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Consent to Treatment

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By reading and acknowledging this form, you, the patient, agree to the following:

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I confirm that I am a resident of the State of California or that I am physically located in the State of California at the time I receive services from Humanistic Psychiatry. I understand that Humanistic Psychiatry provides medical services only within the State of California. My treating clinician may not be able to provide care when I am located outside of California.

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I understand that Humanistic Psychiatry does not accept Medicare, Medicaid, or commercial insurance plans. Upon request, I may receive a Superbill for potential submission to a commercial insurance carrier; however, reimbursement is not guaranteed. I understand and agree that I am fully responsible for all charges and costs related to services provided by Humanistic Psychiatry.

 

I understand that fees are disclosed at the time of selecting my clinician and scheduling my appointment. I authorize Humanistic Psychiatry to charge my credit card for services rendered. I agree to provide accurate and current payment information at the time of scheduling and to maintain valid payment information for future appointments.

 

I understand that I will not be able to communicate with or receive clinical services from Humanistic Psychiatry providers if my payment information is incorrect, my credit card is declined, or payment cannot be completed for any reason. Humanistic Psychiatry reserves the right to modify service fees without prior notice.

I understand that Humanistic Psychiatry does not provide emergency services. In the event of a medical or psychiatric emergency, I agree to call 911 or go to the nearest emergency department.

 

I understand that Humanistic Psychiatry protects the confidentiality of my medical records and will disclose them only to individuals I authorize in writing. Exceptions to confidentiality are described in the Notice of Privacy Practices and include, but are not limited to, court orders, mandatory reporting obligations, and disclosures required to provide routine medical care.

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I agree that any claim, dispute, or legal proceeding arising out of or relating to services provided by Humanistic Psychiatry shall be brought exclusively in the California state superior courts. I further agree that this consent and all related matters shall be governed by and construed in accordance with the laws of the State of California.

I consent to evaluation and treatment as discussed during my appointments. Treatment may include, but is not limited to, psychiatric medications, psychotherapy, laboratory testing, and other clinically appropriate interventions.

 

In the event of a declared public health emergency (including but not limited to COVID-19–related emergency declarations), I understand that my clinician may prescribe controlled substances via telemedicine when legally permitted. I consent to any required laboratory testing or drug screening necessary to remain compliant with controlled-substance treatment policies.

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I understand that if I have not received care from Humanistic Psychiatry for two (2) years or longer, I will be required to complete a new intake evaluation, re-review all treatment documents, and re-authorize any releases of information, which will have expired.