Currently, we are only accepting clients for telehealth services.

NOTE: "CLIENT" refers to the specific individual who will be receiving services, NOT the parent, guardian, or authorized representative. Please ensure that all fields marked with an asterisk (*) are completed.

Please answer the questions accurately, ensuring the client's Name, Date of Birth, and Social Security Number are correct for insurance verification.

The information entered on Page 1 will automatically populate in the other forms.

POLICY SUMMARY
Pathways Behavioral Health Group (PBHG) provides convenient, accessible, high-quality behavioral health services. To ensure continuity of care and access to these services, clients must maintain appropriate insurance coverage. A list of our accepted insurers and payment information is available on our website.

MEDICAID RECIPIENTS
Medicaid recipients will not incur any out-of-pocket expenses for services, including additional costs not covered by Medicaid.

GAMBLING SERVICES
Gambling services are available to all Maryland residents at no cost, regardless of insurance coverage. Participants may be Medicaid eligible, Medicaid ineligible, or privately insured in the state of Maryland. Participants are required to be a state of Maryland resident to receive services at no cost.

COMMERCIAL AND SELF-PAY
The individual insurance companies contracted with PBHG determine the fee rates for accepted insurance. Additional costs, outlined below, apply only to commercial and self-pay clients. For clients with insurance plans that PBHG does not contract with, we may assist by submitting insurance claims on your behalf to help streamline the reimbursement process. Clients are responsible for the remaining balance if an insurance claim is denied or the reimbursement amount does not fully cover the fee.

STEPS IF YOUR INSURANCE CLAIM IS DENIED
If your insurance claim is denied, you should first contact your insurance provider to understand the reason for the denial. You may then resubmit the claim, provide additional documentation if required, or file an appeal following your insurer’s appeal process. PBHG can provide necessary documentation, such as superbills or treatment summaries, upon request to support your appeal. Clients are ultimately responsible for all outstanding balances not covered by insurance.

FEE SCHEDULE
The following fee schedule is not a complete list of all possible charges. The No Surprises Act aims to increase price transparency, and we have always posted our prices on our website for clients to review. If you are an uninsured or self-pay client who wants a Good Faith Estimate, please get in touch with our office.

Service Billing Codes & Rate:

• 90791-Psychiatric Diagnostic Evaluation (Initial Mental Health Assessment) - $235
• 90832-Individual Psychotherapy (16 to 37 minutes) - $95
• 90834-Individual Psychotherapy (38 to 52 minutes) - $110
• 90837-Individual Psychotherapy (53 to 60 minutes) - $175
• 90846-Family Psychotherapy (without the patient present) (26 to 60 minutes) - $175
• 90847-Family Psychotherapy (with the patient present) (26 to 60 minutes) - $175
• 90853-Group Psychotherapy (45 to 60 minutes) - $65

The following services are not billed to your insurance and will be billed directly to the client:

• Consultation Only (Mental Health Assessment) - $300
• Couples Therapy - $175
• Brief Therapy Phone Session (if less than 16 minutes) - $50
• Crisis Session/Call (per 5 minutes if less than 30 minutes) - $45
• Letter or Forms - $35
• Record Requests - $30
• Reports/Psychiatric Report (per half hour) - $50
• Bounced Check Fee - $35
• No Show Fee - $75

PAYMENT PLANS
PBHG understands the importance of flexibility in payment options. We accept various forms of payment, including credit cards, health savings accounts (HSA), checks, and cash. Payment is expected at the end of each session to ensure continuity of care. Please let us know if you have specific needs or wish to discuss flexible payment options. We are here to accommodate you.

CONDITIONS FOR FLEXIBLE PAYMENT OPTIONS
Flexible payment arrangements are available to clients who demonstrate financial hardship or have high out-of-pocket expenses. To qualify, clients must submit a request and may be asked to provide documentation of income, proof of financial hardship, or verification of high medical expenses. Each request is reviewed individually, and approved payment plans will outline clear payment terms and timelines.

MEDICARE/DUAL INSURANCE
PBHG does not accept dual insurance coverage. Suppose you have coverage with both Medicaid and Medicare. In that case, Medicaid will not cover your services, and Medicare will be considered the primary payer. If you require services covered by Medicare, please inform us, and we will gladly provide alternative resources or refer you to agencies that accept dual insurance coverage. Your access to care is essential to us, and we are committed to helping you find the support you need.

EXISTING SERVICE RECIPIENTS WHO ACQUIRE MEDICARE AFTER ADMISSION
When you have dual insurance coverage, one insurance will be considered primary, and the other will be secondary. For example, if Medicare is your primary insurance, Medicaid will act as the secondary. In these cases, Medicaid may retract payments previously made to PBHG for services received during a specified period, leaving you responsible for the outstanding balance. You will receive an invoice detailing the amount owed and be accountable for the payment. PBHG may suspend your services until payment arrangements are established. Please get in touch with us as soon as possible to set up a payment plan.

Suppose you have already received disability benefits but haven't yet received your Medicare card. In that case, you are likely to become eligible for Medicare. We encourage you to discuss this with your caseworker for clarification and further assistance.

INSURANCE & RESPONSIBLE PARTIES
Clients are responsible for verifying their behavioral health benefits with their insurance provider. You will need to pay all copayments and deductibles at the time of service and any portions of fees not covered by your insurance. PBHG will charge copayments and deductibles to the card on file. Please inform PBHG of any changes to your insurance policy. Many insurance plans partially reimburse out-of-network providers and/or allow office visit fees to count toward your out-of-pocket maximum. Upon request, we can provide a "superbill" that you can submit to your insurance for potential reimbursement.

NOTIFICATION OF INSURANCE CHANGES
PBHG will make reasonable efforts to inform clients about any major insurance policy changes that we are made aware of that may affect coverage for services. However, it remains the client's responsibility to regularly verify their insurance benefits, including coverage changes, copays, deductibles, and network participation. PBHG may notify clients of insurance changes through email, postal mail, or in-session communications when applicable.

CANCELLATION AND NO-SHOW POLICY
PBHG requires clients to provide 24-hour advance notice for appointment cancellations, including group therapy sessions, to avoid a missed appointment charge unless other arrangements have been made in advance with your counselor or therapist. Missing a courtesy reminder call does not waive your responsibility to attend or cancel your appointment. PBHG may require a credit card to be kept on file for balances over $200 or after two no-shows at your counselor or therapist's discretion.

FEES AND PAYMENT
All fees are due at the time of service. For clients using insurance, PBHG will submit claims to your primary insurance on your behalf. There is a fee for checks returned due to insufficient funds. Statements are generally sent via email but can be mailed upon request. PBHG will only submit claims to primary insurers for covered services. Suppose insurance payments are delayed beyond 30 days. In that case, we recommend you follow up with your insurer to ensure payment is forthcoming. You will be responsible for the full balance if your claim is denied or payment remains outstanding. Payments can be made by cash, check, or credit card. PBHG may request a credit card authorization on file for clients utilizing telehealth services, self-pay clients, accounts with high balances, or services not covered by your insurance.

FAILURE TO PAY
Clients agree that failure to pay service fees within 14 business days of the service date may be considered voluntary termination of services by the client at PBHG's discretion. Accounts sent to collections will incur the outstanding balance plus all associated collection fees. Clients consent to release relevant information to third-party collection agencies or attorneys for debt recovery. Clients also agree to cover attorney fees and any legal costs if legal action is required to collect payment. Legal proceedings will be conducted in Baltimore, Maryland, and clients waive any objections related to jurisdiction or venue.

UNDERSTANDING OF SEPARATE PRACTICES
Clients acknowledge that Pathways Behavioral Health Consulting, LLC (Pathways Behavioral Health Group or PBHG) and Treyway Multi Treatment Services LLC (TMTS) are independent practices despite sharing physical space. Therefore, separate client records are required. Clients understand that insurance benefits applied to PBHG services cannot be transferred to TMTS. Clients may choose to receive services from one or both practices as needed. Clients consent to exchanging relevant information between PBHG and TMTS to facilitate coordinated care, as indicated by their signature below.

USE OF ARTIFICIAL INTELLIGENCE (AI)
As part of our ongoing commitment to provide the best possible service, PBHG has opted to use an artificial intelligence note-taking tool that assists in generating clinical documentation based on your sessions. This allows for more time and focus to be spent on our interactions instead of taking time to jot down notes or trying to remember all the important details. A temporary recording and transcript or summary of the conversation may be created and used to generate the clinical note for that session. Your provider then reviews the content of that note to ensure its accuracy and completeness. After the note has been created, the recording and transcript are automatically deleted.

This artificial intelligence tool prioritizes the privacy and confidentiality of your personal health information. Your session information is strictly used for the purpose of your ongoing care. Your information is subject to strict data privacy regulations and is always secured and encrypted. Stringent business associate agreements ensure data privacy and HIPAA compliance. Please discuss any questions or concerns you may have about this feature with your provider.

By signing this form, you consent to the use of artificial intelligence as described. You acknowledge that your participation is voluntary and not a condition of receiving services from your clinician, and that you can withdraw your consent at any time.

TELEHEALTH SERVICES
Clients typically seen in the office may schedule telehealth sessions, as most insurance providers cover these services; however, we encourage you to confirm this with your insurance provider. If a scheduled appointment is missed, counselors or therapists may offer a brief phone session (16 minutes or less) during the initially scheduled time for individual, couples counseling, or family therapy. This phone session will be billed at a reduced rate, lower than the standard missed appointment fee. This option for missed appointments is available twice every 30 days.

COURT APPEARANCES, LEGAL REQUESTS, ASSOCIATED COSTS, AND LEGAL FEES
PBHG may be required to provide information or participate in legal proceedings, such as court appearances, depositions, custody reviews, or documentation requests ("Legal Requests"). These services involve additional time and preparation beyond standard care, and the associated costs will be billed to the client or their legal guardian. The fees for these services will be calculated based on the hourly rate equivalent to a self-pay client's 60-minute individual therapy session. This rate applies to activities such as preparation, document review, travel, consultations, waiting time, and any other work related to the Legal Request.

PROVIDER CONTACT OUTSIDE OF SESSIONS
Our priority is to offer you the highest quality of care. In case of emergencies, please call 911. If you are in crisis, contact the 988 Crisis Hotline. For appointment scheduling or billing inquiries, please get in touch with your counselor or therapist, who will provide you with their contact information for these concerns. If you need to speak with your provider outside of your scheduled session and cannot wait until your next appointment, please respect their time.

POLICY & FEE AGREEMENT ACKNOWLEDGMENT
By signing below, you acknowledge that you have reviewed, understood, and accepted the policies outlined in this document. Please feel free to reach out with any questions before signing.

SUMMARY OF SERVICES
Pathways Behavioral Health Group (PBHG) provides outpatient behavioral health services for children, adolescents, and adults. Services are available both in-office and through telehealth. These include clinical evaluations and treatment for various conditions, such as biopsychosocial conditions and behavioral health disorders, including mental and emotional disorders, substance use disorders, and addictive disorders.

THERAPY PROCESS
Therapy is a collaborative process focused on addressing psychological problems, exploring beliefs, and processing emotions. It is built on a foundation of trust between the client and their treatment provider. PBHG utilizes a person-centered approach along with evidence-based therapeutic techniques, such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Solution-Focused Brief Therapy (SFBT), mindfulness-based interventions, and other techniques. Individual and group therapy sessions are tailored to promote personal growth, enhance self-awareness, and improve overall well-being. Active participation from clients is essential to achieving the best outcomes. The process begins with an initial assessment, during which a clinician will ask you to discuss your current concerns, personal history, and any prior treatments. Using this information, an individualized treatment plan will be developed to address your unique goals and needs.

BENEFITS
Therapy offers numerous benefits, including the opportunity to gain deeper self-awareness, improve emotional regulation, and enhance your overall mental health and well-being. By working collaboratively with your treatment team, you can develop effective coping strategies, resolve conflicts, and build healthier relationships. Therapy also provides a supportive environment to explore thoughts, feelings, and behaviors, empowering you to make meaningful changes and achieve your personal goals. As you progress, you may experience increased self-confidence, reduced stress, and an improved ability to manage life's challenges.

RISKS AND BARRIERS
While therapy can be highly beneficial, there may be some risks involved. These can include addressing difficult emotional experiences, confronting unresolved issues, or being challenged in ways that may feel uncomfortable. The process can also bring up strong emotions and may sometimes lead to unanticipated changes in behaviors, thoughts, and feelings. To enhance your experience, it’s important to discuss any questions or discomfort with your treatment team as they arise. Your treatment team will help you understand these experiences and may use different methods, techniques, or referrals as needed to support you in achieving the growth you desire.

CLIENT CONCERNS AND DISCOMFORT
If you feel uncomfortable during the therapy process or have concerns about your provider’s approach, you are encouraged to first discuss these concerns directly with your provider. Open communication can help resolve misunderstandings and improve your therapeutic experience. If you feel unable to address the concern directly with your provider, or if the issue is not resolved, you may contact the Clinical Director or the designated administrative staff at PBHG to request support, mediation, or reassignment to a different provider if appropriate.

TREATMENT OF MINORS
Parents and guardians are strongly encouraged to participate in minors’ treatment. In Maryland, minors aged 12 or older may consent to their own mental health treatment if, in the provider’s professional clinical judgment, the minor is mature and capable of providing informed consent. The provider will assess the minor's ability to understand the nature of the treatment, appreciate the risks and benefits, express a reasoned choice, and engage meaningfully in therapy. If the minor is deemed mature and capable of providing informed consent, they may seek and receive treatment independently, as an adult would. For treatment related to drug abuse or alcoholism, a minor has the same capacity as an adult to consent to treatment or advice. It is at the provider’s professional discretion to determine if, when, and how to inform parents and guardians, except in cases where disclosure would cause harm to the minor.

CONFIDENTIALITY AGREEMENT
To provide you with the highest quality of care and ensure compliance with State and Federal regulations, certain members of your treatment team or supervising staff may access your records. All team members are committed to upholding confidentiality, which is crucial to effective counseling. Your counselor or therapist and treatment team will safeguard your private information to create a safe environment where you can openly share personal information. In most instances, your information will not be disclosed to another party without your written consent. However, certain situations allow for legally permissible disclosures without your permission. The following is a list of exceptions:

• Legal Proceedings: In most legal proceedings, counselors and therapists are prevented from providing information about the treatment. However, a judge may ask your counselor or therapist to testify and/or provide a summary of treatments, documents of treatment planning, or other treatment documents.
• Duty to Warn and Protect: Counselors and therapists are required to warn a potential victim if a client is threatening serious injury to someone. Counselors or therapists may be required to hospitalize a client and/or contact family members if the client threatens to harm him/herself.
• Abuse of Children and Vulnerable Adults: Counselors and therapists are required by law to report if a child, an elderly person, or a disabled person is being abused. Counselors and therapists are also required to report past instances of child abuse when specific information about the abuser is available.
• Telehealth Services: Security protocols can fail, causing breach of privacy of confidential health information.
• Insurance Providers: Insurance companies and other third-party payers are given information that they request regarding services to the service recipient.

NOTICE OF PRIVACY PRACTICES
The Notice of Privacy Practices (NPP) for PBHG explains how your protected health information (PHI) may be used and disclosed. The NPP states that PBHG may revise its terms, and any updates will be made available in the office. You have the right to revoke this consent in writing, except where PBHG has already relied on your prior consent for disclosures. You also have the right to request restrictions on how your PHI is used or disclosed for treatment, payment, and health care operations. While PBHG is not obligated to accept such restrictions, it will adhere to any agreed-upon limitations.

CONFIDENTIALITY OF RECORDS AND RECORDS REQUEST
Federal law and regulations protect the confidentiality of patient records maintained by PBHG. Generally, PBHG is prohibited from disclosing information to individuals outside of the company that would reveal a client’s attendance or identify them as an alcohol or drug user, except under the following conditions:

1. Consent is given by clients aged 12 and older who are receiving services (written consent may be required);
2. Disclosure is authorized by a court order; or
3. Disclosure is made to medical personnel in an emergency, or to qualified personnel for research, audit, or program evaluation purposes.

Violations of federal law and regulations by a program are considered a crime. Suspected violations may be reported to the appropriate authorities as per federal guidelines. Please note that federal law and regulations do not protect any information regarding a crime committed by a patient at the program or against any program staff, or any threats of such crimes. Likewise, information regarding suspected child abuse or neglect is not protected and must be reported to state or local authorities under state law. The policies regarding record requests are outlined in the Fee Agreement and Policies.

COMMUNICATION
PBHG uses a HIPPA compliant Electronic Health Records platform to engage clients in their care. We aim to communicate with you efficiently, which may include phone calls, emails, or text messages. However, please note that these communication methods carry inherent privacy risks. We advise against using email for emergencies, urgent matters, or sensitive information. Appointment reminders, statement notifications, and general information may be sent via email, text, or phone call.

CANCELLATION, FEES, AND PAYMENTS
The policies regarding cancellations, fees, and payments are outlined in the Fee Agreement and Policies. Medicaid clients will not be billed for services provided by mail, telephone, or other non-in-person means; for the completion of forms or reports; or for missed or broken appointments.

TERMINATION OF SERVICES
You have the right to terminate the therapeutic relationship at any time. While your counselor or therapist may wish to discuss this decision with you, you are free to discontinue treatment. Upon termination, you will be provided with a list of community providers and, if appropriate, refer back to your original referral source. Please note that you will be responsible for any outstanding fees for services already rendered.

LEGAL INFORMATION
Please be advised that your counselor or therapist is not qualified to provide legal advice. For legal questions or guidance, it is recommended that you consult with an attorney to ensure your best interests are represented.

COORDINATION OF SERVICES
Your counselor or therapist may coordinate with other service providers within our program, or the community as needed, such as for care coordination, crisis intervention, veteran services, vocational support, medical services, and more. Coordination with community providers will require the client to sign a release of information form.

CONSENT FOR TREATMENT AND ACKNOWLEDGEMENT
I have read and understood the contents of this form and had the opportunity to ask questions and voluntarily agree to participate in treatment and receive services. I understand that the information above is intended to provide an overview of your services and is not exhaustive. I have only entered information about myself or an individual I am authorized to act on behalf of, such as my child. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

• I hereby attest to reading this document and understand its contents.
• I give my voluntary consent to release of information and authorization to pay insurance benefits.
• I authorize PBHG to communicate with me electronically via telephone, email, text messaging, faxing, website, internet and patient portal.
• I authorize payment directly to PBHG.
• I understand that all of the rules and regulations that apply to the provision of healthcare services in the state of Maryland also apply to telehealth.

CLIENT RIGHTS AND RESPONSIBILITY
No client of Pathway Behavioral Health Group (PBHG) will be discriminated against due to ethnic background, gender, religion, sexual orientation, nationality, age or disability. Additionally, as a client, you have the following rights and responsibilities:

1. The right to be treated with dignity, respect and courtesy. The responsibility to treat other clients with dignity, respect and courtesy.
2. The right to confidentiality regarding your treatment, as stipulated by Federal Law. You have the right to refuse observation by others, tape recorders, video recorders, photography, etc. The responsibility to keep any information pertaining to other clients confidential.
3. The right to be free from physical, sexual, psychological, and financial abuse, harassment, physical punishment, and humiliation, threatening, or exploiting actions. The responsibility to inform/report staff if any of these rights has been violated.
4. The right to information regarding your treatment, including access to your records, as stipulated by Federal law. The responsibility to provide accurate information and to inform your counselor or therapist of major events and important issues related to your life or treatment.                                                 
5. The right to consent to individualized treatment and express your preferences regarding type of services, release of information, concurrent services, and the people involved in your treatment. The responsibility to participate fully in the development and implementation of your treatment plan.
6. The right to refuse treatment and not to be required to participate In research projects unless fully informed and having given written consent. The responsibility to understand the possible consequences of refusing treatment.
7. The right to access other support services.  The responsibility to follow through on referrals made on your behalf and to cover the expense of these services, when applicable.
8. The right to present grievances, complaints, and/or suggestions in relation to any aspect of treatment. The responsibility to initiate grievances, complaints, and/or suggestions.

PROGRAM RULES AND REGULATIONS
Clients are expected to adhere to the following guidelines to maintain a safe and respectful environment:

1. Clients will be required to have at least one formal therapy session per month. Therapy sessions may be weekly, biweekly, or monthly as determined by your counselor or therapist. Thirty (30 days) without contact will result in the termination of services and the referral source will be notified.
2. Failure to keep three (3) consecutive therapy sessions will result in a review of the client’s status. If the reasons for missing the scheduled appointments are unacceptable, the client will be discharged and the referral source notified.
3. Clients who appear for therapy sessions while under the influence of any non-prescribed drug, including alcohol, will have that appointment cancelled.
4. Clients will exhibit appropriate behavior while on premises and through telehealth sessions. Disorderly behavior, (i.e., excessive profanity, fighting, threatening behavior, vandalism, theft, possession of drugs or weapons), will result in termination of services.   No weapons of any kind will be permitted on the premises.  Disregard of this rule will lead to immediate discharge and/or arrest.  Verbal abuse is not tolerated and will also lead to discharge. All state, county, and federal laws must be observed, and any violations will be reported to the appropriate authorities while maintaining confidentiality as required by 42 CFR, Part II.
5. Clients are expected to dress appropriately when attending appointments.  Clients should not wear clothing that has vulgar language and/or inappropriate pictures, excessively revealing clothing, clothing considered to be pajamas or undergarments, etc.
6. Clients should refrain from using their cell phones during appointments. 
7. Clients should attend appointments alone and avoid bringing family members and friends to appointments when they are not a part of your treatment.
8. Parents and guardians are strongly encouraged to participate in therapy; however, neither their permission nor their participation is necessary for a minor 12 years or older to receive services.
9. A client’s ability to pay for services will be assessed during the intake interview. The assessed fee must be paid in full and on a timely basis. 

CONFIDENTIALITY IN GROUP SETTING
Group therapy sessions may be led by one or more leaders, including staff in training or interns. All staff and participants must adhere to confidentiality standards. All clients are expected to maintain the confidentiality of others, including refraining from sharing the names or personal stories of group members and ensuring that no one else is present to overhear or view telehealth sessions. Violations of confidentiality may result in removal from the group. Despite confidentiality expectations, there is a risk that group members may not fully uphold confidentiality. If you have questions about specific situations or any aspect of confidentiality, please discuss them with your counselor or therapist. Additional information can be found in the Notice of Privacy Practices.

DISCHARGE/TERMINATION OF SERVICES
Clients who choose to end services will be discharged immediately. Clients who have not attended sessions for 30 days or more and do not have an upcoming appointment scheduled may be discharged without prior notice. Once discharged, clients are no longer under the care of PBHG or its counselor’s or therapist’s. Discharged clients may request re-admission, which will be considered at the discretion of PBHG.

Missing 2 consecutive appointments or 3 out of 5 appointments may result in discharge, as active participation in treatment is essential. Clients who choose not to engage in treatment may also be discharged. Payment for services is required, and refusal to pay may lead to discharge. Sessions will begin and end on time, and clients arriving more than 10 minutes late may be marked as a no-show unless notified. Clients who arrive under the influence of drugs or alcohol will not be treated during that session. The manufacture, distribution, dispensing, possession, use, or being under the influence of controlled substances without a prescription is strictly prohibited, and violations may result in immediate discharge and referral to other services. Finally, clients are expected to respect the confidentiality of other clients at all times.

If you are unable or not interested in returning to PBHG for services for any reason, the following resources may be helpful to you:

• Emergency Services: Call 911 if you are experiencing a life-threatening emergency or require immediate assistance.
• Maryland 988 Crisis Hotline: Call or text 988 for 24/7 confidential support for mental health, substance use, or suicide-related crises.
• 211 Maryland: Call 211 for weekly mental health check-ins with trained professionals for suicide prevention and referrals for mental health, housing, or other support services in your area.
• SAMHSA’s National Helpline: 1-800-662-HELP (4357) for free, confidential, 24/7 treatment referral and information for mental health or substance use disorders.
• Crisis Text Line: Text HOME to 741741 to connect with a trained crisis counselor.
• Primary Care Provider: For general health or mental health support, consult your primary care physician.

RECORDS REQUEST
All requests for records must be submitted in writing. PBHG will respond within 21 working days. Records copies are provided for a fee at the discretion of the counselor or therapist (except Medicaid clients), payable prior to preparation, or at a rate consistent with state and federal guidelines.

GRIEVANCE PROCEDURE
Clients have the right to address treatment concerns, and if needed, to review any disagreements regarding treatment, discharge, or status changes with the Privacy Official. There will be no retaliation against clients who file a grievance. Clients are first encouraged to discuss their concerns with their counselor or therapist, who will work to resolve the issue. If the client remains unsatisfied, they may submit a written complaint to the Privacy Official using the contact information provided below. The Privacy Official will review the situation with all parties to fully understand the circumstances. A resolution will then be created to best address the needs of those involved, and a written response will be provided to the client within ten business days.

Byran T. Lee, M.S., LCADC

Privacy Official

byran.lee@pathwaysbhg.com

Karena T. Lee, M.S., LCADC

Privacy Official

karena.lee@pathwaysbhg.com

If you remain dissatisfied with the response from the Privacy Official, you may contact the following agencies:

Behavioral Health System of Baltimore (BHSB)

Compliance Coordinator

Tower II, 100 S Charles St 8th floor, Baltimore, MD 21201

Maryland Department of Health

Behavioral Health Administration

55 Wade Avenue, Catonsville, MD 21228

ACKNOWLEDGMENT
I have read and understood the contents of this form. I have only entered information about myself or an individual I am authorized to act on behalf of, such as my child. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Pathways Behavioral Health Group (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI:

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI:

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications:

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared:

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared:

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice:

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you:

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated:

You can file a complaint by contacting the Practice using the following information:

Byran T. Lee, M.S., LCADC

Privacy Official

byran.lee@pathwaysbhg.com

 

Karena T. Lee, M.S., LCADC

Privacy Official

karena.lee@pathwaysbhg.com

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications:

• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

OUR USES AND DISCLOSURES

Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

• To treat you: The Practice can use and share PHI with other professionals who are treating you. Example: Your primary care doctor asks about your mental health treatment.
• To run health care operations: The Practice can use and share PHI to run the business, improve your care, and contact you. Example: The Practice uses PHI to send you appointment reminders if you choose.
• To bill for your services: The Practice can use and share PHI to bill and get payment from health plans or other entities. Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

• Public health and safety issues: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or neglect: To report abuse, neglect, or domestic violence.
• Required by law: To comply with federal, state, or local law.
  Judicial and administrative proceedings: To respond to a court order or subpoena.
• Law enforcement: For locating or identifying individuals or disclosing information about a victim of a crime.

Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

• Marketing, sale of PHI, and psychotherapy notes: You may revoke your authorization, at any time, by contacting the Practice in writing. The Practice will not use or share PHI other than as described in this Notice unless you give your permission in writing.

Additional Protections for Substance Use Disorder (SUD) Treatment Records – 42 CFR Part 2 Compliance

In addition to the privacy practices described above, PBHG is committed to protecting the confidentiality of your Substance Use Disorder (SUD) treatment records in compliance with federal regulations under 42 CFR Part 2. These additional protections apply if you are receiving or have received SUD treatment services from PBHG.

• Your Written Consent is Required: PBHG will not disclose your SUD treatment records without your specific, written consent, except in limited situations allowed by federal law. This includes any disclosure to external health care providers, family members, or others.
• Exceptions to Written Consent: PBHG may disclose your SUD treatment records without your written consent:
  
  • In a medical emergency where disclosure is necessary to provide medical care.
  • In response to a court order meeting specific legal criteria.
  • To report suspected child abuse or neglect.
  • To qualified personnel for audits, program evaluations, or research (subject to strict confidentiality protections).
• Prohibited Use in Legal Proceedings: Your SUD treatment records cannot be used as evidence in legal proceedings against you without a valid court order.
• Your Rights:
  
  • You have the right to refuse to authorize disclosure of your SUD treatment records.
  • You may revoke your authorization at any time by submitting a written revocation to PBHG.
  • You are entitled to receive a copy of any consent form you sign.
• Notice of Risks if You Authorize Disclosure: If you authorize PBHG to disclose your SUD treatment records to a third party, those records may no longer be protected under 42 CFR Part 2, but they may still be protected by HIPAA and applicable state law.

OUR RESPONSIBILITIES

• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website.
• The Practice will inform you if PHI is compromised in a breach.

I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

PURPOSE OF TELEHEALTH SERVICES
Pathways Behavioral Health Group (PBHG) provides behavioral health services through secure video calls, phone calls, and other electronic methods to make services accessible. These sessions require a private space and reliable technology (e.g., computer or smartphone). While PBHG uses HIPAA-compliant platforms to protect your information, online communication carries some risks, such as unauthorized access or breaches due to unsecured internet or outdated software.

Emails are used for scheduling and general information. Some telehealth options that are not HIPAA-compliant may not have the same level of protection for your information. These systems might not use the highest security measures and could be more at risk for unauthorized access. They may also store your data in places that have different privacy rules, which could mean less control over how your information is stored or deleted. It’s important to understand these risks and choose the option that makes you feel comfortable. Always try to have your sessions in a private space to help keep your information safe and confidential.

TELEHEALTH CONSENT
By signing below, I consent to telehealth services and understand the following:

1. I must be physically located in Maryland to participate in telehealth services.
2. I can withdraw consent at any time without affecting future care or benefits.
3. Individual and group sessions must be held in a private, secure space to protect confidentiality.
4. Clients will not record sessions. However, providers may utilize a HIPAA-compliant artificial intelligence (AI) tool that temporarily records and transcribes sessions solely to assist with generating clinical documentation. These recordings and transcripts are automatically deleted once the clinical note has been reviewed and completed. This process complies with HIPAA regulations and requires separate client consent. Participation in the AI tool is voluntary and not a condition of receiving services.
5. If you are assigned an intern, their academic program may require them to record a session for training purposes. In this case, you will be asked to complete a separate consent form, and recordings will only occur if you provide your written permission.
6. Telehealth may not be suitable in emergencies or severe mental health crises.
7. Technical issues may interrupt sessions; reconnection or rescheduling may be necessary.
8. I understand the strengths and limitations of each method and have been informed of the security measures PBHG takes to protect my confidentiality in each type of transmission. I consent to the use of these transmissions as deemed appropriate for my treatment needs.
9. I understand that there may be instances where a non-HIPAA-compliant platform is required. If such a platform is used, I am informed of the associated privacy and confidentiality risks, including:reduced data protection;
   
   1. risk of unauthorized access;
   2. heightened cybersecurity vulnerabilities;
   3. varied data storage and privacy policies; and
   4. limited control over data deletion.
10. I accept these risks and consent to receive telehealth or telephonic services via this transmission if necessary, recognizing that PBHG will prioritize secure, HIPAA-compliant platforms whenever possible.
11. I understand these potential privacy and confidentiality risks associated with using a non-HIPAA-compliant platform. I accept these risks and consent to receive telehealth or telephonic services via this transmission if necessary, recognizing that PBHG will prioritize secure, HIPAA-compliant platforms whenever possible.
12. I understand that the same privacy laws protecting the confidentiality of my protected health information (PHI) apply to telehealth sessions, except in specific cases requiring mandatory reporting (e.g., child, elder, or vulnerable adult abuse; danger to self or others; legal proceedings involving my mental or emotional health).
13. I understand that my counselor or therapist may need to contact my emergency contact or relevant authorities in case of an emergency. I agree to provide my current location and an emergency contact at the start of each session.

ACKNOWLEDGMENT
I have read and understand this consent form. By signing, I agree to telehealth services, including understanding potential risks, the optional use of HIPAA-compliant artificial intelligence tools for clinical documentation, and the security measures taken to protect my privacy. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Mental Health Advance Directives:

A mental health advance directive (sometimes called a psychiatric advance directive) is a legal document you can prepare now to express specific needs and preferences for your mental health treatment in the event you are unable to make or communicate such decisions in the future. This allows you to appoint someone to assist with various health care matters, including a mental health crisis, and provides your specific directions regarding mental health treatment.

Benefits:

• Protects you from unwanted treatment.
• Provides clear instructions about medication and treatment to guide decision making.
• Improves communication between medical, support, and treatment networks, which may prevent involuntary treatment or admission to a hospital.
• Enhances your recovery.

Mental Health Advance Directives include:

• Your preferred hospitals and service providers.
• People you have authorized to make health decisions and with whom information may be shared or not shared.
• Any allergies, adverse reactions, and other health issues.
• Desired visitors.
• Specific preferences regarding treatment.

Resources:

• Flyer for the general public
• Mental Health Association of Maryland's In​​​​formation about Mental Health Advance Directives
• SAMHSA's App: My Mental Health Crisis Plan

Acknowledgement:

I acknowledge that I am 16 years of age or older and have been given the opportunity to be educated about and/or make an advance directive for mental health services. This directive includes a directive regarding provision of health care, withholding or withdrawal of life-sustaining procedures or appointment of an agent to make healthcare decisions for me. I also understand that this form is valid for one year from the date of completion, and it is my responsibility to notify my counselor or therapist of any changes to the information provided.

PURPOSE OF THIS FORM
Pathways Behavioral Health Group (PBHG) is committed to delivering high-quality behavioral health services. To support our commitment to professional development, we offer training opportunities for graduate-level student interns who work under the direct supervision of licensed mental health professionals. This form requests your consent for an intern to participate in your care.

INTERN INVOLVEMENT
Interns at our practice are advanced students receiving specialized training in treating behavioral health and co-occurring disorders. They work under the supervision of licensed mental health professionals to ensure the quality of care. Interns may:

• Conduct intake assessments and gather relevant clinical history.
• Participate in individual, group, and family therapy sessions.
• Assist in developing treatment plans and implementing intervention strategies.
• Maintain documentation in accordance with professional and legal standards.
• Record sessions as part of their practicum or internship coursework.

SUPERVISION AND CONFIDENTIALITY
All interns receive supervision from licensed mental health professionals, who oversee and review their work to ensure the highest standards of care and support. Confidentiality laws and professional ethics entirely apply to interns. Any information shared in sessions will be treated with strict confidentiality, except as required by law (e.g., mandated reporting of abuse, threats of harm to self or others, or legal subpoenas).

YOUR RIGHTS

• You have the right to decline or withdraw your consent at any time without affecting your access to care.
• You may request that a licensed clinician, rather than an intern, be the primary provider for your treatment.
• You can inquire about the credentials of both the intern and their supervising clinician.
• You may ask questions at any time regarding the intern’s role in your treatment.

ADDITIONAL INFORMATION

• Qualifications and Training: Interns are required to have completed core coursework in counseling, therapy, psychology, or social work and must be actively enrolled in an accredited graduate program. Their prior training includes coursework and supervised practicum experience specific to behavioral health. You may request specific details about your assigned intern's qualifications and educational background.
• Notification of Assigned Intern: You will be informed of the specific intern assigned to your care prior to their involvement. PBHG staff will provide the intern’s name, academic background, and supervising clinician’s information.
• Concerns About Intern Performance or Care: If you have any concerns about the intern’s performance or the care you receive, you may discuss these concerns with the supervising clinician or the Clinical Director. You also have the right to request a reassignment or discontinue working with the intern at any time.

CONSENT STATEMENT
I acknowledge that I have read and understand this consent form. I voluntarily agree to allow an intern, under the supervision of a licensed mental health professional, to be involved in my mental health and/or substance use disorder treatment. I understand that I have the right to withdraw this consent at any time. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

TUBERCULOSIS (TB)
Tuberculosis (TB) is an infectious disease that primarily affects the lungs but can also impact other parts of the body. It spreads through the air when someone with active TB in the lungs or throat coughs, sneezes, or talks. While TB is not easily contracted, prolonged close contact with someone infected, such as among family members or in shared spaces, can increase the risk. Untreated TB can be fatal, but it is treatable and curable with proper medication.

Treatment for Tuberculosis: The standard treatment for active TB disease involves taking a combination of antibiotics, usually including isoniazid, rifampin, ethambutol, and pyrazinamide. Treatment typically lasts 6 to 9 months, depending on the individual’s response and the presence of drug-resistant TB strains. It is critical to complete the full course of treatment to ensure the infection is fully eradicated and to prevent antibiotic resistance.

TOBACCO
Tobacco use is a leading preventable cause of disease and premature death, responsible for approximately 443,000 deaths annually in the U.S., including indirect fatalities from secondhand exposure and prenatal smoking effects. Quitting smoking is critical for improving health and life expectancy, with many resources available to support cessation efforts.

Effective Smoking Cessation Resources:  Effective resources for quitting smoking include evidence-based programs such as the American Lung Association’s Freedom From Smoking® program, nicotine replacement therapies (e.g., patches, gums, lozenges), prescription medications like varenicline (Chantix) and bupropion (Zyban), and behavioral counseling. Combining medication with counseling significantly increases the chances of successfully quitting.

HIV/AIDS
HIV is the human immunodeficiency virus that damages the immune system by targeting CD4+ T cells. It is primarily transmitted through unprotected sex, sharing needles, or from mother to child during birth. Early symptoms can be mild or absent, so testing is essential if exposure is suspected. Preventive measures include consistent condom use, limiting sexual partners, and consulting with healthcare providers about pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

SEXUALLY TRANSMITTED DISEASES (STDS)
Sexually transmitted diseases, or STDs, are infections often spread through sexual contact. Common symptoms include painful urination, unusual discharge, and sores. Practicing safe sex, reducing partners, and getting vaccinated (e.g., for HPV or hepatitis B) are effective ways to lower STD risks. Prompt medical attention is advised for symptoms, and testing can confirm any suspected infections.

Long-Term Effects of Untreated STDs:  Untreated STDs can lead to serious long-term health complications. For example, untreated chlamydia and gonorrhea can cause pelvic inflammatory disease (PID) in women, leading to infertility and chronic pelvic pain. Syphilis can result in severe neurological and cardiovascular problems if left untreated. HIV can progress to AIDS without treatment, severely weakening the immune system. Early diagnosis and treatment are crucial to prevent these potential health impacts and protect overall well-being.

HEPATITIS
Hepatitis refers to liver inflammation, which can result from viruses (types A, B, C, D, and E), alcohol use, or autoimmune disease. Hepatitis B and C can lead to chronic liver conditions, including cirrhosis and cancer. Preventive measures include good hygiene practices, safe food handling, and vaccinations for hepatitis A and B, especially when traveling to areas with high hepatitis rates.

FOR TREATMENT OR TESTING
For testing or treatment, please visit your primary care physician (PCP) or request a referral from your counselor or therapist.

ACKNOWLEDGMENT
By signing below, I confirm that I have read and understand the information provided about infectious diseases, including tuberculosis, tobacco use, HIV/AIDS, sexually transmitted diseases (STDs), and hepatitis. I acknowledge that I am aware of the risks, prevention methods, and the importance of seeking testing or treatment as necessary. I understand the recommendations provided and agree to follow up with my healthcare provider or the suggested resources if I have any concerns or questions. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

PURPOSE
Overdose Prevention Education ensures all clients, regardless of substance use history, are educated on recognizing and responding to overdose risks, equipping them with lifesaving knowledge and harm reduction strategies. This universal approach fosters safety, reduces stigma, and empowers clients to protect themselves and their communities.

WHAT IS AN OVERDOSE?
An overdose occurs when a person consumes more of a substance—or a combination of substances—than their body can process. This can result in the central nervous system (CNS) being unable to regulate essential life functions, such as breathing, heart rate, and consciousness. Overdose symptoms vary depending on the substance but may include unconsciousness, slowed or stopped breathing, seizures, irregular heartbeat, or a blue tint to the skin or lips. Overdoses can be fatal, but fatalities are often preventable with timely intervention.

WHO IS AT RISK?
Anyone who uses substances can experience an overdose—whether it’s their first time or they are a long-time user. Factors like tolerance, drug potency, and mixing substances can make it difficult to predict how a drug or combination of drugs will affect someone. It’s essential to emphasize that there is no completely “safe dose.”

FACTORS THAT INCREASE OVERDOSE RISK

1. Tolerance: Tolerance can change due to weight fluctuations, new medications, periods of abstinence, or changes in physical or mental health. After a break in use, even a previously tolerated dose can lead to overdose.
2. Mixing Substances:
   
   • Combining depressants (e.g., opioids, alcohol, benzodiazepines) can dangerously suppress breathing and heart rate.
   • Mixing stimulants (e.g., cocaine, methamphetamine) with depressants can mask overdose symptoms, increasing risk.
   • Alcohol is a frequent factor in mixed-drug overdoses, worsening dehydration and CNS depression.
   • Prescription drugs mixed with street drugs can lead to unpredictable effects and overdose.
3. Drug Potency and Quality: Street drugs often vary in potency and may contain unknown substances like fentanyl, a synthetic opioid significantly more potent than heroin. Testing drugs with fentanyl test strips can reduce risk.
4. Using Alone: Using alone increases the risk of fatal overdose since no one is available to call for help or administer naloxone.
5. Health and Drug Accumulation: Poor health, dehydration, or recent illness can make it harder for the body to process substances. Repeated dosing before the body has metabolized prior doses can also lead to overdose.
6. Past Overdose Events: Individuals who have overdosed before are at a higher risk of experiencing another overdose.
7. Route of Administration: Injecting substances carries a higher overdose risk than smoking or snorting due to the rapid onset of effects.

SIGNS AND SYMPTOMS OF OVERDOSE BY SUBSTANCE

Opioids (e.g., Heroin, Fentanyl, Prescription Painkillers)

• Unresponsiveness or unconsciousness
• Slow or stopped breathing
• Pinpoint pupils
• Blue or grayish lips, skin, or nails
• Weak, slow, or absent pulse
• Gurgling or choking sounds

Action: Administer naloxone immediately if available and call emergency services.

Stimulants (e.g., Cocaine, Methamphetamine, MDMA)

• Chest pain or rapid heartbeat
• Elevated body temperature (hyperthermia)
• Agitation, paranoia, or confusion
• Seizures
• Excessive sweating or dry, hot skin
• Sensations of skin crawling
• Difficulty breathing

Action: Cool the person down, ensure they have access to air, and call emergency services.

Benzodiazepines (e.g., Xanax, Valium, Ativan)

• Extreme drowsiness or unconsciousness
• Slow or stopped breathing
• Slurred speech
• Unsteady gait or lack of coordination
• Weak or slow pulse
• Paradoxical agitation (rare)

Note: Naloxone has no effect on benzodiazepine overdoses. However, if opioids are involved, administer naloxone and seek emergency care.

Alcohol

• Confusion, stupor, or unresponsiveness
• Vomiting while unconscious
• Slow or irregular breathing (less than 8 breaths per minute)
• Hypothermia (cold, clammy skin)
• Blue or pale skin, especially around lips or fingernails

Action: Turn the person on their side to prevent choking and call emergency services.

Hallucinogens (e.g., LSD, Psilocybin, PCP, Ketamine)

• Agitation or extreme confusion
• Violent behavior (especially with PCP)
• Seizures
• Elevated blood pressure or heart rate
• Nausea or vomiting
• Respiratory distress (in rare cases with ketamine or high doses of other hallucinogens)

Action: Provide a calm environment and seek emergency help if symptoms escalate or if the person is a danger to themselves or others.

Synthetic Cannabinoids (e.g., "Spice," "K2")

• Extreme agitation or paranoia
• Rapid heart rate
• Seizures
• Nausea and vomiting
• Chest pain
• Difficulty breathing

Action: Call emergency services immediately, as synthetic cannabinoids can cause unpredictable and severe reactions.

Inhalants (e.g., Nitrous Oxide, Paint Thinners, Glue)

• Confusion or hallucinations
• Slurred speech
• Loss of motor control or coordination
• Unconsciousness or coma
• Irregular or rapid heartbeat
• Seizures

Action: Remove the person from the source of inhalants, provide fresh air, and call emergency services.

Depressants Combined with Alcohol (e.g., Opioids, Benzodiazepines, Barbiturates)

• Severe CNS depression
• Respiratory arrest (stopped breathing)
• Unresponsiveness or inability to wake up
• Pale, cold, or clammy skin

Action: Administer naloxone if opioids are involved, seek emergency medical assistance, and ensure the person is not left alone.

HARM REDUCTION STRATEGIES

The best way to prevent an overdose is ABSTINENCE. Below is a list of harm reduction strategies to prevent an overdose:

1. Carry Naloxone (Narcan): Naloxone can reverse opioid overdoses if administered promptly. It is safe, widely available, and easy to use. While naloxone does not reverse cocaine or stimulant overdoses, it can save lives in cases involving opioid use.
2. Test Your Drugs: Use fentanyl test strips to check substances for contamination. This is especially important for non-opioid drugs like cocaine, which are increasingly contaminated with fentanyl.
3. Don’t Use Alone: If using, let someone you trust know or use overdose prevention tools like supervised consumption sites or apps that alert emergency responders if you stop responding.
4. Start Low, Go Slow: If you haven’t used recently or are trying a new batch, start with a small amount.
5. Avoid Mixing Substances: Mixing substances increases the risk of overdose. If possible, avoid using alcohol or benzodiazepines with opioids.
6. Stay Hydrated and Nourished: Proper hydration and nutrition help the body metabolize substances and reduce overdose risk.

ACKNOWLEDGMENT OF OVERDOSE EDUCATION

By signing below, I acknowledge that I have read and received information about overdose prevention, the risks associated with substance use, and harm reduction strategies. I understand the importance of taking proactive steps to reduce overdose risk. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Emergency Contact #1

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Emergency Contact #2

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Primary Care Physician (PCP) Notification

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Other Behavioral Health Provider Notification

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Other Behavioral Health Provider Notification

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Other Behavioral Health Provider Notification

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