FORESIGHT MENTAL HEALTH CONSENT

Foresight Mental Health Consent PDF

We’re pleased that you’ve chosen Foresight Mental Health, PLLC and its affiliates (“Foresight Mental Health,” “we,” “us,” or “our”) for your mental healthcare needs. We’re excited to have the opportunity to support you on your path to well-being.

This Informed Consent explains what you, a patient of Foresight Mental Health (a “Patient” or “Client”), can expect of your Foresight Mental Health healthcare professional (“Foresight Professional”) and Foresight Mental Health services. After you have carefully read this consent and had an opportunity to have your questions answered, certain state laws require that you sign and date it before beginning services.

Mental Health Services and Foresight Professionals

Foresight Mental Health offers healthcare services both in-person and through telehealth technologies, such as interactive audio, video, and messaging, using Foresight Mental Health’s third-party mobile and web applications (the “Foresight Health Apps”). These services include psychotherapy, psychiatry, nutrition and IVA-2 testing services.

The Foresight Professionals include skilled and experienced Psychiatrists, Psychologists, Licensed Professional Counselors, Licensed Clinical Social Workers, Marriage and Family Therapists, Psychiatric Mental Health Nurse Practitioners, Nutritionists/Dietitians, and equivalent licensed professionals. Foresight Professionals also may include Associate Licensed Professional Counselors, Associate Licensed Clinical Social Workers, and Associate Marriage and Family Therapists.

Foresight Mental Health will match you with the best available Foresight Professional based on your needs and their area of expertise. Your Foresight Professional’s credentials will be made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your Foresight Professional.

Psychotherapy

Psychotherapy, often referred to as therapy or talk therapy, includes an array treatments to help individuals identify and change troubling emotions, thoughts, and behaviors, typically in one-on-one or group settings. Therapy involves assessment, diagnosis, treatment plans and sessions. Treatment seeks to relieve symptoms that affect a person’s daily functioning, improving their quality of life.

At Foresight we utilize evidence-based practices to effectively treat the diverse community we serve. We incorporate psychiatry and therapy services whenever appropriate to strengthen treatment outcomes.

Consent to Treatment by Associate Therapists

If your Foresight Professional is an Associate Licensed Professional Counselor, Associate Licensed Clinical Social Worker, or Associate Marriage and Family Therapist, this means they have completed the necessary education for licensure, are registered with the appropriate licensing board, and are supervised by a fully licensed provider. Associate therapists are trained professionals working under the supervision of a licensed provider to ensure the quality of your care.

Your Foresight Professional will inform you if they are an Associate and provide you with their registration number, the name of their employer, and the credentials of their supervisor. By signing this consent, you agree that if your Foresight Professional is an Associate, they may consult with their supervisor regarding your care. Their supervisor may observe sessions directly or review audio or video recordings of your sessions, if you have consented to such recordings.

You are also consenting to the possibility of receiving care from an Associate therapist. However, you will always be notified during scheduling if your appointment is to be scheduled with an Associate. You may decline to see an Associate and request a licensed therapist at the time of scheduling. This consent only signifies your agreement to receive care from an Associate therapist should you choose to proceed with scheduling with an associate.

Foresight Mental Health will match you with the best available professional based on your needs and their expertise. Your Foresight Professional’s credentials will always be made available to you before your appointment. If you have questions about these credentials, please direct them to your Foresight Professional.

Psychiatry

Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders.

Psychiatry providers may order medical and psychological tests to assess a patient’s physical and mental health. Their training enables them to understand the connections between emotional and medical conditions, genetics, and family history. They evaluate data, diagnose conditions, and collaborate with patients to create treatment plans. Treatment options may include psychotherapy, medication, and psychosocial interventions, tailored to each patient’s needs.

Supportive psychotherapy is provided alongside medication management appointments. This therapy may include insight-oriented discussions, behavior modification, or general support. While it offers benefits like reduced distress, improved relationships, greater self-awareness, and better stress management, it also carries risks, such as experiencing uncomfortable emotions when addressing difficult aspects of life. Success is not guaranteed, and progress requires active participation. Due to its brief nature, supportive psychotherapy with medication management is most effective when you engage in work outside of sessions and have a primary psychotherapist.

Nutrition

Nutrition services provide patients with education and counseling on their diet. Nutrition services in psychiatry and therapy settings focus on overall health and well-being while also focusing specifically on mental health. Nourishment of the body can have a significant effect on mental and behavioral health. Registered Dietitians help identify foods and eating habits that may be impeding health and wellness and replace them with practices that are harmonious to your body and mind.

Frequency and Duration of Appointments

Initial Evaluations

Our usual practice involves a detailed initial evaluation, which typically takes up to one hour. This thorough assessment is vital to kickstart your treatment because it helps us understand your medical history, symptoms, and why you’re seeking help. After your first visit, your clinician will decide if you need more evaluation or can begin treatment. Sometimes, you might need an extra visit to finish the initial assessment. If that happens, your clinician will schedule another appointment, lasting 30 to 60 minutes, to complete it. Please remember that in psychiatry, there’s no guarantee your provider will continue your current medications or prescribe the same ones as your previous provider did.

Ongoing Appointments

Psychotherapy: In the realm of mental health, the journey towards well-being is deeply personal and varies for each individual. Typically, the duration of therapy is influenced by clinical appropriateness tailored to individual needs. While many common therapeutic approaches often propose a range of 6-20 sessions for measurable outcomes, it’s essential to note that some individuals might require shorter or longer durations based on the complexity of their concerns and progress in treatment. Moreover, factors such as treatment goals, type of therapy modality, and frequency of sessions can influence the overall time frame.

Psychiatry: If it is determined that you need ongoing treatment following the initial evaluation, you’ll need follow-up appointments for medication refills and to monitor your progress. These follow-up appointments typically last 15 to 45 minutes, but their duration can vary depending on specific circumstances. Normally, we schedule 15 or 30 minutes, but the actual time needed may be shorter. Your provider will determine the frequency of these follow-ups, considering factors like medication adjustments, your condition’s severity, and appointment availability. There’s no fixed follow-up schedule since it varies for each patient. Some patients with acute conditions might need weekly appointments, while those on stable medication regimens with no changes may go as long as 3 to 6 months between appointments. Please keep in mind that patients taking controlled substance medications will need to check in at least every 3 months to continue their medication refills, and sometimes even more frequently than that.

Benefits of Tele-Mental Health

Generally, tele-mental health offers benefits, such as improved access to care by allowing Patients to remain in their current location (e.g., home or work) while their clinician consults and/or obtains test results at distant/other sites, efficient mental health evaluation and management, and the expertise of specialists that Patients otherwise might not have access to. By signing this document, I consent to participate in telehealth services. However, I understand that I have the option to not schedule or use virtual care if I prefer not to.

Potential Risks of Tele-Mental Health

There are potential risks associated with tele-mental health, which include, but may not be limited to the following:

Your Foresight Professional may determine that the transmitted information is of inadequate quality, which then requires a face-to-face meeting with the Patient.
Delays in medical evaluation and treatment could occur due to equipment deficiencies or failures.
Security protocols could fail, causing a breach of privacy of personal medical information.
Lack of access to complete medical records, which could result in adverse drug interactions, allergic reactions, or other judgment errors in rare cases.
It may become clear that telecommunications technology is not an appropriate mode of treatment given a patient’s presenting symptoms or level of functioning, resulting in a recommendation that the patient obtain additional in-person care.

Privacy and Confidentiality

All Foresight Professionals are ethically and legally bound to maintain your privacy and confidentiality and none of your personal information will be shared or disclosed with any other individual without your consent.

Exceptions to confidentiality do exist in certain situations, such as the following:

If legal entities (i.e. court, police, FBI, etc.) order the release of certain records in a court case or criminal proceeding.
If your insurance company is reimbursing your treatment, it has the right to know your working diagnosis as outlined in the Diagnostic and Statistical Manual of Mental Disorders, dates of service, and certain other information to approve the payment of benefits.
If your Foresight Professional has reason to suspect that a child, elderly, or dependent person is being abused or neglected, they are legally obligated to report this information to the appropriate authority.
In circumstances in which, to the best of your Foresight Professional’s professional judgment, they believe that you may be a danger to yourself or others.
If you were to make your mental health an issue in a legal proceeding.
If your account is overdue and arrangements for payment have not been negotiated, a collection agency may be provided with dates of service, type of service, and total amount due.
If your treatment would benefit from consultation with another Foresight Professional. Your identifying information will not be disclosed during this form of consultation. All other consultations with professionals external to Foresight will involve a conversation and your written consent.
If you are experiencing a life-threatening emergency and unable to provide consent.

Family and Friends Involvement

We may provide your protected health information to individuals, such as family members, close friends, or others involved in your care or who help pay for your care, as permitted under the Health Insurance Portability and Accountability Act (HIPAA). This disclosure will only occur in the following circumstances:

You provide explicit consent for us to share your information.
We determine, based on our professional judgment, that you would not object to the disclosure.
You are unable to provide consent due to being unconscious, incapacitated, or experiencing a psychiatric emergency, and we believe disclosure is in your best interest.

Examples of permissible disclosures include:

We may assume your agreement to share information if a family member or friend accompanies you to your appointment or participates in discussions regarding your care.
If you are unable to consent (e.g., unconscious or incapacitated), we may share information with individuals involved in your care or payment for care if, in our professional judgment, it is in your best interest.

In any case where disclosure is made under these circumstances, we will limit the information shared to what is directly relevant to the individual’s involvement in your care. For example, this may include providing updates on your condition, treatment needs, or payment-related information.

If and when you regain the ability to make decisions, we will seek your preferences regarding any ongoing disclosures. If you prefer that we limit or stop sharing information with a specific individual, please notify us promptly, and we will honor your request in accordance with applicable laws.

Consultation with Other Providers

To ensure the quality and continuity of your care, your provider may consult with other professionals about your treatment. These consultations may occur internally within Foresight Mental Health or externally with providers outside the organization, depending on the circumstances.

Internal Consultations: Providers within Foresight Mental Health who are involved in your care may collaborate and share relevant information to ensure the highest quality treatment. This collaboration may include situations where two Foresight providers are independently treating the same patient (e.g., a therapist and a psychiatrist). Written permission from the patient is not required for these internal consultations, as they are covered under HIPAA as part of treatment coordination and healthcare operations.
External Consultations: Any consultations involving professionals outside of Foresight Mental Health will require your written consent via a Release of Information (ROI). The ROI must specify what information may be shared, with whom, and for what purpose.

The ROI remains active for the duration specified by you on the form but can be revoked at any time by submitting written notice to sct@foresightmentalhealth.com. It is important to note that any disclosures made prior to revoking the ROI cannot be undone.

In all cases, whether internal or external, Foresight Mental Health ensures that only the minimum necessary information is shared to support your care, in accordance with HIPAA regulations.

Subpoenas and Legal Proceedings

Asking your mental health provider to participate in any legal proceedings on your behalf can create conflicts of interest and may compromise the therapeutic relationship. As such, we ask that that neither you, your legal representatives, nor anyone acting on your behalf subpoena Foresight Mental Health or its providers to testify in court, provide custody evaluations, or produce mental health records for use in legal proceedings, including but not limited to divorce, custody disputes, or other legal matters. Foresight Mental Health does not provide custody evaluations, legal opinions, or expert testimony regarding parenting, custody, or visitation matters.

If Foresight Mental Health or its providers are subpoenaed or court-ordered to appear, provide records, or testify, we will comply as required by law. However, you agree to compensate Foresight Mental Health as proscribed by state or federal law. In the event, there is no state or federal limitation, you agree to compensation Foresight Mental Health for any legal-related work, including but not limited to:

Time spent preparing, reviewing records, or consulting with attorneys,
Travel and related expenses (e.g., parking, meals),
Waiting time and testimony.

The rate for legal services is $75 per 15 minutes, with a minimum charge of $900 (3 hours), which must be paid in advance or upon invoicing. Additional charges may apply for administrative fees, copies of records, and other associated costs.

By signing this consent, you acknowledge your responsibility for these fees and agree to follow this policy.

Assignment of Benefits

I hereby assign all mental health and/or medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other mental health/medical plan to issue payment via check or EFT directly to Foresight Mental Health/Foresight Mental Health Group PLLC for mental health services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

In the event that I receive a check from my insurance company for these services, I agree to forward payment to Foresight Mental Health/ Foresight Mental Health Group, PLLC.

Release of Billing Information

I consent to the use and disclosure of my protected health information for billing purposes and payment for treatment. I understand that Foresight will share my patient protected health information according to federal and state law for treatment and payment, and in accordance with Foresight’s Notice of Privacy Practices.

I understand that my health record may include information on a diagnosis/treatment related to psychiatric, psychological, or mental conditions, drug and/or alcohol use, sexually transmitted infections (STIs), AIDS, and/or HIV status, and genetic testing.

Expiration/Revocation: I understand that I may revoke this authorization at any time by giving written notice to Foresight. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my information have already acted in reliance on this authorization.

The information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. State and federal law specifically mandates that any patient medical record and/or personal health information containing drug and alcohol diagnosis and treatment, mental health, and sexually transmitted infections, including HIV/AIDS are privileged and confidential and may only be disclosed by express authorization, except as required by law. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 CFR Part 2 and Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I understand that I may refuse to sign this authorization. Foresight may not condition treatment, payment, enrollment, or eligibility on the authorization of this release. This Authorization (Agreement) is, and related documents entered into in connection with this Agreement are deemed signed when a party’s signature is delivered electronically. The signor is executing this Agreement electronically, and intends to be bound by the Agreement, and agrees that the electronic signatures shall be deemed original signatures having the same legal effect as original signatures, to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, and any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary. The signor acknowledges that this term is hereby incorporated into the Agreement.

Payment

Payment for services rendered is expected in a timely manner.
Best practices at Foresight require you to provide your credit card information to Foresight for auto-charging purposes to ensure uninterrupted treatment.
All major credit/debit cards are accepted, as well as HSA/FSA cards with a Visa/Mastercard logo.
Your saved payment method will be charged within 48 hours of your appointment.
In the event that you are unable to pay via credit card, Foresight will accept payment via personal check or money order. Checks and money orders should include the client’s name and date of service the payment applies to. Checks and money orders can be sent to:
- Foresight Mental Health
  PO Box 530077
  Atlanta, GA 30353-0077
Upon request, a detailed billing receipt will be furnished.
Non-payment of charges and an account balance of $500 or greater could result in discontinuation of appointments and cessation of care, albeit with suitable referrals and transition strategies provided.
Failure to settle outstanding amounts may necessitate engagement with legal/collection avenues.

Credit Cards

We prioritize the convenience and security of our clients. For this reason, the preferred method of payment is through a credit card kept on file. Please note:

Your card will be securely stored and can be automatically charged for services rendered within 48 hours following your appointment.
In the event you do not have a credit card available, we do accept check payments. Please mail your checks to our designated P.O. Box address listed above (also located on our website).
We kindly inform you that we do not accept cash payments to ensure both your security and that of our team.

By proceeding with our services, you provide consent to this payment arrangement.

Commonly Used Codes

If you have an insurance plan that has a deductible or coinsurance cost you may need to know the codes often used to assess your cost for treatment.

Psychotherapy commonly used CPT codes include but are not limited to:
- Therapy Initial Evaluation: 90791
- Individual Therapy: 90832, 90834, 90837 – with 90834 and 90837 being the most common.
- Family/Couples: 90846, 90847, 90849
- Group Therapy: 90853
Psychiatry commonly used CPT codes include but are not limited to:
- Initial Evaluations: 90792, 99204, 99205 with 90792 being the most common.
- Follow-up Visits: Vary depending on the session but are most commonly a combination of 2 codes. One for medication management and one for therapy including psychotherapy/supportive/behavior modifying/or insight-oriented discussion.
- 99212, 99213, 99214 (medication management) + 90833 and/or 90836 (brief supportive therapy)
- At Foresight we provide brief supportive therapy with medication management, which may increase your cost share depending on your insurance. While Foresight will provide an estimate of your cost share, please be sure to check with your insurance company if you have questions about the cost of visits. We provide this service and will bill for it when performed, adjustments will not be made for services performed.

Out of Network Fees and Self-Pay Rates

All clients not using insurance, regardless of previous status, will be required to pay our full self-pay rate for care. Self-pay rates will be quoted upon booking an appointment and a Good Faith estimate will be sent via email within 48 hours of booking.

Documentation, FMLA/Disability and Other Fees

At Foresight Mental Health, we understand that patients/clients may need to take a period of time off from work or have other reasons that may require support from your provider. We are here to assist by completing the appropriate documentation or sending/faxing your medical records (must sign a release first). Prior to assisting with these needs, here are the following requirements that you must understand and agree to before we can assist. Note: Therapy providers are not able to complete disability. Disability must be completed by and at the discretion of your NP or MD.

Requirements:

Your provider must be in agreement with your request.
Paperwork/forms will NOT be filled out on the first appointment and will be approved at the discretion of the provider.
You must regularly attend scheduled appointments as determined by your provider.
Only your provider can change the frequency of your sessions.
Excessive cancellations or reschedules may result in a termination of services. After the 3rd cancellation and/or reschedule of an appointment, the patient/client may be terminated due to noncompliance at the discretion of the provider.
Paperwork Fee: A minimum fee of $50.00 will be charged for completing any paperwork/letter/form/etc. outside of standard medical requests.
1. Disability: Initial – $75.00; Renewal – $50.00
2. FMLA: Initial – $75.00; Renewal – $50.00
  The final dollar amount depends on the complexity and time required to complete the documentation and is at your provider’s discretion. The appropriate fee must be paid prior to paperwork being filled out and sent/faxed.
Timeline for Completion: Turnaround time to complete requested paperwork is 10 business days and commences after fees have been collected.
Sending Medical Records Fee: The fee for sending printed medical records is $25.00 with an additional $0.05 per page over 50 pages. Fees must be paid before submitting medical records.
A release of information must be completed by the patient/client prior to sending paperwork and/or medical records.

Not abiding by these guidelines may result in termination of services and the appropriate personnel will be notified that the provider will no longer support the patient’s FMLA/Disability/Related Concern claim due to noncompliance with the treatment plan.

Foresight reserves the right to pause treatment for unpaid account balances. Additionally, certain services, including but not limited to documentation requests and ADHD testing, may not be processed or completed until the outstanding balance is settled. Patients are encouraged to resolve balances promptly to avoid interruptions in care or delays in service.

All fees may be subject to change.

No Shows and Cancellations

Unless otherwise prohibited by a Patient’s insurance plan, a late fee will apply when a Patient does not show within 10 minutes of the scheduled appointment time or does not cancel at least 48 hours prior to their appointment time, unless due to unforeseeable events to be determined by the Foresight Professional. At the time of your appointment, you must be physically located within the state where services were booked. If you are outside the state where your provider is licensed, the appointment will be stopped, a late cancellation fee will be charged, and the appointment will need to be rescheduled.

For those seeing multiple service lines, clients are ultimately responsible for ensuring that psychiatry and therapy appointments are not scheduled on the same day. Insurance providers often will not cover both services when performed on the same day. Late cancellations will apply for those needing to cancel or reschedule within 48 hours and self-pay rates will apply to any appointments not covered by insurance.

Late Cancellation & No-Show Fee: Therapy = $125.00; Nutrition = $150.00; Psychiatry = $150.00

** The fees at the Decatur, GA location are based on appointment type and provider. Please consult your provider or administrative staff for an estimated cost for missed appointments that is based on your treatment type.

Repeated no-shows or late cancellations may result in the termination of care and referral to an external provider. If you book a new appointment using the self-scheduling tool, it is your responsibility to cancel any previously scheduled appointments to avoid fees.

Technical Issues

If you experience technical difficulties, you must contact the practice within 10 minutes of the appointment start time to verify your attempt to join and troubleshoot. Preferred contact is through the patient portal or by calling the office and leaving a voicemail for timestamp verification.

Patient-related issues (e.g., poor internet connection, WiFi outages) do not qualify for fee waivers.
Patients are responsible for having a stable internet connection, downloading Zoom as a backup, and being in a safe and private space for the appointment.

Appointment Links

California appointments: one day before the appointment.
Non-California appointments: 30 minutes before the appointment.

Patients are responsible for confirming they have the necessary link and must contact the practice if it is not received. Outreach by the provider or practice (e.g., resending links, calls, voicemails) is a courtesy only and failure to receive outreach will not be a basis to waive fees.

Exceptions to these policies due to unforeseeable events will be determined at the discretion of Foresight Mental Health.

Treatment and Confidentiality of Minor Children

Generally, and depending on state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor.

Parents may request information about their child’s diagnosis or treatment. Although release of this information will be provided in accordance with state law, it is best that the process be collaborative among any minor who is 12 and over, the parent, and Foresight Professional in order to maintain the relationship established between the minor and clinician because the relationship between the patient and health care provider is important to treatment success. Therefore, unless there is a safety concern, minors who are 12 and over would be consulted about the disclosure and encouraged to share the information with the parent first to establish better communication within their family.

Parental Involvement and Communication

Foresight encourages active parental involvement in the child’s care. However, there are circumstances where a clinician may determine that limited parental involvement is necessary, including:

When medication is recommended, guardian consent is required before a prescription can be issued.
Situations involving abuse, neglect, or serious impairment by a parent.
Legal restrictions (e.g., court orders, parenting plans).
Instances where parental involvement would be detrimental to the child’s mental health or treatment progress, as determined by the clinician in good faith.

Parental Expectations Regarding Treatment

Maintain open communication with each other regarding their child’s treatment and scheduled appointments.
Notify one another of changes to appointments or treatment plans. Foresight will not routinely provide updates to non-custodial or absent parents.
Resolve conflicts regarding treatment participation outside of therapy sessions.

Written and oral communications from any parent may be shared at the clinician’s discretion with the other parent or the child, as appropriate. Written communications, emails, and telephone messages are part of the child’s medical record, which may be accessed by authorized individuals as permitted by law. Psychotherapy notes are excluded from this record set.

Foresight welcomes the involvement of stepparents, siblings, grandparents, chosen family, or other individuals in treatment discussions when appropriate. Participation in care will depend on the child’s needs, the legal guardians’ wishes, previously granted permissions, and any relevant custody agreements or court orders.

Custody Arrangements and Parental Responsibility

It is the responsibility of the parent(s) or legal guardian(s) to inform Foresight Mental Health of any custody arrangements or updates to custody agreements that may affect the child’s care. Providers will honor custody agreements to the extent they are made aware of them.

Failure to Disclose or Falsification of Custody Information

If custody arrangements are not disclosed or are falsified, the parent or guardian who failed to provide accurate information will be held responsible for any discrepancies in care, including but not limited to:

Unauthorized disclosures.
Failure to obtain consent from the other party as required by the custody agreement.

Foresight Mental Health will not be liable for actions taken based on incomplete or falsified custody information provided by a parent or guardian. Parents are expected to provide accurate and up-to-date custody documentation at the time of registration and to inform Foresight promptly of any changes to custody or legal authority regarding the child. This documentation is critical to ensure that all treatment decisions, disclosures, and consents follow legal and custodial requirements.

Withdrawal of Treatment and Termination of Care for Minors in California

Foresight prioritizes the child’s well-being while adhering to state laws and clinical best practices. If one parent seeks to discontinue treatment while the other wishes to continue, Foresight will:

Review Legal Documentation: If a custody agreement, parenting plan, or court order designates decision-making authority, Foresight will follow it. If joint consent is required, one parent alone cannot terminate treatment.
Follow Termination Policy: If disputes interfere with care or if no clear legal authorization is provided, Foresight may terminate services with proper notice and offer referrals to ensure continuity of care.

Consent to Electronic Communications

By signing below, I hereby authorize Foresight Mental Health, and its service providers, to communicate with
me via email, phone call, and/or text message at the email address and/or number provided below, including
through auto-dialed, auto-generated, and/or pre-recorded messages. I understand that such emails/messages may include, without limitation, information and reminders about paying for services, appointments, and other health care purposes. I understand that my consent to communicate via email or text message is not a condition of my obtaining services from Foresight Mental Health.

I understand that communications sent via unencrypted email or via text messages over an open network are inherently unsecure, and there is no assurance of confidentiality of information communicated in this manner. Nevertheless, I want Foresight Mental Health to communicate with me via email and/or text message as provided below:

I certify I am the user and/or subscriber of the email address and/or mobile number provided. I accept full responsibility for emails and/or text messages sent to or from this address or number.
I understand that emails and text messages have inherent privacy risks, especially when access to my computer or mobile device is not password-protected or access is provided by my employer.
I understand there may be a delay when responding to emails or text messages; thus, if I have an urgent situation, I should not rely on email or text message to request assistance but should seek assistance by means consistent with my needs (e.g., by contacting my primary care provider or calling 911).
I understand that, in order to process and/or respond to my emails or text messages, individuals at Foresight Mental Health other than those directly involved in my care may need to read my email or text message and that any email or text message and response thereto may become part of my medical record – as appropriate.
I agree to hold Foresight Mental Health and its affiliates harmless from any and all claims and liabilities;
arising from or related to emails or text messages sent to the email address and/or number provided above.
I agree to notify Foresight Mental Health in writing in the event my email address or mobile number
changes.
I understand that I can opt out of electronic communication at any time via the patient portal or by calling 1-888-588-8995.

I acknowledge that I understand and agree with the following (Patient Bill of Rights):

Initial Evaluation and Treatment: I consent (or my child) to undergo a mental health evaluation and authorize Foresight Professional(s) to provide necessary care and treatment.
Telehealth Agreement: I approve the use of Foresight Mental Health’s telehealth services, understand their boundaries, and will verify identity before services to a minor. I understand it is up to the Foresight Professional to determine whether or not my (or my child’s) specific clinical needs are appropriate for a telehealth visit.
Provider’s Credentials: I’ve reviewed the professional’s qualifications.
Treatment Information: I’ve been informed about treatment risks, benefits, alternatives, and also the potential outcomes of forgoing treatment.
Treatment Recommendations: I’m aware that I will be updated on treatment recommendations, such as medications, therapy, labs, or referrals.
Location Updates: I will notify Foresight of any changes in my (or my child’s) location during telehealth visits.
Privacy and Security: I recognize the healthcare provider’s commitment to safeguarding health information and acknowledge that telehealth might involve sharing data with practitioners elsewhere, potentially out-of-state.
Technical Risks: I am aware of potential technical failures during telehealth sessions and absolve Foresight Mental Health of responsibility for any resulting issues.
Right to Modify Telehealth Use: I can suspend, terminate, or opt-out of telehealth services anytime.
Emergency Situations: In emergencies, I will dial 9-1-1, understanding that Foresight Professionals cannot directly connect me to local emergency services.
Alternative Options: I am aware of in-person alternatives to telehealth and potential limitations in their availability.
No Guaranteed Outcomes: Expected benefits are understood, but specific results are not assured.
Data Handling: I acknowledge that healthcare data might be shared for logistical reasons. If others are present during telehealth for technical reasons, I will be informed and can request confidentiality or end the session.
Prescription Clarity: No guaranteed prescription will be provided post-consultation.
Access to Medical Records: I can request a copy of my (or my child’s) medical records, given law compliance and related costs.
Service Discontinuation: I understand that Foresight Professional(s) may cease services if deemed clinically appropriate, and in such cases, will be supported in any necessary transitions.
State-Specific and Patient Rights: I have read and understand the State-Specific Disclosures for my location during telehealth visits and the Patient Bill of Rights.

IN CASE OF EMERGENCY

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In a medical emergency, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call 988 or the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

Minor Child Patients – Specific Informed Consent Terms

I understand that a parent, legal guardian, or legal representative must accompany a minor child to their first appointment. My Foresight Professional will discuss and reach an understanding with the parent, legal guardian, and/or caregiver as to when their presence will be required at subsequent appointments. If the minor must be brought to the initial and subsequent appointments by a caregiver, please identify the caregiver:

________________________________________________________
Full Name of Caregiver and Relationship to Child

I understand the risks and benefits of the services and have had my questions regarding the services explained. By signing below, I hereby give my informed consent to receive services, including via a telehealth visit, under the terms described above. I am also fully aware, have read, understand and agreed to Foresight Policies, Terms and Conditions posted on Foresight Mental Health’s website at: https://foresightmentalhealth.com/.

______________________________________________
Client / Parent or Legal Guardian Signature

_________________________________________________
Parent or Legal Guardian Name

_________________________________________________
Relationship to Client

______________________
Date