Informed Consent for Behavioral & Mental Health Care

BEHAVIORAL HEALTH INFORMED CONSENT

This form provides an overview of behavioral and mental health services offered at our practice, outlines the potential benefits and risks, reviews your rights as a patient, and seeks your informed consent to participate in treatment. Please read carefully and ask your provider if you have any questions before signing. If you require this form in another language or accessible format, or need accommodations for your treatment, please notify us so we can assist you appropriately.

Patient Information

About Behavioral Health

Behavioral health treatment involves working with a licensed mental health professional to address emotional, psychological, or behavioral challenges affecting your daily life and relationships. Treatment may include individual, couples, or group therapy, as well as evidence-based approaches like cognitive-behavioral therapy (CBT), trauma-informed care, and mindfulness techniques. Your care will be tailored to your specific needs and goals, focusing on understanding and managing your thoughts, emotions, and behaviors in a constructive way. Sessions typically last 45 to 60 minutes and may occur weekly or biweekly, either in person or via secure telehealth platforms. If you choose to participate in telehealth sessions, you will be asked to sign a separate telehealth consent form in addition to this consent form.

Therapy is a collaborative process, and your active participation is key to progress. You can expect open, respectful dialogue in a safe, supportive environment, where you may explore current concerns, personal history, and coping strategies. While therapy can lead to increased emotional awareness, stronger relationships, and symptom relief, it can also bring up difficult emotions and requires time and commitment. Your therapist will offer guidance and support, but your honesty and engagement will play a central role in achieving meaningful change. You are always encouraged to ask questions or express any concerns about your treatment.

This consent will remain in effect for the duration of your treatment unless you withdraw it in writing or until updated by the practice.

Confidentiality

Your privacy is very important to us, and the information you share during your sessions will be kept confidential. This means that what you discuss with your provider will not be shared without your permission. If you would like your provider to discuss your treatment with another person, such as a family member or another healthcare provider, you will need to sign a release form giving them permission to do so.

It is important to note that there are some exceptions to this rule where the law requires your provider to break confidentiality. These situations include:

• If you share that you are planning to harm yourself or others (such as thoughts of suicide or harming someone else).

• If your provider suspects that a child, elderly person, or vulnerable adult is being abused or neglected.

• If your records are requested by a court order or subpoena

In these rare cases, your provider must share certain information to protect your safety or the safety of others. If this happens, your provider will discuss it with you as much as possible. Additionally, some providers may be under the supervision of another mental health professional, which means your case might be reviewed by a supervisor to ensure you are receiving the best care. If this applies to your provider, they will let you know.

Risks and Benefits

Benefits of behavioral health treatment include, but may not be limited to:

• Improved emotional regulation: Learn techniques to better manage overwhelming feelings such as anxiety, anger, or sadness in healthy and constructive ways.

• Enhanced self-awareness: Gain deeper insight into your thoughts, emotions, behaviors, and patterns, which can lead to more intentional and effective decision-making.

• Symptom reduction: Experience relief from symptoms associated with mental health conditions such as depression, anxiety, post-traumatic stress disorder (PTSD), and others.

• Strengthened coping skills: Develop practical strategies for managing stress, life transitions, and interpersonal challenges.

• Improved relationships: Increase communication skills, boundary-setting, and empathy, which can strengthen personal and professional relationships.

• Greater sense of control and well-being: Feel more empowered to address challenges, make positive changes, and achieve personal goals.

• Personal growth and resilience: Foster a stronger sense of identity, purpose, and emotional resilience over time.

• Safe and supportive environment: Engage in a confidential and nonjudgmental space where you can explore sensitive or difficult topics.

Risks of behavioral health treatment include, but may not be limited to:

• Emotional discomfort: Discussing painful memories, emotions, or experiences may temporarily increase feelings of sadness, anxiety, anger, or distress.

• Relationship disruption: Changes in thoughts, behaviors, or emotional responses during therapy may lead to shifts or tensions in personal relationships.

• Symptom fluctuation: In some cases, symptoms may initially worsen before improvement is observed as deeper issues are addressed.

• Unanticipated personal insights: Gaining new awareness about oneself may lead to difficult realizations or decisions regarding one's lifestyle, values, or relationships.

• Lack of immediate results: Progress may take time and may not follow a linear path; some patients may experience frustration with the pace of change.

• Dependence on therapist: There is a potential for developing over-reliance on the therapist for decision-making or emotional support if clear boundaries are not maintained.

• Treatment may not be effective for all individuals: Despite best efforts, not all individuals respond to therapy in the same way, and some may require alternative or additional treatment approaches.

Results of Treatment

It is important to understand that results of behavioral health treatment can NOT be guaranteed. Each person's response to treatment is unique, and outcomes can vary based on individual factors such as the specific nature of your condition, how you respond to the therapy, your commitment to your care and treatment plan, and other personal health and lifestyle factors.

Achieving the best results often involves a process of trial and error, where adjustments to your treatment plan may be necessary to find what works best for you. Consistently following the prescribed treatment plan and attending regular follow-up appointments are crucial for monitoring your progress and making any needed changes to your plan. Your active participation and open communication with your provider are key to optimizing your treatment outcomes.

In some cases, if your condition is severe or if you experience significant difficulties despite treatment, more intensive treatment may be required. This could include a higher level of mental health or psychiatric care. Your provider will discuss these options with you if necessary.

Contraindications

Behavioral health treatment in a private practice setting may not be appropriate for all individuals. Certain clinical situations require a higher level of care and supervision than private practice or outpatient therapy can provide. For example, individuals experiencing acute psychiatric symptoms that pose an immediate risk of harm to themselves or others—such as active suicidal or homicidal ideation, or psychosis—may require inpatient hospitalization or intensive crisis intervention services. Similarly, those with severe mental health conditions that significantly impair their ability to function or engage meaningfully in treatment may benefit from more structured or comprehensive care settings.

Patients who are unable to consistently attend sessions, follow treatment recommendations, or maintain basic safety and stability outside of therapy may not be well-suited for private practice behavioral health services. In some cases, co-occurring substance use disorders, unmanaged medical conditions, or cognitive impairments may interfere with the effectiveness of therapy and require additional or alternative treatment modalities.

A thorough clinical assessment will be conducted to determine whether behavioral health treatment in a private practice setting is appropriate for your individual needs. Recommendations for a higher level of care may be made if it is determined that behavioral therapy alone is unlikely to provide the level of support and intervention necessary for your safety and well-being.

Alternative Treatments

If private/outpatient behavioral health treatment is determined to be inappropriate or insufficient to meet your clinical needs, there are several alternative levels of care and therapeutic interventions available. Alternatives include, but may not limited to: inpatient psychiatric care, partial hospitalization programs, intensive outpatient programs, residential treatment facilities, or medication management with a psychiatrist. Although it is important to remember that each alternative comes with its own scope of care, risks, benefits, and eligibility criteria.

Financial Responsibility

The cost of your treatment can vary depending on the type of services provided, the length of sessions, and the specific provider. Insurance coverage may help offset some of these costs, but the extent of coverage varies between plans. It is essential to check with your insurance company to understand what services are covered, any co-payments, deductibles, and out-of-pocket maximums.

Billing statements will be provided for the services rendered, and it is your responsibility to review these statements carefully. Any charges not covered by insurance will be billed directly to you. Payment arrangements should be discussed with our billing department if you have concerns about your ability to pay.

You are responsible for any costs not covered by insurance, including co-pays, deductibles, and charges for missed or canceled appointments. If there are changes to your insurance coverage or financial situation, please inform us promptly to ensure your billing information is accurate and up-to-date. If you have questions about billing or need assistance, our office staff is available to help clarify any issues and discuss payment options.

Informed Consent

I have received, reviewed, and understand this consent form and have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

I certify that I have read, or have had read to me, the contents of consent form.

I understand the potential risks associated with behavioral and mental health treatment in a private practice/outpatient setting and understand that results may vary and cannot be guaranteed.

I understand that I have the right to make decisions about the behavioral and mental health care that I receive, that I can refuse behavioral and mental health care at any time, and that I can revoke this consent at any time (except to the extent services have already been provided).

Contraindications and alternative treatment options have been fully explained to me.

I understand that to the extent my care is not covered by my insurance, that I will be fully financially responsible for the cost of my treatment.

I consent and authorize the practice and its providers to provide me with behavioral and mental health treatment and care.

I understand that the practice reserves the right to determine at any time that it is not appropriate for me to receive services. I understand that in such event, the practice will notify me of this decision and I will be provided with resources for accessing alternative and more appropriate mental health care services.

I certify that I have read and fully understand the statements above on all pages and I consent fully and voluntarily to its contents.

* If patient is unable to sign on behalf of self, then complete the following section:

(e.g., parent, spouse, representative, guardian, etc.)

Reason: Minor Incapacitated

* If you are a legal representative of the patient named above, you must provide documentation proving your valid legal authority to give consent on behalf of the patient (e.g., power of attorney, healthcare surrogate form, court order, appointment of a guardianship, order appointing personal representative, letter of administration, etc.).

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