INFORMED CONSENT for PSYCHIATRIC SERVICES
    Must be completed 24 hours prior to your first appointment or it will need to be rescheduled 

    INITIAL EVALUATION & SESSIONS 
    A thorough psychiatric evaluation will be conducted during the initial session. This assessment focuses on determining the best treatment plan possible and is specific to each individual patient. In some situations, extra sessions are needed to complete an appropriate evaluation.

    If there is a potential of any physical danger to you or others, you will call 911 immediately or go to the closest emergency room.

    Note:     I do not have admitting privileges, nor am I affiliated with or on staff at any hospital. Should I deem more intensive services are needed than I can provide, I will do my best to ensure your safety and obtain the appropriate level of care, but I cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.

    MEDICATION MANAGEMENT 
    Psychiatric medications can be used in conjunction with psychotherapy to treat many conditions. It is important to find the best combination of medications and therapy for each individual case. In situations that warrant the use of medications, it is imperative for you to understand the target symptoms and likely outcomes. Additionally, since all medications have the potential for side effects, it is important you understand the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) of each medication.
    Since you are seeing me for medication management only:
    • If you have a therapist, you will contact your therapist first for any emergency or crisis, unless it may be medication related
    • You will inform me if you are/am considering stopping therapy, or have actually stopped therapy.

    REFILL REQUESTS
    It’s good practice to request refills while you still have 1-2 weeks of medication remaining. Suddenly stopping medications can be dangerous and cause withdrawal effects. Therefore, it is imperative that you do not run out of medications.

    CONTROLLED SUBSTANCES
    • I am licensed as a Medicinal Cannabis Provider in Maryland Only
    • I do not prescribe Suboxone at this time, but I would be happy to assist you in finding a Suboxone program near you.
    • I do not prescribe opioids as pain management is not my specialty, but I can assist you in finding a pain management clinic.

    CONFIDENTIALITY 
    Confidentiality is a cornerstone of mental health treatment and is protected by the law. All records are stored using an industry leading electronic health record called Simple Practice and Headway. Your records should only be accessed by your current provider and yourself. Please note that it is policy to always protect this information in accordance with all legal and ethical standards. All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. Most records will be available to you through your patient portal. Because client records are professional documents, they can be misinterpreted and can be upsetting. If the records you need are not accessible, I will either be happy to provide the records to an appropriate mental health professional of your choice or to prepare an appropriate summary. If you wish to see the original records, it is best to review them with me so that we can discuss their content.

    If you would like other providers or persons to have access to your records, please completed a release of information.

    Several exceptions to confidentiality do exist. As a mandated reporter I am required by law to disclosure the following information:
    • Danger to Self – if there is threat to harm yourself, we are required to seek hospitalization for the client, or to contact family members or others who can help provide protection
    • Danger to others – if there is threat of serious bodily harm to others, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization
    • Suspicion of Child, Elder, or Dependent abuse – if there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, we must file a report with the appropriate state agency
    • Certain Judicial Proceedings – if you are involved in judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances in which your emotional condition is an important element, a judge may either subpoena your records or require testimony through a court order.
    • If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
    • Insurance Reimbursement-if pursued, insurance companies often require information about diagnosis, treatment, and other important information (as described above) as a condition of your insurance coverage
    • If you pay by credit card, my name will appear on your credit card statement
    • If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collection agency or other responsible party.

    We also reserve the right to consult with other professionals when appropriate. In these circumstances, your identity will not be revealed and only important clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential. If a referral is necessary, this will be discussed in session and your provider will work to collaborate with these professionals and coordinate your care. Please note, however, that although we attempt to identify top quality professionals with very high standards of care, we cannot be responsible for the services/treatment that they provide. It is always your responsibility to determine if a professional referral is acceptable, and alternative options will be considered.

    Written HIPAA Privacy Practices and HIPAA video can be found here in multiple languages: https://www.hhs.gov/hipaa/for-individuals/index.html

    CONTACTING YOUR PROVIDER 
    The preferred method for contacting your provider is through Headway’s Patient Portal. Response time is approximately 24 to 48 hours unless otherwise noted. Email may also be used to communicate, but keep in mind that this is not a secure means of communication and if you wish to converse via email your confidentiality cannot be ensured. If you need to contact your provider by phone, please leave a voice message, but we cannot guarantee that your message will be received or responded to in a timely fashion. If this is an emergency, please contact 911 immediately instead of calling the office. Emergency psychiatric services are provided by all hospitals through their emergency rooms and do not require appointments.

    CANCELLATIONS, LATE FEES AND NO-SHOW POLICY 
    There is a cancelation and/or no-show fee, unless notice is provided at least 48 business hours in advance. You may cancel by deleting your appointment from the scheduling calendar (you will be locked out from cancelling 48hrs in advance). If you are more than 15 minutes late to an initial evaluation or 10 minutes late to a med check, it will be cancelled and the no-show fee will be applied (remember appointments are only 20 minutes). If there are more than 3 no show appointments in a row, services may be terminated. If you miss your scheduled appointment and need medication refills, you can request an order be written with enough medication to last until your next scheduled appointment.

    ​PROFESSIONAL FEES
    • Private Pay Initial Psychiatric evaluations (40 minutes) = $350
      Private Pay Medication Checks (20 minutes) = $150
      Comprehensive Written Psychiatric/Psychosocial Evaluation for a 3rd Party = $400
    • No Shows or Cancellations within 48hrs of the appointment: $25
    • Form Completion (worker’s compensation, school, employer; doctor’s notes, letters, or reports): $25 per 15 minutes (most forms take 15 minutes).
    • Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority: TBD

    By signing my name below, I acknowledge that I am my own guardian and have read and understand the information above and agree to the terms outlined. 
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