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  • Consent for Psychiatric Treatment

  • Please read this form carefully. Ask your provider about anything that is unclear before signing.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Care Setting (check one)*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Consent to Evaluation and Treatment

    I voluntarily consent to psychiatric evaluation and treatment by the providers and clinical staff of Limitless Mind Lab. Treatment may include a diagnostic interview, mental status examination, review of medical and medication history, collateral information from family or caregivers, supportive counseling, behavioral and environmental recommendations, coordination with other treating professionals, and — when clinically appropriate — the prescription, review, or adjustment of medication.

  • 2. Nature of Psychiatric Care

    Psychiatric care is a collaborative process, and outcomes cannot be guaranteed. Progress depends on many factors, including the accuracy of the information provided, the patient's participation, and the patient's response to treatment. My provider has offered to discuss the expected benefits, reasonably foreseeable risks, and available alternatives for any treatment recommended, including the alternative of no treatment.

  • 3. Medication

    Medication is not automatically prescribed. If medication is recommended, my provider will discuss its purpose, common and serious side effects, alternatives, and what monitoring is required. I understand that I may ask questions at any time and may decline any medication.

  • 4. Right to Ask Questions, Refuse, or Withdraw

    I understand that I may ask questions at any point, may refuse any part of the evaluation or treatment, and may withdraw this consent at any time by notifying Limitless Mind Lab in writing. Withdrawing consent will not affect care already provided.

  • 5. Confidentiality and Its Limits

    Information shared during treatment is confidential and protected by state and federal law, including HIPAA. There are limited circumstances in which the law permits or requires disclosure without my authorization, including:

    • — A serious and imminent risk of harm to the patient or to another identifiable person.
    • — Suspected abuse, neglect, or exploitation of a child, a vulnerable adult, or an elderly person.
    • — A valid court order, subpoena, or other legal requirement.
    • — Disclosures permitted by law for treatment, payment, and health care operations.
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  • 6. Emergencies and After-Hours Care

  • Limitless Mind Lab is not an emergency or crisis service and does not provide 24-hour coverage. In a mental health emergency I will call 988 (Suicide & Crisis Lifeline) or 911, or go to the nearest emergency department. Office hours are Monday through Friday, 8:30 a.m. to 4:45 p.m.

  • Consent for Telehealth (Virtual Visits)

  • Complete this section if any of your care will be delivered by secure virtual visit.

    I consent to receive psychiatric services from Limitless Mind Lab by telehealth. I understand that:
    • Telehealth uses secure, HIPAA-compliant video or audio technology in place of an in-person visit.
    • The same standards of confidentiality and professional practice apply to a virtual visit as to an in-person visit.
    • Technology can fail. Connections may drop, audio or video quality may be poor, and — despite reasonable safeguards — no electronic transmission can be guaranteed secure.
    • My provider may determine that a condition is not appropriate for telehealth and may ask me to be seen in person or referred elsewhere.
    • I am responsible for being in a private, safe location during the visit, and for providing my current physical address so emergency services can be directed if needed.
    • Visits are not recorded by Limitless Mind Lab without separate written authorization, and I will not record a visit without my provider's written permission.
    • I may withdraw this telehealth consent at any time without affecting my right to future in-person care.

  • Coordination of Care and Release of Information

  • So that care is safe and well-coordinated, I authorize Limitless Mind Lab to exchange clinical information with the individuals and organizations I check below:
  • Select individuals and organizations to authorize release of information:*
  • This authorization remains in effect for one year from the date signed unless I revoke it earlier in writing. Revocation does not apply to information already released in reliance on this authorization.

  • Acknowledgments

  • Please acknowledge the following:*
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  • Please acknowledge the following:*

  • Signatures

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • If the patient is unable to consent, complete the section below.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Relationship / authority (check one):
  • Documentation of authority reviewed and placed in the medical record:
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Retain the signed original in the patient's medical record and offer a copy to the patient or legal representative. This form is a template and should be reviewed by your practice's attorney or compliance advisor before use.
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  • Should be Empty: