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I voluntarily consent that I will participate in outpatient behavioral health treatment at Alternative Consulting Enterprises, LLC for myself or the identified person whom I am the Legal Guardian. I understand that services may be provided by licensed counselors, unlicensed counselors, psychologists and/or psychiatrists. Services may include interviews, assessments, psychotherapy, and medication management.
I understand that outpatient behavioral health treatment has both benefits and risks. Risks may include experiencing unwanted feelings or thoughts when discussing past or current life experiences. I understand that psychotherapy includes benefits such as improving quality of life and mental wellness.
I understand that the exchange of health records between medical providers is essential in providing coordination of care. I understand that ACE will work to coordinate care with my Primary Care physician on an on-going basis by requesting medical records at the onset of treatment and every year thereafter unless the appropriate Release of Information has been revoked or suspended.
I understand that I have a choice to participate in medication management in order to address my mental wellness. If I receive medication management services, I understand that I may experience side effects from medications, which I will immediately report to my psychiatrist.
By signing below, I acknowledge that I have read and understand the Consent for Outpatient Behavioral Health Treatment.
I voluntarily consent that I will participate in telehealth services which is a form of telemedicine using two-way real-time interactive audio transmission that allows patients to access psychiatric care and outpatient services using videoconferencing. I understand that network and software security protocols shall be utilized to protect the confidentiality and integrity of the information shared. I understand that I am responsible for providing an environment free of interruptions and distractions so that effective telehealth services may occur.
I understand that the benefits include improved access and availability of psychiatric care. I understand that potential risks may include: insufficient information sharing from poor video or audio interference, failure of equipment may result in delays in medication evaluations, and the observation of client affect and other behavioral observations may be less accurate due to the nature of video conferencing.
I understand that the laws that protect privacy and confidentiality of health information apply to all telehealth services. I understand that I have the right to withhold or withdrawal my consent for telehealth services and in-person services must be provided by the agency. I understand that while receiving medication management services, I may receive medication that may cause adverse side effects which I will immediately report to my psychiatrist. I understand that if the agency determines that telehealth services are not deemed to be clinically appropriate that the agency may discharge to another provider or to the managed care organization.
I voluntarily consent that I will participate in telepsychiatry which is a form of telemedicine that allows patients to access psychiatric care using videoconferencing. I understand that network and software security protocols shall be utilized to protect the confidentiality and integrity of the information shared.
I understanding that the laws that protect privacy and confidentiality of health information apply to Telepsychiatry. I understand that I have the right to withhold or withdrawal my consent at any time with a formal written request. I understand that while receiving medication management services, I may receive medication that may cause adverse side effects which I will immediately report to my psychiatrist.
By signing below, I acknowledge that I have read and understand the Consent for Telepsychiatry.
