FORESIGHT MENTAL HEALTH CONSENT
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 therapy, psychiatry, nutrition and IVA-2 (Integrated Visual and Auditory) testing services.
The Foresight Professionals include licensed, skilled and experienced Psychiatrists, Psychologists, Professional Counselors, Clinical Social Workers, Marriage and Family Therapists, Psychiatric Mental Health Nurse Practitioners, Nutritionists/Dietitians, and equivalent licensed professionals. Foresight Mental Health will match you with the best available Foresight Professional based on your location and needs and each Professional’s 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 are treatment methods used to help people work through personal problems, improve behaviors and thought patterns, improve relationships, get help with mental health difficulties, and learn more about themselves. It is an interactive process whereby people receive support to help them examine and change areas of their lives that may be interfering with their happiness or well-being.
There are many different styles and philosophies of psychotherapy and not all of them may be right for you. The first session with a new therapist is often a good time not only to discuss your problems but also to evaluate whether you feel this is a “good fit” for you. We encourage you to ask questions about your therapist’s expertise and training. Please feel free to express any concerns, and if you feel you might like to try someone else with a different style, we can help you get a referral. Foresight provides psychotherapy in several settings including individual, couples, family, and group.
Psychiatry is the branch of medicine focused on the diagnosis, treatment, and prevention of mental,
emotional, and behavioral disorders.
Psychiatry providers may order or perform a full range of medical laboratory and psychological tests which, combined with discussions with patients, help provide a picture of a patient’s physical and mental state. Their education and clinical training equip them to understand the complex relationship between emotional and other medical illnesses and the relationships with genetics and family history, to evaluate medical and psychological data, to make a diagnosis, and to work with patients to develop treatment plans. Psychiatry providers use a variety of treatments – including various forms of psychotherapy, medications, psychosocial interventions and other treatments, depending on the needs of each patient.
Supportive psychotherapy intervention services are provided with medication management appointments. Supportive psychotherapy with medication management can include psychotherapy, insight-oriented discussions, behavior modifying discussions, or supportive therapy. Therapy with medication management has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has repeatedly been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. The shorter nature of supportive psychotherapy with medication management requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions and have a primary psychotherapist.
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
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.
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, the type of therapeutic modality, and the 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 between 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. The frequency of these follow-ups will be determined by your provider, 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 is intended to serve the same purpose as psychotherapy and psychiatry, as described above, but your Foresight Professional will be at a remote location and will not be physically present with you during therapy sessions. 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 receiving therapy services using a secure audio-visual, or messaging technology platform. Further, the Professional is often able to be more efficient in furnishing mental health evaluation and management services and to obtain any consults and/or test results from other locations.
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 or is incomplete, which then requires a face-to-face meeting with the Patient.
- Delays in medical evaluation and treatment could occur due to technological deficiencies or failures.
- Security protocols could fail, causing a breach of privacy of personal medical information.
- 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 your Foresight Profession recommending in-person care.
In the event that you and your Foresight Professional experience technical difficulties and get disconnected, your Foresight Professional will contact you using your contact information on file. You must keep your contact information current.
By signing this document, I consent to receive therapy services using a secure audio-visual, or messaging technology platform (“Tele-Mental Health). I have read the above and understand the potential benefits and risks associated with Tele-Mental Health. I understand that I can discuss the risks and benefits further with my Foresight Professional and that I have the option to discontinue Tele-Mental Health at any time.
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 or as required or allowed by law.
Exceptions to confidentiality do exist which require Foresight to disclose information in certain situations without your authorization, such as the following:
- If a court orders the release of records or a judge issues a warrant, subpoena or summons in a court case or criminal proceeding.
- If law enforcement requests records in limited circumstances
- If your insurance company is reimbursing your treatment, it has the right to know information relevant to its decision to pay (for example, your diagnosis, the services furnished).
- 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 authorities.
- If, 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 Foresight Professional thinks that your treatment would benefit from consultation with another Foresight Professional. If this occurs, your Foresight Professional will attempt not to use identifying information to the extent possible. If your Foresight Professional would like to seek a consultation with a professional outside of Foresight, they will discuss the reasons for that consultation and seek your written consent.
- If you are experiencing a life-threatening emergency and unable to provide consent.
By signing this consent, you agree that you have read and understand Foresight Mental Health’s Notice of Privacy Practices, which explains your rights to your health information and how Foresight Mental Health uses your information.
IN CASE OF EMERGENCY
IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY, FORESIGHT SERVICES ARE NOT SUFFICIENT. 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).
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 a minor are separated, Foresight will only furnish Mental health services to the minor with the written consent of both parents. If the parents of the minor are divorced, you agree to furnish a copy of the divorce or custody decree that identifies whether one or both parents are responsible for medical decision making. Foresight will determine whether one or both parents must consent for treatment of 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 the treatment of the minor.
Parents may request information or records 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 treatment process be collaborative. For minors 12 and over, the parents/legal guardians agree to work with the Foresight Professional to ensure the Foresight Professional and the minor are able to establish and maintain an effective treatment relationship. This relationship is essential to treatment success. Upon consultation with a minor who is 12 years of age or older, and as permitted by state law, the Foresight Professional will advise the parent(s)/legal guardian(s) as to whether the parents/legal guardians should be involved directly with treatment and whether disclosure of information is recommended. Most often, minors 12 and over are encouraged to share the information directly with the parent(s)/legal guardian(s) first in order to establish better communication within their family.
Minor Child Patients – Specific Informed Consent Terms
I understand that, as the parent(s), legal guardian(s), or legal representative(s) or the minor, I must be present for the minor child’s first appointment. Thereafter, our Foresight Professional will inform me/us as to when my/our presence is required for subsequent appointments. If someone other than the parent(s), legal guardian(s) or legal representative(s) will transport the minor to and from in-person appointments or be present during a Tele-Mental Health visit, I will notify the Foresight Professional. Potential caregivers who I authorize to transport to or be present for therapy services include the following:
By signing this consent, you confirm that you have read and understand the information contained in this form. You have the right to ask Foresight staff to read the form to you and to ask further questions to ensure your understanding of the information contained in this consent.
I acknowledge that I understand and agree with the following (Patient Bill of Rights):
- Initial Evaluation and Treatment: I consent (or for my child) to undergo a mental health evaluation and authorize Foresight Professional to provide necessary care and treatment.
- Tele-Mental Health Agreement: I approve the use of Foresight Mental Health’s Tele-Mental Health services, understand its benefits and risks, and will verify my or my minor’s identity before services commence. I understand it is up to the Foresight Professional to determine whether telehealth is an appropriate modality for my (or my child’s) specific clinical needs.
- Provider’s Credentials: I have been informed of and/or reviewed my Foresight Professional’s qualifications and licenses.
- Treatment Information: I have been informed about treatment risks, benefits, alternatives, and the potential outcomes of forgoing treatment.
- Treatment Recommendations: I am aware that my Foresight Professional will provide me information regarding their treatment recommendations, including information regarding any medications, therapy, labs, or referrals they recommend.
- Location Updates: I will notify my Foresight Professional of any changes in my (or my child’s) location during telehealth visits.
- Privacy and Security: I recognize that Foresight and its Professionals are committed to safeguarding my protected health information and acknowledge that I have read and understand Foresight’s Notice of Privacy Practices.
- Technical Risks: I am aware of potential technical failures during Tele-Mental Health sessions and the actions that will occur upon a technical failure. I 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 for myself or my minor anytime.
- Emergency Situations: In emergencies, I will dial 9-1-1, understanding that Foresight Professionals cannot directly connect me to local emergency services. If the Foresight Professional believes that the minor may be at risk of harming themselves or others, or if they suspect the child has been a victim of abuse or neglect, the Foresight Professional may contact the appropriate authorities, including 911 and/or the local police.
- Alternative Options: I am aware of the options to request in-person services, but that if my Foresight Professional is unable to furnish such services on a routine basis, I (or my minor) may be referred for alternate care.
- No Guaranteed Outcomes: I understand the expected benefits of treatment, and I am aware that neither Foresight nor my Foresight Professional can assure or guarantee specific results .
- Data Handling: I acknowledge that Foresight is not able to ensure that I (or my minor) is in a location that protects my (or my minor’s) privacy and confidentiality. If for some reason I am not in a secure and confidential location, or if technical issues compromise privacy, I can request to end the session until privacy and confidentiality can be assured.
- Prescription Clarity: I understand that my Foresight Professional will use their reasoned professional judgment in making treatment recommendations. Neither Foresight nor Foresight Professionals will guarantee that prescription medications will be prescribed or furnished post-consultation. Further, my Foresight Professional has the right to decline requests for medication prescriptions if they suspect misuse or do not believe the prescription to be clinically indicated.
- Access to Medical Records: I can access and/or request a copy of my (or my child’s) medical records, to the extent allowable by federal and state requirements. I understand there may be a fee for copying and sending records.
- Service Discontinuation: I understand that my Foresight Professional may cease services if deemed clinically appropriate, and in such cases, they will support me in any necessary transitions.
State-Specific and Patient Rights: I have read and understand the State-Specific Disclosures for my location and accept that where there is a conflict between the state-specific disclosure and this agreement, the state-specific disclosure rules.