INTAKE - Minors Logo
  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Client Information and Consent

    Welcome and thank you for considering YourTime Psychiatry and Medical Cannabis LLC ("YourTime Psychiatry and Medical Cannabis LLC", "us", "Company") for your medical needs. This document contains important information about our professional services and business policies.

    Licensed Medical Professional

    The medical professional is engaged in private practice providing medical care services to clients on behalf of the Company and not personally. In addition, all staff of the Company are providing services in their capacity under the Company and not personally.

    Appointments

    Appointments are made by calling 612-867-1382 during the normal business hours listed at https://yourtime-psychiatry.webflow.io. Please call to cancel or reschedule at least 24 hours in advance, or you may be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. If you are late, you will be charged for the full amount of the appointment if your insurance coverage allows, and there will be no pro-rating of the fee. If the Medical Professional has to cancel the appointment, you will be entitled to a refund. You shall be discharged from services after three (3) no-shows for appointments automatically.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    The number of sessions needed depends on many factors and will be discussed by the Medical Professional. Your initial session will involve an evaluation of your needs and depending on your circumstances further evaluative sessions may be required. At the end of the evaluation process the undersigned Medical Professional will be able to provide you with some first impressions of what practice may include and a treatment plan to follow if both you and the Medical Professional agree to work together in your services. You should evaluate this information along with your own opinions of whether you feel comfortable working with the Medical Professional. If you have questions about procedures feel free to discuss them with the Medical Professional at any time. If you have doubts your Medical Professional will be happy to help you set up a meeting with another medical professional for a second opinion.

    Crisis or Emergency

    If you have a medical emergency - contact 911 and/or visit your nearest emergency room. If you have an active suicidal plan and/or concerns about self-harm or safety, follow your harm reduction plan, if one exists, and then contact 911 and/or visit your nearest emergency room.

    Length of Visits

    The initial intake and evaluative session is normally scheduled for one (1) hour or one hour and a half (90 minutes) and may run longer depending on the testing or assessments a client is asked to complete. Further evaluative sessions may be scheduled as needed for the Medical Professional to accurately assess your needs. Once the evaluation process is completed medical sessions are generally 15 to 45 minutes in length depending on the circumstances. Total length of visit shall include chart review done during and after the visit, and may not be the total actual.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit. face-to-face contact time. An adult must be present at all times for a minor's visit; drop offs are not allowed.

    Cancellations

    Cancellations must be received at least 24 hours before your scheduled appointment; otherwise you may be removed as a patient. You are responsible for calling to cancel or reschedule your appointment. If you miss three (3) appointments, the Company may discharge you as a patient at the Company's discretion.

    Payment for Services

    You are solely responsible for payment of services. If you have current and valid insurance which we accept, we will bill your insurance for these fees. We accept the following insurances: Medicare, MN-MA (Medicaid), UCare, BCBS, Health Partners, Hennepin Health, and Medica/UBH.

  • Diagnostic Assessment: $400 Follow up: $200 Medical Cannabis Certification (Including PTSD Assessment if needed): $400

    Medical Cannabis Recertification: $300

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Free Medical Cannabis Certification/Recertification if involved with psychiatry and psychotherapy at our clinic (medication management and individual psychotherapy) and current acceptable insurance (Medicare, MN-MA, UCare, BCBS, Health Partners)*

    These fees are subject to change upon thirty (30) days' prior notice to you. If you are unable to pay, or are not willing to pay, the higher fee after receipt of notice, services may be terminated and you may be given referrals to other competent providers. The undersigned Medical Professional will look to you for full payment of your account, and you will be responsible for payment of all charges. Different copayments are required by various group coverage plans. Your copayment is based on the Medical Policy selected by your employer or purchased by you. In addition, the co-pay may be different for the first visit than for subsequent visits. You are responsible for and shall pay your copay portion of the undersigned Medical Professional's charges for services at the time the services are provided, unless there is applicable insurance coverage in force. It is recommended that you determine your copayment before your first visit by calling your benefits office or insurance company.

    Although it is the goal of the undersigned Medical Professional to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or the Medical Professional's testimony are requested by you or required by law, regardless of who is responsible for compelling the production or testimony, you will be responsible for and shall pay the costs involved in producing the records and the hourly rate charged by the Medical Professional at the time of the request or service of the subpoena (current rate is $450/hour) for the time involved in traveling to and from the testimony location, reviewing records and preparing to testify, waiting at the location, and giving testimony. Such payments are to be made at the time or prior to the time the services are rendered by the Medical Professional. The Medical Professional may require a deposit for anticipated court appearances and preparation. You will not be entitled to a pro-rated refund.

    Page 4 of 19

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Mandated Reporting

    Under certain state law, persons in designated professional occupations are mandated to report suspected child abuse or neglect or maltreatment of vulnerable adults. Persons who work with children and families are in a position to help protect children from harm. These persons may be required by law to report, if they know or have a reason to believe that a child or vulnerable adult is being abused or neglected. As a mandated reporter, the mental health professional may be required to break confidentiality and report certain information to the appropriate authorities.

    After-Hours Emergencies

    Please know that your Medical Professional and YourTime Psychiatry and Medical Cannabis LLC do not provide twenty-four (24) hour crisis or emergency services. Should you experience an emergency necessitating immediate medical attention, immediately call 911 or if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.

    The COPE mobile crisis teams can come to where you are. The teams respond to anyone in the county who is having a mental health crisis and needs an urgent response. If the situation is life-threatening or you need immediate response call 911.

    COPE Hennepin County: Adults 18 and over Call 612-596-1223.

    COPE Hennepin County: Children 17 and under, call 612-348-2233.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit. For other area Mental Health Crisis Response resources are below for your use as appropriate.

    Anoka: 763-755-3801, Carver/Scott: 952-442-7601

    Dakota: 952-891-7171, Washington: 651-777-5222

    Ramsey: adults - 651-266-7900, Sherburne: 800-635-8008

    Hennepin: adults - 612-596-1223, Stearns: 800-635-8008, Olmsted: 1-844-274-7472.

    Wright County - 1-800-635-8008

    The Minnesota Warmline provides a peer-to-peer approach to mental health recovery, support and wellness. Calls are answered by our team of professionally trained Certified Peer Specialists, who have first hand experience living with a mental health condition. The Warmline provides a safe, anonymous and confidential environment to connect with people who are here to listen. Open Monday-Saturday, 12 PM to 10 PM Call: 651.288.0400 Toll Free 877.404.3190 or text "Support" to 85511

    Lifeline Network: If you're thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States.

    Poison Control: 800-222-1222. 24 hour hotline for help with medication questions such as questions about accidental overdose, drug interactions or medication side effects.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit. For other area Mental Health Crisis Response resources are below for your use as appropriate.

    Anoka: 763-755-3801, Carver/Scott: 952-442-7601

    Dakota: 952-891-7171, Washington: 651-777-5222

    Ramsey: adults - 651-266-7900, Sherburne: 800-635-8008

    Hennepin: adults - 612-596-1223, Stearns: 800-635-8008, Olmsted: 1-844-274-7472.

    Wright County - 1-800-635-8008

    The Minnesota Warmline provides a peer-to-peer approach to mental health recovery, support and wellness. Calls are answered by our team of professionally trained Certified Peer Specialists, who have first hand experience living with a mental health condition. The Warmline provides a safe, anonymous and confidential environment to connect with people who are here to listen. Open Monday-Saturday, 12 PM to 10 PM Call: 651.288.0400 Toll Free 877.404.3190 or text "Support" to 85511

    Lifeline Network: If you're thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States.

    Poison Control: 800-222-1222. 24 hour hotline for help with medication questions such as questions about accidental overdose, drug interactions or medication side effects.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Contacting Your Medical Professional

    Your Medical Professional is often not immediately available by telephone. This phone number is not a crisis line or for urgent or emergency medical care. The office number 612-867-1382 is answered by voicemail that the Medical Professional will monitor from time to time throughout hours s/he will not take calls when with a client. There is no guarantee on response times and the best time for communication at the next scheduled appointment, but the Medical Professional shall attempt to return a call within 72 hours. The Medical Professional set this up for you before your first appointment.

    Your Medical Professional does not accept friend or contact requests from current or former clients on any social networking sites. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the Medical Professional and the client. It can blur the boundaries of the professional relationship and are not permitted. Any attempt by a client to surreptitiously gain access to the Medical Professional's personal site(s) will be cause for termination of the services.

    Medical Professional's Incapacity or Death

    You acknowledge that, in the event the undersigned Medical Professional becomes incapacitated or dies, it will become necessary for another Medical Professional to take possession of your file and records. By signing this information and consent form below, you give consent to allowing another licensed medical professional selected by the undersigned Medical Professional to take possession of your file and records and provide you with copies upon request, or to deliver them to a Medical Professional of your choice. The undersigned Medical Professional will select a successor Medical Professional within a reasonable time and will notify the appointed licensed medical professional. Audio and Video Recordings You acknowledge and, by signing this information and consent form below, agree that neither you nor the undersigned Medical Professional will record any part of your sessions unless you and the Medical Professional mutually agree in writing that the session may be recorded. You further acknowledge that the undersigned Medical Professional objects to you recording any portion of your sessions without the Medical Professional's written consent. You expressly agree that audio and video recordings used for security or training purposes are not part of services, and are therefore not protected by confidentiality or any other provisions under this agreement.

    Page 8 of 19

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Legal

    This Agreement shall be construed in accordance with, and governed by, the laws of the State of Minnesota as applied to contracts that are executed and performed entirely in Minnesota. The exclusive venue for any court proceeding based on or arising out of this Agreement shall be the county of the medical office address. The parties agree to attempt to resolve any dispute, claim or controversy arising out of or relating to this Agreement by arbitration, which shall be conducted under the then current arbitration procedures of the American Arbitration Association any other procedure upon which the parties may agree. The parties further agree that their respective good faith participation in arbitration is a condition precedent to pursuing any other available legal or equitable remedy, including litigation, arbitration or other dispute resolution procedures. If any legal action or any arbitration or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default or misrepresentation in connection with any of the provisions of this Agreement, YourTime Psychiatry and Medical Cannabis LLC and the Medical Professional shall be entitled to recover legal fees and other costs incurred in that action or proceeding, including lost revenue, in addition to any other relief to which it or they may be entitled. You release YourTime Psychiatry and Medical Cannabis LLC and the Medical Professional from any good faith refusals of medical records as allowed by law.

    Consent to Treatment

    I, voluntarily, agree to receive (or agree for my child to receive) Medical assessment, care, treatment, or services, and authorize YourTime Psychiatry and Medical Cannabis LLC to provide such care, treatment, or services. I understand that I am not guaranteed a positive outcome. I agree to follow the agreed upon treatment plan and to inform YourTime Psychiatry and Medical Cannabis LLC if I alter my treatment plan, experience side effects, or cease to follow my treatment plan. In order to recieve the complimentary medical cannabis services, the patient must be involved in active psychiatry as a current patient and Company may provide additional rules and boundaries at their sole discretion.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

     

    I understand and agree that I will participate in the planning of my care (or my child's care), treatment, or services, and that I may stop such care, treatment, or services that I receive (or my child receives) through YourTime Psychiatry and Medical Cannabis LLC at any time.

    By signing this Client Information and Consent form, I, the undersigned client (or parent/guardian), acknowledge that I have read, understood, and agreed to be bound by all the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

    I acknowledge that I received a copy of this signed information and consent form from my Medical Professional.

  • Clear
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  • Clear
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  • (If client is a minor and parents are separated)

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Minor Treatment Form - Consenting on their Own

    Individuals under the age of 18 cannot be treated for health related services without consent. Exceptions to this are governed by Minnesota Statutes, Chapter 144. Exceptions are summarized below and all other treatment requires parental / guardian consent. In signing below I give the Company permission to treat my son/daughter. I may revoke this consent at any time with written notice to the Company.

    Conditions When Parental Consent Is Not Needed For Treatment of Minors

    144.341 Living apart from parents and managing financial affairs, consent for self. Notwithstanding any other provision of law, any minor who is living separate and apart from parent(s) or legal guardian, whether with or without the consent of a parent or guardian and regardless of the duration of such separate residence, and who is managing personal financial affairs, regardless of the source or extent of the minor's income, may give effective consent to personal medical, dental, mental and other health services, and the consent of no other person is required.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    144.342 Marriage or giving birth, consent for health service for self or child. Any minor who has been married or has borne a child may give effective consent to personal medical, mental, dental and other health services, or to services for the minor's child, and the consent of no other person is required.

    144.343 Pregnancy, venereal disease, alcohol or drug abuse, abortion. Any minor may give effective consent for medical, mental and other health services to determine the presence of or to treat pregnancy and conditions associated therewith, venereal disease, alcohol and other drug abuse, and the consent of no other person is required.

    144.344 Emergency treatment. Medical, dental, mental and other health services may be rendered to minors of any age without the consent of a parent or legal guardian when, in the professional's judgment, the risk to the minor's life or health is of such a nature that treatment should be given without delay and the requirement of consent would result in delay or denial of treatment. 144.3441 Hepatitis B vaccination. A minor may give effective consent for a hepatitis B vaccination. The consent of no other person is required.

    144.345 Representations to persons rendering service. The consent of a minor who claims to be able to give effective consent for the purpose of receiving medical, dental, mental or other health services but who may not in fact do so, shall be deemed effective without the consent of the minor's parent or legal guardian, if the person rendering the service relied in good faith upon the representations of the minor. 144.346 Information to parents.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    The professional may inform the parent or legal guardian of the minor patient of any treatment given or needed where, in the judgment of the professional, failure to inform the parent or guardian would seriously jeopardize the health of the minor patient.

    144.347 Financial responsibility.

    A minor so consenting for such health services shall thereby assume financial responsibility for the cost of said services.

    Minor Treatment Form - Consenting with Legal Guardian/Parent

    Parental / Legal Guardian Consent:

    I give Company permission to treat:

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  • My signature indicates that I am the legal parent or guardian of the above named minor and that I am allowing my child to be treated at the Company in the event of an accident, injury, illness, or other medical condition. I understand that I am responsible for all costs incurred and that an insurance ready bill will be provided for me to submit to my insurance company. I recognize that I have the right to revoke this consent and that this consent is not needed when the above named individual reaches the age of 18 or meets any of the conditions identified above.

  • Clear
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  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

  • Clear
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  • (If client is a minor and parents are separated)

    CRISIS AND HARM REDUCTION AGREEMENT

  • Clear
  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

  • 6. Call 911 if steps 1-5 do not help me de-escalate and I feel like I cannot maintain my safety. At any time I can text MN to 741741 as an additional resource for me.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    Medication and refills

    Medication refill requests will be addressed within 3 business days (Monday-Friday, excluding holidays). Please plan ahead to avoid running out of medication. Refills for controlled substances may require additional time for review and cannot be guaranteed within this timeframe.

    There are no guarantees as to the outcome of treatment.

    I agree to the following plan and to follow all steps outlined

  • Clear
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  • (Signature of Parents, legal guardian or authorized representative) (Date, MM/DD/YYYY)

    CONTROLLED SUBSTANCES AGREEMENT

    I, a patient of the Provider, understands that the Provider may utilize controlled substances (schedule II - V) as part of my treatment. In addition, my Medical Professional has the sole discretion to determine whether or not to prescribe any medication that may be addictive.

    I understand I will not have my medications replaced if they are lost or stolen.

    For an after hours emergency, including withdrawal symptoms, overdose or loss of medications, I will go to the emergency room. I understand my Provider is not available outside of regular business hours.

    I understand my Provider is not available to alter my medication schedule or dosage outside of scheduled appointments.

    I will obtain all medication from the same pharmacy and will inform the Provider of the name of that pharmacy.

  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

    I will inform the Provider if I have been prescribed any controlled substances by a provider outside of this clinic.

    My provider may provide tapering of medications if required, under the sole discretion of the provider.

    I understand that a prescription may be given early if the Medical Professional or the patient will be out of town when the refill is due. These prescriptions will contain instructions to the pharmacist that the prescriptions(s) may not be filled prior to the appropriate date.

    If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.

    I understand that I may be asked to bring my medications in their original container to the Provider clinic while I am on any controlled medication.

    I understand that failure to adhere to these policies and/or failure to comply with Medical Professional's treatment plan may result in cessation of therapy with controlled substance prescribing by this Medical Professional or referral for further specialty assessment, as well as possible discharge from the practice.

    I, the undersigned patient, attest that the foregoing was discussed with me, and that I have read, fully understand, and agree to all of the above requirements.

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  • Risks of Services

    There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. You assume the risk of services by signing this form. The Medical Professional is not liable for any adverse reactions to services. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional. The Company is not liable for any adverse reactions to mental health services or medications. The Company may discharge you at its sole discretion based on the amount of controlled substances you have been prescribed by another provider and the frequency of use. No weapons of ANY kind are allowed on the Company premises. Violent psychosis is not treated and treatment will stop immediately if this is indicated.

    Medication expectations

    You may or may not be started on a medication the first time you meet with NP. If you are already on medication, there may or may not be changes made to medication(s) at the first visit.

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  • Consent to Participate in a Telehealth Consultation

    1. Telehealth

    Telehealth includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of protected health information, and education using synchronous or asynchronous audio, video, or data communications. I understand that my health care provider, through the Company (the "Company" wishes me to engage in a Telehealth consultation with the Company. This means that I, or a designee, will, through an interactive video connection, or via telephone means, be able to consult with a designated healthcare practitioner about my condition.

    2. Identity Verification

    I may be expected to provide a copy of my driver's license and other identity verifying documentation requested by the healthcare practitioner before any health services are provided.

    3. Privacy and Security of Communications All electronic communications between me and the healthcare practitioner will be transmitted using reasonable measures to ensure confidentiality. I will be responsible to secure and protect the functionality, integrity, and privacy of my hardware, files, and communication. Password protection for accessing my hardware and files is recommended. If others will be accessing the same computer, be aware that programs exist that copy every keystroke I make. It is recommended that I schedule my sessions with the undersigned healthcare practitioner when and where I can ensure the greatest level of privacy for all communications. Be sure to fully exit all programs and hardware at the end of each session. I explicitly waive confidentiality if there is another individual at my distant site I am using Telehealth at.

    4. Risks Associated With Distance Services

    There are privacy and security risks and consequences associated with Telehealth despite the policies and procedures in place to guard against them. The risks and consequences include, but are not limited to, interrupted or distorted transmission of data or information due to technical failures and access or interception of my protected health information by unauthorized persons.

    By signing this information and consent form below, I acknowledge the limitations inherent in ensuring client confidentiality of information transmitted in Telehealth and agree to waive my privilege of confidentiality with respect to any confidential information that may be accessed by an unauthorized third party despite the reasonable efforts of the Company to arrange a secure line of communication.

  • My health care provider has explained to me how the video conferencing technology will be used.

    I understand that this consultation will not be the same as a face-to-face visit since I will not be in the same room as the healthcare practitioner, and that some parts of a visit may be conducted by individuals present with me at the direction of the healthcare practitioner. I also understand individuals may be present at either location to operate the audio/video equipment and that these individuals must maintain the confidentiality of health information disclosed, or if they join I at my discretion, then confidentiality may be waived.

    I understand there are possible risks of an incomplete or ineffective consultation because of the technology, and that if any of the risks occur, the consultation may terminate. The risks may include:

    a. Failure, interruption or disconnection of the audio/video connection;

    b. A picture that is not clear enough to meet the needs of the consultation;

    c. A minor risk of access to the consultation through the interactive connection by electronic tampering.

    I understand that in place of this Telehealth session I may seek face-to-face consultation with a health care provider.

    I understand that I will not receive any royalties or other compensation for taking part in this Telehealth session or for the authorized use of any consultation images or audio.

    I release the Company, its employees, agents and assigns from any and all liability which may arise from this Telehealth consultation, the use of interactive audio/visual connections, or from the taking or authorized use of any images or audio obtained.

    5. Communication Interruptions

    If I am unable to connect with the Telehealth platform or are disconnected during a session due to a technological breakdown, I will try to reconnect within 5 minutes. If reconnection is not possible the Company can be reached at the business phone number.

    6. E-Mail and Text Messages

    The undersigned healthcare practitioner may use and respond to email and text messages only to arrange or modify appointments. Please do not send emails related to my treatment electronic communications are not completely secure and confidential. Any health related questions or issues will not be addressed by the healthcare practitioner in any electronic communication but will be dealt with during my next health session. Any electronic transmissions of information by me are retained in the logs of my service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. I should know that any e-mails or any communications sent via Facebook, online and specifically the Company website are not secure, and I assume the risks of the insecure transmission.

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    7. Audio and Video Recordings

    I acknowledge and, by signing this information and consent form below, agree that neither I nor the undersigned healthcare practitioner will record any part of my sessions unless I and the Company mutually agree in writing that the health session may be recorded. I further acknowledge that the Company objects to me recording any portion of my sessions without the Company's written consent. I expressly agree that audio and video recordings used for security or legal and documentation purposes are not part of my health records, and are therefore not protected by confidentiality or any other provisions under this agreement.

    8. Consent to Treatment Using Telehealth and Distance Health Services I voluntarily agree to receive synchronous (or asynchronous) assessment, care, treatment, and services through the use of email and texts and authorize the Company to provide such care, treatment, or services as are considered necessary and advisable. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

    HOW AND WHEN TO DISCONTINUE TELEHEALTH SERVICES

    Telehealth services and care may not be as effective as face-to-face services. The Company will continually assess the appropriateness of Telehealth for me. If the Company determines that I would be better served by receiving different services, such as face-to-face services, recommendations for treatment and treatment providers or facilities will be provided to me. I may also communicate to my provider that Telehealth services are no longer appropriate for me. My provider will consider patient safety (e.g., suicidality) and health concerns (e.g. viral risk; mobility; immune function), community risk, and the psychiatrist's health when deciding to do Telehealth services versus in-person.

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  • Notice of Privacy Practices of YourTime Psychiatry and Medical Cannabis LLC

    Effective January 1, 2023

    This notice describes how mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    Your Time Psychiatry and Medical Cannabis LLC, is required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a copy of the revised notice sent by regular mail to the last address you have provided to me for this communication purpose.

    Understanding Your Personal Health Information

    Each time you visit a hospital, physician, mental health professional, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms; examination and test results; diagnoses; treatment; in the case of a mental health professional, psychotherapy notes; and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

    Basis for planning your care and treatment.

    Means of communication among the many health professionals who contribute to your care.

    Legal document describing the care you received.

    Means by which you or a third-party payer can verify that services billed were actually provided a tool in educating health professionals.

    Source of data for medical research.

    Source of information for public health officials charged with improving the health of the nation a source of data for facility planning and marketing.

    Tool with which we can assess and continually work to improve the care we render and

    Understanding what is in your record and how your health information is used helps you to:

  • Means to ensure its accuracy.

    Way to better understand who, what, when, where, and why others may access your

    Means to make more informed decisions when authorizing disclosure to others.

    Your Health Information Rights

    Although your health record is the physical property of my practice, the facility that compiled it, the information belongs to you. You have the following privacy rights:

    1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or health care operations. You should note that I am not required to agree to be bound by any restrictions that you request but am bound by each restriction that I do agree to.

    2. In connection with any patient directory, the right to request restrictions on the use and disclosure of your name, location at this treatment facility, description of your condition and your religious affiliation. I do not maintain a patient directory.

    3. To receive confidential communication of your PHI unless I determine that such disclosure would be harmful to you.

    4. To inspect and copy your PHI unless I determine in the exercise of my professional judgment that the access requested is reasonably likely to endanger your life, emotional or physical safety or that of another person. You may request copies of your PHI by providing me with a written request for such copies. I will provide you with copies within ten (10) business days of your request at my office. You may be charged for each page copied and you will be expected to pay for the copies at the time you pick them up.

    5. To amend your PHI upon your written request to me setting forth your reasons for the requested amendment. I have the right to deny the request if the information is complete or has been created by another entity.

    I am required to act on your request to amend your PHI within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you. If I deny your requested amendment, I will provide you with written notice of my decision and the basis for my decision. You will then have the right to submit a written statement disagreeing with my decision which will be maintained with your PHI. If you do not wish to submit a statement of disagreement, you may request that I provide your request for amendment and my denial with any future disclosures of your PHI.

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    6. Upon request to receive an accounting of disclosures of your PHI made within the past 6 years of your request for an accounting. Disclosures that are exempt from the accounting requirement include the following:

    Disclosures necessary to carry out treatment, payment, and health care operations.

    Disclosures made to you upon request.

    Disclosures made pursuant to your authorization.

    Disclosures made for national security or intelligence purposes.

    Permitted disclosures to correctional institutions or law enforcement officials.

    Disclosures that are part of a limited data set used for research, public health, or health care operations. I am required to act on your request for an accounting within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which I will provide the accounting. You are entitled to one (1) accounting in any twelve (12) month period free of charge. For any subsequent request in a twelve (12) month period you will be charged a reasonable fee allowed by law for each page copied and you will be expected to pay for the copies at the time you pick them up.

    7. To receive a paper copy of this privacy notice even if you agreed to receive a copy electronically.

    8. To pay out-of-pocket for a service and the right to require that I not submit PHI to your health plan.

    9. To be notified of a breach of your unsecured PHI.

    10. The right to complain to me and to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. You may submit your complaint to me in writing setting out the alleged violation. I am prohibited by law from retaliating against you in any way for filing a complaint with me or Health and Human Services.

    11. If your records are maintained electronically, the right to receive a copy of your PHI in an electronic format and to direct in writing that a third party receive a copy of your PHI in an electronic format.

  • Uses and Disclosures

    It is my policy to protect the confidentiality of your PHI to the best of my ability and to the extent permitted by law. There are times however, when use or disclosure of your PHI, including psychotherapy notes, is permitted or mandated by law even without your authorization.

    Situations where I am not required to obtain your consent or authorization for use or disclosure of your PHI include the following circumstances:

    By myself or my office staff for treatment, payment, or health care operations as they relate to you.

    For example: Information obtained by me will be recorded in your record and used to determine the course of treatment that should work best for you. I will document in your record our work together and when appropriate I will provide a subsequent health care provider with copies of various reports that should assist him or her in treating you once we have terminated our therapeutic relationship.

    For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. In the event of an emergency to any treatment provider who provides emergency

    To defend myself in a legal action or other proceeding brought by you against me.

    When required by the Secretary of the Department of Health and Human Services in an investigation to determine my compliance with the privacy rules.

    When required by law insofar as the use or disclosure complies with and is limited to the relevant requirements of such law.

    Examples: To a public health authority or other government authority authorized by law to receive reports of child abuse or neglect.

    If I reasonably believe an adult individual to be the victim of abuse, neglect or domestic violence, to a governmental authority, including a social services agency authorized by law to receive such reports to the extent the disclosure is required by or authorized by law or you agree to the disclosure and I believe that in the exercise of my professional judgment disclosure is necessary to prevent serious harm to you or other potential victims. If I make such a report I am obligated to inform you unless I believe informing the adult individual will place the individual at risk of serious injury.

    In the course of any judicial or administrative proceeding in response to:

    An order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed.

    A subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order, by the person requesting the PHI.

  •  Child custody cases and other legal proceedings in which your mental health or condition is an issue are the kinds of suits in which your PHI may be requested. In addition I may use your PHI in connection with a suit to collect fees for my services.

    In compliance with a court order or court ordered warrant, or a subpoena or summons issued by a judicial officer, a grand jury subpoena or summons, a civil or an authorized investigative demand, or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry and the request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought and de-identified information could not reasonably be used.

    To a health oversight agency for oversight activities authorized by law as they may relate to me (i.e., audits; civil, criminal, or administrative investigations, inspections, licensure, or disciplinary actions; civil, administrative, or criminal proceedings or actions).

    To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or performing other duties as authorized by law.

    To funeral directors consistent with applicable law as necessary to carry out their duties with respect to the decedent.

    To the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

    If use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

    To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.

    To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation.

    To a public health authority or other appropriate governmental authority authorized by law to receive reports of child abuse or neglect.

    To a law enforcement official if I believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on my premises.

    Using my best judgment, to a family member, other relative or close personal friend, or any other person you identify, I may disclose PHI that is relevant to that person's involvement in your care or payment related to your care.

  • To authorized federal officials for the conduct of lawful intelligence, counterintelligence, and other national security activities authorized by the National Security Act and implementing authority.

    To Business Associates under a written agreement requiring Business Associates to protect the information. Business Associates are entities that assist with or conduct activities on my behalf including individuals or organizations that provide legal, accounting, administrative, and similar functions.

    To family members and others involved in your care prior to your death, unless doing so would be inconsistent with any prior expressed preferences you have made known to me, but limited to PHI relevant to the family member or other person's involvement in your health care or payment.

    I may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

    If you have any questions and would like additional information you should bring this to my attention at the first opportunity. I am the designated Privacy Officer for my practice and will be glad to respond to your questions or request for information.

    Business Name: YourTime Psychiatry and Medical Cannabis LLC

     

  • Client Consent Form

    I understand that as part of my health care, the undersigned therapist originates and maintains health records describing my health history, symptoms, evaluations and test results, diagnosis, treatment, psychotherapy notes, and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other health care providers, and to carry out other routine health care operations such as assessing quality and reviewing competence of health care professionals.

    The Notice of Privacy Practices for YourTime Psychiatry and Medical Cannabis LLC provides specific information and a thorough description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and I have been given the opportunity to review the notice prior to signing this consent. Before implementation of any revised Notice of Privacy Practices, the revised Notice will be mailed to me at the address I designate below. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or health care operations and that I am not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that YourTime Psychiatry and Medical Cannabis LLC has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.

    I have been provided and have received YourTime Psychiatry and Medical Cannabis LLC's Notice of Privacy Practices.

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