Consent Form

SERVICES

Insight Mental Wellness is a group practice that offers a variety of mental health services to include medication management, psychotherapy sessions, psychological evaluation, and other advance therapeutic services such as rTMS, Genetic testing services, Alfa Stim, Spravato (Esketamine), and Medication-Assisted Treatment (Suboxone) services for children, adolescents, adults, and geriatric population. Our goal as providers and clinicians is to work with you on an individual basis to collaboratively form a successful treatment plan that ensures improvement in quality of life and stability of your mental and overall health. Insight Mental Wellness is an integrated clinic of mental health providers. At any time, there may be other mental health professionals that will visit with you based on the scheduled service. There is always consistency with your set treatment plan. You can also request an appointments via our website. First appointment is your intake session. This will be focused on biopsychosocial information gathering to facilitate your treatment. This process can be conducted by any of the approved clinic staff/aids and reviewed and finalized by the clinic provider/clinician for preliminary diagnosis. The following areas of information will be reviewed to include history on your medical, medications, social, substance use, family, hospitalizations, and reason for visit and desired goal for treatment. There is NO medication management done during this session. You MUST complete your paperwork and provide all documents and IDs prior to this visit. YOU WILL NOT BE SEEN BY THE CLINIC UNLESS ALL FORMS ARE COMPLETELY FILLED OUT AND NEEDED DOCUMENTS RECEIVED PRIOR TO YOUR VISIT. There is a cancellation/rescheduling/no-show fee that will be assessed per clinic policy. The session ranges from 20-30 minutes. Medication Management: During this appointment, your provider will focus on you while reviewing and discussing your intake information to assist in formulating diagnosis and facilitating a successful treatment plan. The provider will work collaboratively with you to come up with recommendations on a successful treatment plan for optimal health. When the treatment plan includes the use of prescription medication/over the counter (OTC)/ or supplements medication, your provider will discuss with you the nature of your disorder, the reason for the medication, and any possible alternative treatments such as advanced therapeutic treatments. As part of your treatment plan with medication management, you may be requested to complete certain laboratory testing(s). Depending on the form of treatment indicated or controlled medications prescribed, you will be required in accordance with the clinic policy to complete random procedures such as Genetic testing, Electroencephalogram (EEG), Electrocardiogram (EKG), Urine Toxicology Screening (typically random and based on provider discretion). You will
be required to schedule and maintain a monthly appointment for controlled medication review and follow ups. Clinician as a standard practice Initial psychiatric medication management ranges from 45-60 minutes and follow-up visits range from 20-30 minutes. This is a group practice, and your sessions may be conducted by any of our providers with specific review of your treatment plan for consistency of care. Medications - It is very helpful for you to bring all of your pill bottles for review. Your provider can then determine which psychotropic medications are best used with your other prescribed medications. It also helps us know if new medications, including those prescribed by another provider, have been added. Please provide your provider of such changes. Samples - We may be fortunate to have available some medication samples provided free-of charge from local pharmaceutical representatives. Generally, these are used when first starting a new medication or when the pharmacy cost would otherwise prohibit you from using the medication. We can also assist you in applying for medication assistance directly from the pharmaceutical company. Many of their assistance plans are quite generous. Please do not hesitate to ask about availability of samples. Sample medications cannot be mailed out from IMW. If you have a designated person pick up your samples, you will need to provide us with their name in advance. They will need to show their identification and sign out your samples. From time to time, the pharmaceutical representatives will visit our office to update us on their products and to deliver samples. Laboratory tests can be ordered from time to time to investigate medical problems interfering with your mental health and/or to monitor medication side effects. Your provider might try to obtain recent lab results from your other doctors if available. If necessary, you may obtain the ordered lab at your primary care doctor’s office or at any other facility available with your insurance carrier. Your provider will assist you in arranging for laboratory tests. If you have not heard back about the results of labs ordered by your IMW provider in two weeks, please call our office for results.

Psychotherapy: Evidence based studies conclude that therapy along with medication management is an established form of effective treatment plan with mental health treatment. Our clinicians engage in various forms of specialty care. A successful psychotherapy session entails building a good rapport with your clinician with active engagement and trust building over the course of your sessions. Our clinicians utilize behavioral modification techniques to foster healthy habits, Challenging beliefs, and Mindfulness. Your first appointment will entail review of general information about your current situations, concerns, and goals for therapy. Based on your assessment, your clinician may suggest more than one approach or therapy technique. Therapy sessions are considered complete in agreement with the patient/guardian. There may be a phase out session or referral to another clinician depending on the patient's progress or expressed desire. Initial therapy sessions last 45-60 minutes and follow up sessions are between 30 minutes to 55 minutes (Depending on your insurance benefits). Sessions are set for weekly, biweekly, or monthly based on medical necessity. IMW is pleased to work with a variety of psychotherapists in the community. We refer patients to the appropriate therapists when indicated, thereby guiding you to the best match of patient and therapist. If you specifically wish to see a therapist, please advise your provider. Psychological Testing(s): The testing process involves an initial personal assessment by the psychologist, completion of indicated batteries of psychological assessment, and a review of report(s). The total time of the evaluation may vary upon the identified testing (s). There may be moments of emotional distress during the testing process. You may indicate a need to pause the evaluation process at any time. A technical assistant often works with the psychologist in
completing this process. The evaluation processes are often split up by hours or days based on space availability. Upon completion of the test(s), the psychologist prepares a report based on the information gathered from your testing. Your report can be used to facilitate your overall treatment planning and medication management at the clinic. Your finalized report can also be shared with any parties desired with your written consent. Conditions Commonly Evaluated Include:

ADHD Asperger’s Disorder

Autism Spectrum Disorder

Developmental Delays/Disorders

Dementias

Dyslexia

Executive Functioning Disorders

Learning Disabilities

Memory Impairments

Mental Retardation

Personality Disorders

Clarification on Psychiatric/Mental Health Disorders

Various neurological and medical conditions (e.g., pre surgical/bariatric psychological evaluation) with potential neurocognitive effects Transcranial Magnetic Stimulation (rTMS): TMS (transcranial magnetic stimulation) Therapy was FDA cleared in October 2008 for patients suffering from depression who have not achieved satisfactory improvement from prior antidepressant medications. Using pulsed magnetic fields, transcranial magnetic stimulation therapy stimulates the part of the brain thought to be involved with mood regulation. TMS Therapy is a short outpatient procedure, performed in your psychiatrist’s office and supervision while you remain awake and alert. During TMS Therapy, a magnetic field is administered in very short pulses to the part of the brain that research has demonstrated to be associated with depression. The typical initial course of treatment is about 19-40 minutes, depending on what the doctor determines is the correct protocol, the treatment frequency is determined based on evaluation over 4-6 weeks.

Telepsychiatry Services: Televists are a form of video/audio conferencing that allows our providers and clinicians to provide services to you in the comfort of your own desired location, anywhere in the state of Texas with privacy. The Clinic will provide access to secure HIPAA compliant conferencing mediums at the time of your visit. While our server is secure and the video platform is HIPAA compliant, we cannot guarantee your confidentiality due to our inability to control your server or the environment in which you are joining the session. You must have a high-speed internet to permit a smooth session and click the link provided to you at the time of your appointment to enable the session. The Clinic ensures that the interaction between every patient and his or her healthcare provider is completely secure and HIPAA compliant. The teleconferencing software instantly encrypts all forms of data, including video and audio. With telemedicine, travel to our office -— and the stress that accompanies it -— is eliminated. In addition, telemedicine enables treatment continuity for patients who usually come to the office but are sick or traveling. Please don’t hesitate to contact our office for more information and to determine if telemedicine/video medicine is a good choice for you. Televisits based services and care may not yield the same results nor be as complete as face-to- face service for some patients. The need for in-person clinic visits can be determined by the provider/clinician based on necessity. If there is a conflict in treatment plan based on assessment, the clinic will refer you to a local clinic for continuation of care

If you are under the age of 18, Texas State Law requires that we obtain permission from your parent or managing conservator/guardian in order to offer you psychiatric treatment/counseling services. Under Texas State Law, parents/guardians may still have access to your counseling/psychiatric record and/or could talk with your provider whether parental consent is necessary or not. A provider may contact a parent/guardian without consent, if deemed necessary. The signee below agrees to and provides consent on behalf of the minor based on all the information provided in this form. Termination of Service(s): The clinic reserves the right to terminate care if a case of patient noncompliance with treatment plan/medication management/follow up recommendations becomes the barriers to a successful treatment. We encourage you to discuss any concerns you have about our work together. Other factors that may result in termination of treatment by the clinic include, but are not limited to, violence or threats toward clinic/staff, irreconcilable differences, or refusal to pay for services in due time. Insight Mental Wellness reserves the right to terminate services after 2 incidents of rescheduling/no-shows/or same day cancellation of appointment. If the applicable fees are not paid by the follow up appointment, we will not be able to schedule another appointment and the patient may be discharged from the practice. Referrals - At IMW we are glad to receive from others and refer to other providers for continuation of care or collaborative care. (Example, physicians, other therapists, employee assistance programs, etc.) We may also recommend that you see another provider, such as a medical specialist or specialized therapist, if it is felt that a more comprehensive consultation is warranted.

I understand that it is my right as a patient to receive a copy of my HIPPA rights at any point of being a patient of IMW. Notice of Privacy applies to all forms of services provided at the clinic. All medical records remain confidential and only released with your consent (verbal/written) authorizing disclosure of your information. However, if there is any information related to animal abuse, including cases of neglect and hoarding. Vulnerable Adults and Children: Mental health professionals are required by law to report stated or suspected abuse of a child or vulnerable adult to the appropriate social service agencies and/or legal authorities. Prenatal Exposure to Controlled Substances: in keeping with protecting vulnerable
populations, Mental Health Providers are required to report admitted use of controlled substances during pregnancy that are potentially harmful to the fetus. Minors/Guardianship: Parents or legal guardians have the right to access a minor client’s health information. Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The practice reserves the right to change the privacy policy as allowed by law.

The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.

The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

The practice may condition receipt of treatment upon execution of this consent.

We may phone, email, or send a text to you to confirm appointments.

We may leave a message on your answering machine at home or on your cell phone.

We may discuss your medical treatment plan to include diagnosis with pertinent members of your healthcare collaborative team in order to further enhance your care.

I, identified patient / parent or guardian of minor / guardian of patient, hereby authorize the disclosure of information from my health record.

I understand that the records to be released/obtained may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness.

I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

ONLY applicable when requesting personal records for your own purpose: I acknowledge I will pay any associated cost(s) with retrieving personal copies of my medical records before they are released to myself.

RIGHTS: I understand: I have the right to revoke this Authorization by written request at any time; my revocation will be effective upon receipt, but will have no impact on uses or disclosures made while my Authorization was valid; my records may be subject to re-disclosure by recipient(s) and unprotected by Federal or State law; I may inspect a copy of my Protected Health Information to be used or disclosed under this Authorization; I may refuse to sign this Authorization and my refusal will not affect my eligibility for care or condition treatment; and a copy of this signed, dated Authorization shall be effective as the original.

Expiration: This authorization shall become effective immediately and shall remain in effect and valid from the date of signing and throughout your treatment duration with the clinic. Otherwise, provide a termination date to the clinic at will, except to the extent that action has been taken in reliance on it.