Informed Consent

for Treatment

Last updated: August 21, 2025

This consent applies to healthcare services provided by Neuroscience Psychiatry & Integrative Wellness PLLC (“Neuroscience Psychiatry”).

When the patient is a minor, consent will be obtained from the person legally authorized to provide consent, except when applicable law permits the minor to consent independently.

Services

Services may include:

  • Psychiatric assessment

  • Diagnosis

  • Medication management

  • Psychotherapy

  • Behavioral interventions

  • Treatment planning

  • Patient education

  • Coordination of care

  • Monitoring

Medication management and psychotherapy may be integrated during the same encounter when clinically appropriate.

No treatment or specific outcome is guaranteed.

Voluntary Participation

Treatment is voluntary to the extent provided by applicable law.

Patients and legally authorized representatives may ask questions, discuss treatment recommendations, seek another opinion, or withdraw consent as permitted by law.

Risks, Benefits, and Alternatives

Mental-health treatment may improve symptoms, functioning, relationships, and quality of life.

Psychotherapy may involve discussion of difficult thoughts, emotions, experiences, or behaviors and may temporarily increase distress.

Medication may cause side effects, allergic reactions, interactions, withdrawal or discontinuation effects, mood or behavioral changes, or other adverse effects.

Your clinician will discuss material risks, benefits, alternatives, and monitoring requirements when appropriate.

Medication and Prescribing

Medication decisions are based on clinical judgment, clinical appropriateness, applicable law, and available medical information.

No medication is guaranteed solely because it is requested.

Controlled medications may require additional evaluation or monitoring, including:

  • Prescription-monitoring review

  • Medical records

  • Laboratory testing

  • Toxicology testing

  • Vital signs

  • Treatment agreements

  • Collateral information

  • In-person evaluation when appropriate

A clinician may decline to prescribe or discontinue medication when clinically appropriate or legally required.

Telehealth

Telehealth provides healthcare when the patient and clinician are in different physical locations.

Potential benefits include convenience, access, and continuity of care.

Potential limitations include:

  • Technology failure

  • Interrupted communication

  • Reduced physical examination capability

  • Privacy risks

  • Situations where telehealth does not provide sufficient information for safe treatment

Patients may be asked to confirm their current physical location during telehealth appointments.

A clinician may recommend in-person evaluation or another level of care when appropriate.

Privacy

Patients should participate in telehealth from a private location whenever possible.

No electronic system can guarantee absolute privacy.

Clinical sessions should not be recorded unless all participants have been informed and applicable consent requirements are met.

Minor Patients

When treating a minor, the clinician will determine appropriate involvement of the parent or legal guardian based on:

  • The minor's age

  • The type of service

  • Clinical needs

  • Safety considerations

  • The minor's legal ability to consent

  • Applicable privacy and confidentiality laws

Minor patients may be offered private time with the clinician when clinically appropriate.

Confidentiality between a minor and clinician is important to effective treatment but is not absolute.

Information may be disclosed when authorized or required by law, including circumstances involving safety concerns, suspected abuse or neglect, or other legally required reporting.

Parental or guardian access to a minor patient's information will be handled according to applicable federal and state law.

Emergencies

Neuroscience Psychiatry does not provide emergency or continuously monitored crisis services.

For emergencies:

Call 911 or go to the nearest emergency department.

For suicidal crisis or emotional distress:

Call or text 988.

Do not rely on email, voicemail, SMS, or portal messaging for emergencies.

Communication Between Visits

Routine messages may not be reviewed immediately.

Any stated response-time goal applies only to routine, non-urgent communication.

Patient Responsibilities

Patients and, when applicable, parents or legal guardians agree to provide accurate information and notify the clinician of important changes involving:

  • Medications

  • Supplements

  • Medical conditions

  • Substance use

  • Pregnancy

  • Symptoms

  • Side effects

Patients are responsible for attending necessary follow-ups and completing monitoring needed for safe treatment.

Coordination of Care

Your clinician may recommend obtaining medical records, laboratory results, collateral information, or communication with other healthcare professionals.

Insurance and Financial Responsibility

When insurance information is provided and insurance billing is requested, the patient or responsible party authorizes Neuroscience Psychiatry to submit claims and provide information reasonably necessary for payment and healthcare operations.

Insurance benefits are determined by the patient's health plan.

Ending Treatment

Patients or legally authorized representatives may end treatment as permitted by law.

Neuroscience Psychiatry or the clinician may also terminate care when clinically or legally appropriate.

Reasonable steps regarding notice, medication safety, urgent needs, and transition of care will be taken when required.

Consent

By signing, I acknowledge that:

  • I have read and understand this information.

  • I have had an opportunity to ask questions.

  • I understand potential risks, benefits, and alternatives.

  • Specific treatments may require additional informed-consent discussions.

  • I voluntarily consent to outpatient mental-health treatment or am legally authorized to provide consent on behalf of the patient.

  • I consent to telehealth when clinically appropriate.