INFORMED CONSENT FORM

Effective Date: [Date]

 

This Informed Consent outlines the nature of mental health and medical services, including telehealth, as well as your rights and responsibilities as a patient. Please review this document carefully. By signing or electronically acknowledging this form, you confirm your understanding and voluntarily consent to receive services from Get Healthy Directory.

 

A. Nature and Scope of Services

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Get Healthy Directory provides mental health services, including psychotherapy, counseling, psychiatric evaluation, and medication management, depending on the licensure and scope of practice of your assigned provider.

Treatment involves discussing your concerns, symptoms, and experiences to assess your needs and set goals. Providers use evidence-based approaches tailored to you. Recommendations, including therapy or medications, will be reviewed with you, along with potential benefits, risks, and alternatives.

 

Potential Benefits

Possible benefits may include:

• Reduction in emotional distress or psychiatric symptoms

• Improved coping skills and emotional regulation

• Improved relationships and daily functioning

• Increased insight and self-understanding

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Potential Risks

Possible risks may include:

• Emotional discomfort (e.g., sadness, anxiety, anger, frustration)

• Recall of distressing memories or experiences

• Temporary worsening of symptoms before improvement

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Because treatment outcomes vary, results cannot be guaranteed. Your progress depends on your participation and engagement.

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You have the right to:

• Ask questions at any time

• Decline or discontinue any recommended treatment

• Withdraw consent at any time without losing access to future care

 

B. Telehealth Services

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Telehealth delivers healthcare services using secure technologies such as video conferencing, telephone, or secure messaging when you and your provider are in different locations.

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Benefits of Telehealth

• Increased access to care

• Convenience and reduced travel

• Ability to receive services in familiar environments

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Risks and Limitations of Telehealth

• Possible technology failures or interruptions

• Potential security risks despite safeguards

• Reduced ability to assess some nonverbal cues or physical symptoms

• Possible need for in-person care if clinically indicated

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Telehealth is voluntary. You may request in-person services or withdraw consent at any time.

Your provider will regularly assess whether telehealth remains appropriate for your needs.

 

C. Technology and Privacy Protections

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Get Healthy Directory uses platforms that comply with the HIPAA Privacy and Security Rules. While safeguards are in place, absolute security cannot be guaranteed.

To reduce risks, you agree to:

• Use a private location for sessions when possible

• Avoid public Wi-Fi or shared computers

• Protect your login credentials

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You understand that unauthorized access, hacking, or technical failures, while unlikely, are possible.

 

D. Emergency and Crisis Situations

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Telehealth is not appropriate for emergency situations.

If you are experiencing:

• Thoughts of harming yourself or others

• Severe emotional distress

• Medical or psychiatric emergencies

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You must call 911 or go to the nearest emergency room immediately.

 

You may also contact:

• 988 Suicide & Crisis Lifeline (U.S.): Call or text 988

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You agree to provide accurate and current:

• Physical location at the time of each session

• Emergency contact information

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If you disconnect during a crisis and cannot be reached, your provider may contact emergency services or your emergency contact.

 

E. Provider Licensing and Location

Your provider is licensed in specific U.S. states and may only provide services to you while you are physically located in a state where they are authorized to practice, as required by state licensing laws.

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You agree to:

• Accurately disclose your physical location during each session

• Notify your provider if you relocate or travel to another state

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Services may be suspended if legal requirements for practice cannot be met.

 

F. Medication Management (If Applicable)

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If your provider is legally authorized to prescribe medications and determines that the medication is clinically appropriate, they will discuss:

• Purpose of the medication

• Expected benefits

• Possible side effects and risks

• Alternatives, including no medication

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You have the right to refuse medication without affecting your access to therapy services.

If you agree to medication treatment, you agree to:

• Take medications only as prescribed

• Inform your provider of all medications and supplements you use

• Report side effects promptly

• Do not stop medication without medical guidance

• Do not share or misuse prescribed medication

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Prescriptions will be sent electronically to a pharmacy of your choice. Neither your provider nor Get Healthy Directory dispenses medication.

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Certain federal or state laws may require:

• In-person evaluation

• Identity verification

• Additional clinical documentation

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Before certain medications, including controlled substances, can be prescribed or refilled, in accordance with the Ryan Haight Act and related regulations.

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G. Confidentiality and Mandatory Reporting

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Your health information is protected under HIPAA and applicable state privacy laws. Information shared in treatment is confidential except when disclosure is legally required, including but not limited to:

• Suspected abuse or neglect of a child, elderly person, or dependent adult

• Risk of serious harm to yourself or others

• Court orders or lawful subpoenas

• Certain public health reporting requirements

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Providers may also have a legal duty to warn identifiable individuals of a credible threat of harm.

Additional confidentiality protections under 42 CFR Part 2 may apply to substance-use treatment services, when applicable.

 

H. Records and Data Retention

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Your medical records are maintained in secure electronic systems and retained in accordance with federal and state record-keeping laws, which typically require retention for a minimum number of years after last service or after a minor reaches adulthood.

You may request access to your records in accordance with HIPAA and state law by contacting:

 

Records Contact:

 info@gethealthydirectory.com

You acknowledge receipt of the Practice Policy explaining how your health information may be used and disclosed.

 

I. Fees, Insurance, and Billing

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You are responsible for understanding and meeting your financial obligations.

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You acknowledge that:

• You are responsible for charges not covered by insurance

• Insurance billing may require disclosure of clinical information to payers

• Payment responsibility remains even if insurance denies coverage

You authorize Get Healthy Directory to:

• Release necessary information to insurers

• Receive insurance payments directly on your behalf

• Bill you for remaining balances

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Fees are due in accordance with the financial policies provided separately.

 

J. Voluntary Consent and Acknowledgment

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By signing or electronically accepting this form, you acknowledge that:

• You have received and understood information about treatment and telehealth

• You had the opportunity to ask questions and received satisfactory answers

• You consent to receive services via telehealth when clinically appropriate

• You understand you may withdraw consent at any time

• No guarantees have been made regarding treatment outcomes