CONSENT TO TREATMENT

1. Nature of Treatment

I understand that I am seeking psychiatric mental health services through Bella Dora Health, operated by a Psychiatric Mental Health Nurse Practitioner (PMHNP). Services may include: Psychiatric evaluation, Psychotherapy (talk therapy), Medication management, Referrals for additional care as needed

The goal of these services is to support my mental health and well-being through individualized treatment planning. 

2. Risks and Benefits

I understand that:

• Psychotherapy may involve discussing personal difficulties and can lead to emotional discomfort.
• Medication may cause side effects or interactions. My provider will explain any potential risks, side effects, or alternatives.
• There is no guarantee of improvement, and treatment outcomes vary for each individual.

3. Confidentiality

All communications and records are confidential and will not be disclosed without my written consent, except as required by law, including:

• If there is a risk of harm to myself or others
• Suspected abuse or neglect of a child, elder, or vulnerable adult
• Court order or legal requirement

I understand that my information may be shared with Bella Dora Health (Andrea Castellano PMHNP‑BC and/or any other Bella Dora Health employees or providers) as needed to support treatment, operations, and continuity of care — and that all such information will be protected under HIPAA‑compliant safeguards.

4. Telehealth
If I choose to participate in telehealth services, I understand:

• My provider will take reasonable steps to ensure my privacy.
• Technical issues may occur.
• I must be located in the state where my provider is licensed at the time of the session.

My provider may use secure, HIPAA‑compliant systems for documentation, communication, and appointment delivery (both in‑person and remote), including secure clinical notes, telehealth services, and relevant pharmacy/order‑processing portals when applicable.

5. Medication Management
If I am prescribed psychiatric medication:

• I agree to take medications only as prescribed.
• I understand the risks and benefits as explained by my provider.
• I agree to attend regular follow-up appointments and notify my provider of any side effects or concerns.
• I understand that misuse of medications or missed appointments may result in discontinuation of medication services.
• I agree to give my provider 48 hours to respond to text messages or emails.
• I agree to give my provider 7 days notice for prescription refills.

All requests must be given with a 7 day notice and must be submitted through the website under " FORMS then prescription Refill forms".

I acknowledge and agree to provide at least 7 days’ notice for all prescription refills to ensure adequate time for review and processing.

• If my provider suggests medication and/or natural supplements, I agree to clear this with my PCP prior to administering it. 

I agree to provide real‑time vital signs during appointments when requested. If I am unable to provide real‑time readings, I attest that the vitals I report are accurate, truthful, and obtained as I represent them.

6. Supplements and Herbal Guidance (Optional Services / Education)
In addition to the treatments described above, my provider may offer general guidance or educational information about supplements or herbal options. This guidance is provided strictly for educational purposes. I understand I should always consult with my physician (or another qualified licensed provider) prior to using any supplement or herb.

7. Voluntary Participation
I understand that I may choose to stop treatment at any time. I agree to communicate any concerns or decisions to discontinue with my provider. I release Bella Dora Health

8. Emergencies
Bella Dora Health does not provide emergency or crisis services.  In the event of an emergency, I will call 911 or go to the nearest emergency room. National Suicide & Crisis Lifeline: 988

9. Fees and Cancellations- $150 per hour and prorated for 45, 30 minute sessions.  Costs and fees will be discussed prior to or during the first visit if applicablelk.  24-hour cancellation notice is required.  Fee for cancelling same day or within a 24-hour period may result in a $75 fee.    

Acknowledgment and Consent

By signing this consent, I acknowledge that:

• I understand that Bella Dora Health and its provider(s) will make every reasonable effort to provide safe, evidence-based, and ethical care within the scope of psychiatric practice.
• I agree to participate actively in my care, including providing accurate health information, reporting side effects or adverse reactions promptly, and adhering to the agreed-upon treatment plan.
• I release Bella Dora Health, its provider(s), and staff from any liability or claims for unintended outcomes, side effects, or perceived harm that may occur as a result of:
  • Participating in psychotherapy or medication treatment,
  • My own decisions to refuse, delay, or alter recommended treatment,
  • Misuse or unauthorized use of prescribed medications,
  • Failure to disclose relevant health information,
  • Misunderstanding of treatment goals or limits of service,
  • Technological failure or breach during telehealth sessions, despite reasonable precautions.

I understand that this consent applies from the first visit and continues for all past, present, and future services provided by Bella Dora Health under this agreement.

This release does not absolve Bella Dora Health from responsibility in cases of gross negligence, malpractice, or willful misconduct, and I retain my right to address such instances through appropriate legal or licensing channels. I understand this release is intended to promote mutual respect, shared responsibility, and transparency in the therapeutic relationship.