-face within two hours. The on-call qualified professional will have access to the crisis plan for everyone.

RIGHT OF DETERMINATION APPEAL PROCESS

EVOLVE YOURSELF will not deny, interrupt, suspend, reduce, or terminate your services without a good cause. If you are a Medicaid recipient (or eligible to be one) and a decision has been made to deny, reduce, suspend, or terminate services being received, then you have the right to appeal the decision. A notification of the decision will be sent by your MCO. If you need clarification on any issues, please contact Evolve Yourself LLC immediately. We will assist you with the appeal process follow-up. Recipients may be expelled or suspended from services when the agency can no longer meet the recipient's needs or guarantee their safety. Evolve Yourself LLC shall notify recipients once a specific time is determined to restore services. Evolve Yourself LLC shall make efforts to recommend appropriate services that will meet the recipient's needs and discharge plan, if any.

ABUSE / NEGLECT PROTOCOL / PROCEDURE

It is your right to be free of harm, abuse, neglect, and exploitation. Evolve Yourself LLC prohibits any abuse or neglectful conduct on the part of any individual employed or contracted by the agency or serving in a consultative capacity.

If for any reason, you have questions, concerns or complaints that involve any kind of abuse, sexual, physical etc. you should call the Texas Department of Family and Protective Service at 1-800- 252- 5400

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Acknowledgment Form At the time of admission, all individuals receiving services from Evolve Yourself, LLC. will receive a packet of information containing the following documentation: Members' Rights and Responsibilities: I have received the client rights information and other handouts relevant to the services I am requesting, outlining my responsibilities. I understand that it is my right to ask questions if I need clarification or have concerns. Confidentiality/Privacy Notice (HIPAA): I have received a copy of the Evolve Yourself, LLC. Privacy Notice. If I have a complaint concerning the privacy of my health care information I can contact the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights toll-free at 1- 877-696-6775. Acknowledgment of Abuse/Neglect Reporting Requirement: All health and human service professionals are required by state law to report suspected abuse or neglect of certain populations (e.g. children, elderly or adults with disabilities) to the appropriate authorities. If you have any questions about this, please feel free to ask for a better understanding before you sign. Your signature below acknowledges receipt of this

Corporate Compliance with Grievance Procedures: It is the policy of Evolve Yourself, LLC. to provide services that fully comply with all federal, state, and local regulations and applicable laws, and to adhere to explicit ethical standards throughout all facets of the organization's operations. Evolve Yourself, LLC. will ensure these conditions of operation are met through an organized and ongoing comprehensive corporate compliance program.

Orientation Policy/ Client Handbook: Orientation into the Mental Health Program includes both verbal and written information to the client. A tour of the facility is also conducted to acquaint clients and their families with the different health and safety equipment, as well as to provide information as

to areas that are "off limits" to visitors. Handbook Received

By signing below, I am indicating that I have received and reviewed the above documentation and had the opportunity to have any questions answered.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Assignment of Benefits and Release of Medical Information for Billing Purposes Assignment of Benefits

I understand that in order for anyone to directly bill Medicaid or other insurance carriers for my outpatient medical care or to provide billing information to a collection agency if necessary, I must give permission.

I hereby assign, transfer, and set over unto Evolve Yourself (EY) , as its interests may appear, all medical benefits now due or becoming due to me under the terms of any third party insurance coverage that I am currently entitled to or that I become entitled to in the future under the terms of the described policy. I hereby direct any third party insurance entity whose benefits are now due or become due to me, including Medicare, Medicaid, or commercial insurance companies, to pay such benefits directly to the above named agency for services provided by that agency.

If I am hospitalized by Evolve Yourself (EY) staff for a mental illness and/or an addictive disorder, I may receive a bill from the hospital. Evolve Yourself (EY)is not responsible for the payment of this bill.

Release of Medical Information

I understand that the information contained in my medical record is confidential. However, I specifically give consent for the Evolve Yourself (EY) to release necessary medical information to Medicare (Health Care Financing Administration and its agents), Medicaid (Bureau of Health Services Financing) or other insurance carriers on my behalf.

Medical Information is to be disclosed for the purpose of monetary reimbursement only. This consent is subject to written revocation at any time except to the extent that action has already been taken upon this consent. I understand that some of my billing information, which may include my date of birth, address, telephone number and Social Security Number, may be given to a collection agency if I fail to uphold my agreement with EY to pay fees for services that I receive at Evolve Yourself, LLC.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Email/Text Messaging Consent Form

In order to communicate with you by email, we need to be sure you are aware of the privacy issues that could arise when we communicate this way, and to document that are aware of these issues and agree to them. If you want to communicate with your care provider through email or text messaging, please read and sign the form

Potential Risks of Using Text Messaging: Evolve Yourself (EY) may offer clients the ability to stay in touch via text messaging if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Text messaging has a number of risks one should consider before making a final decision about its use. These include, but are not limited to, the following: 1. Text messages may not be received 2. Text messages can be circulated, forwarded or stored I electronic files 3. Text messages can be immediately sent worldwide and received by many intended and unintended recipients 4. Senders can easily misaddress a text message 5. Text messaging is easier to falsify than handwritten or signed forms 6. Backup copies may exist even after sender and/or recipient has deleted their copies 7. Text messages can be intercepted, altered, forwarded or used without one's knowledge or permission 8. Text messages can be used as evidence in court 9. Text messages can be lost in transmission Potential Risks of Using Email: Evolve Yourself (EY) may offer clients the ability to stay in touch via email if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Emailing had a number of risks that consumers should consider before using email. These include, but are not limited to, the following: 10. Email messages may not be received. 11. Email can be circulated, forwarded and stored in numerous paper and electronic files, in intended 12. Senders can easily misaddress an email message 13. Email messages can immediately broadcast worldwide and received by many intended and unintended recipients 14. Email can be easier to falsify than handwritten or signed documents 15. Back-up copies of email may exist even after the sender or the recipient has deleted his or her

copy 16. Email can be used as evidence in court

17. Email can be intercepted, altered, forwarded or used without authorization or detection 18. Email messages can be lost in transmission

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Conditions for the Use of Text Messaging and/or Email: EY will use reasonable methods to protect the security and confidentiality of email information sent and received. However, because of the risk listed above, EY cannot guarantee the security and confidentiality of text or email communication, and is not responsible for improper disclosure of confidential information that is not caused by EY's intentional misconduct. Consent to the use of texting or email includes agreement with that following terms: a) Email and/or text message correspondence must be specifically requested and initiated by the 1. consumer or the minor consumer's parent/guardian. b) Your care provider shall not email or text any Protected Health Information unless you specifically request him/her to do so. c) Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted. d) Emails and/or text messages containing clinical content will become a part of your medical record. e) Although SSS staff will never endeavor to read and respond promptly to an email or text message, SSS cannot guarantee that any particular text or email will be read and responded to within any particular period. Thus, you should not use text messaging or email for medical emergencies or other time-sensitive matters. f) You are responsible for informing the provider of any information that you do not want to send by text message and/or email. g) Your email/text will not be forwarded to a third party without your expressed permission, (or as required by law) unless you have already signed a release for SSS to communicate with a third party. h) You may withdraw consent to communicate by text or email via written communication to the provider at any time. If a life-threatening crisis should occur, you should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room immediately. i) You are responsible for protecting your password and access to your phone and/or email account and any text or email you send or receive from SSS to ensure your confidentiality. Your care provider cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.

Consumer Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand the risks associated with email and/or text communication and consent to the conditions herein. Any questions I may have had were

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Please provide us with your updated emergency contact information and the contact information of your evacuation destination.

Do you have somewhere to evacuate?Yes Do you plan to evacuate?YesNo

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

I, Parent/Legally responsible person, do give Evolve Yourself LLC Services staff the permission to visit my child at school to provide mental health rehabilitation services to my child.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Member's Freedom of Choice Form

By signing below, I acknowledge that I freely choose to receive services from the above provider, and I acknowledge my responsibility to notify my previous provider to coordinate care.

This provider assumes responsibility of coordinating care with the prior provider record.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Consent to Release or Obtain Information

P: 877-997-2620 F: 504-910-1020

EMAIL:info@evolveyourself.co 9894 Bissonnet St, Ste 242 Houston, TX 77036

to obtain healthcare information or release healthcare information of the recipient named above from/to: (Primary Care Dr Information)

Social History Laboratory Results Doctor's Progress Notes

Psychological Evaluation Medical History, Examination, Reports Quarterly Summary Pharmacy Notes

This consent is subject to written revocation at any time except to the extent that action has already been taken in reliance upon this consent. This authorization shall expire on (date or event I understand that if I do not specify an expiration date/event, this authorization shall expire one year from the date of consent. I understand that the treatment/services are not contingent upon my signing or not signing this authorization. I freely and voluntarily give my authorization for the release of information for my health records.

TO PARTIES RECEIVING THIS INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit you from making further disclosures of it without specific written consent of the person to whom it pertains. A general authorization for the release of health or other information is not sufficient for this purpose.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Consent to Release or Obtain Information

P: 877-997-2620 F: 504-910-1020

EMAIL:info@evolveyourself.co 9894 Bissonnet St, Ste 242 Houston, TX 77036

to obtain healthcare information or release healthcare information of the recipient named above from/to: (Emergency Contact)

Social History Laboratory Results Doctor's Progress Notes

Psychological Evaluation Medical History, Examination, Reports Quarterly Summary Pharmacy Notes

This consent is subject to written revocation at any time except to the extent that action has already been taken in reliance upon this consent. This authorization shall expire on (date or event I understand that if I do not specify an expiration date/event, this authorization shall expire one year from the date of consent. I understand that the treatment/services are not contingent upon my signing or not signing this authorization. I freely and voluntarily give my authorization for the release of information for my health records.

TO PARTIES RECEIVING THIS INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit you from making further disclosures of it without spe cific written consent of the person to whom it pertains. A general authorization for the release of health or other information is not sufficient for this purpose.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Consent to Release or Obtain Information

P: 877-997-2620 F: 504-910-1020

EMAIL:info@evolveyourself.co 9894 Bissonnet St, Ste 242 Houston, TX 77036

to obtain healthcare information

or release healthcare information of the recipient named above from/to: (School Information)

All Healthcare information relating to the following treatment, condition, or dates:

This consent is subject to written revocation at any time except to the extent that action has already been taken in reliance upon this consent. This authorization shall expire on (date or event I understand that if I do not specify an expiration date/event, this authorization shall expire one year from the date of consent. I understand that the treatment/services are not contingent upon my signing or not signing this authorization. I freely and voluntarily give my authorization for the release of information for my health records.

TO PARTIES RECEIVING THIS INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit you from making further disclosures of it without spe cific written consent of the person to whom it pertains. A general authorization for the release of health or other information is not sufficient for this purpose.

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

CONSENT & ACKNOWLEDGMENT REGARDING COURT TESTIMONY

(Client Name), acknowledge and

understand that Evolve Yourself does not provide court testimony in any civil or criminal cases. This includes but is not limited to depositions, in-person testimony, or expert witness services.

While Evolve Yourself does not testify in court, the agency may provide a written letter or affidavit summarizing services provided, treatment progress, or other relevant information upon request. Such documentation will be prepared for a fee, which will be disclosed prior to preparation. The preparation of such a document does not guarantee that it will meet specific legal requirements, and the client is responsible for consulting with their attorney regarding its use.

The fee for preparing a letter or affidavit must be paid in advance and is non-refundable. The fee structure will be provided upon request and must be agreed upon before the preparation process begins. Acknowledgment & Agreement: By signing below, I acknowledge that I have read, understand, and agree to the above terms. I understand that Evolve Yourself will not testify in any legal proceedings on my behalf and that any requested written documentation will be provided for a fee.

Authorized Representative of Evolve Yourself :

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Medical/ Behavioral Health Advance Directive agree/ disagree to the consent of this advance directive regarding (my personal or that of my minor child's) medical/ behavioral health care. In the following section(s), please initial in the blank spaces that you have chosen.

 

Part II: Living Will

Section 1: These are my wishes.

 

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

Evolve Yourself Staff Check all that apply

( )The treatment team certifies that it met face-to-face/virtually with the client and/or caregiver or legal guardian to collaboratively identify services.

( )The treatment team certifies that the services outlined in this Treatment Plan are based on an initial and ongoing assessment and further certifies that the services outlined in this Treatment Plan are medically necessary, appropriate and comprehensive in approach, as well as, consistent with the client's ISC Plan, FINS Plan and/or other interagency plan, if any such plan(s) exist.

( ) The treatment team's professional opinion is that the client is ready to engage in the services outlined in this Treatment Plan and it is reasonable to expect a rehabilitative outcome.

() I participated face-to-face/virtually with a member of the Treatment team in identifying my needs and in developing this Treatment Plan which reflects my treatment objectives. ( )I freely choose to receive and participate in the services outlined in this Treatment Plan.

The parent/guardian and clients over the age of 6 must sign the Treatment Plan.

Discharge Planning Reviewed by LMHP Yes / No

Discharge Plan Currently Unchanged

Evolve Yourself, LLC - Mental Health Rehabilitative Services Houston, Beaumont, Forth Worth, TX

I / We hereby consent to engage in teletherapy services with Evolve Yourself using interactive audio and/or video communication. I understand that there will be communication that involves my medical/mental health information, both orally and visually with the health care practitioner(s I understand the following: I have the right to withdraw consent at any time without affecting my right to future care or treatment. I understand that these services are being provided remotely from my therapist(s)/ counselors home(s) and I consent to the services being provided in this manner. I further consent to receive these services remotely, if provided in that manner, from Evolve Yourself LLC physical location at 9894 Bissonnet St, Suite 242, Houston, Texas.

III.I understand I have the right to access my medical information (and have copies) in accordance

with HIPAA privacy rules and applicable laws. I understand that the laws that protect the confidentiality of my medical information also apply to teletherapy. Unless we explicitly agree otherwise our teletherapy exchange is confidential and others will not be in the room except when another family member is an active participant of the session(s I understand there are risks, including, but not limited to, the possibility, despite reasonable effort by the therapist, that the transmission of my information could be interrupted by unauthorized persons, and the transmission of my information could be disrupted or distorted by technical failures. I will be responsible to inform health care provider of any changes in my insurance plan. I understand that I may benefit from teletherapy but results cannot be guaranteed or assured. I understand that if I am experiencing suicidal/homicidal thoughts or making plans to harm myself, I may also call the National Suicide Prevention Lifeline at 1-800-273-TALK I understand that I am responsible for providing the computer or necessary telecommunication device with internet access for my teletherapy sessions. I agree to arrange a location with sufficient lighting and privacy that is free from