TTT Policies - Therapy Treatment Team

THERAPY TREATMENT TEAM, LLC POLICY STATEMENT AND TREATMENT CONSENT FOR COUNSELING, PSYCHOLOGY AND PSYCHIATRIC TREATMENTS

Welcome to Therapy Treatment Team. This document contains important information about the counseling, Psychiatry, or psychological services you (or your child) will receive. Please read it carefully and feel free to ask any questions you may have. This Policy Statement and Treatment Consent is between Therapy Treatment Team, LLC (which includes its employees and providers, referred to hereinafter as “Therapy Treatment Team, LLC”, “we”, “us”, “our”, “psychological services provider”, “psychiatric provider”, “psychologist(s)”, “therapist(s)”, and “counselor”). Therapy Treatment Team is committed to providing quality, professional healthcare to all of our clients (client is referred to as “client”, “patient”, “you”, “I,”, “me,”, or “my” herein). I voluntarily consent to care and treatment by the independently contracted Therapy Treatment Team provider, therapist, psychologist, Psychiatric Prescriber, or the Psychiatric-Mental Health Nurse Practitioners (PMHNP).

PROCESS OF THERAPY/EVALUATION

Participation in therapy can result in several benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part. Psychotherapy requires active involvement, honesty, and openness to change your thoughts, feelings, and/or behavior. Throughout the course of your treatment, your therapist will ask for your feedback and views on your therapy and progress. You are encouraged to respond openly and honestly to this, as sometimes, more than one approach can help deal with a certain situation.

For the counseling process to be successful, your commitment to the process is essential. This commitment includes regular attendance, active participation, and completion of the process through the planned termination of counseling services. Homework may be used between sessions to help enhance your growth process. You may initially begin to find some relief from symptoms, and this may make it tempting to terminate services. However, this initial relief is often temporary if counseling is stopped abruptly. Because all therapists want to see you have the greatest growth possible during the time you are here, we will work with you to plan a successful wrap-up. This is an important part of the counseling process, and we highly encourage you to honor your work by not neglecting this phase.

During evaluation or therapy, be mindful that remembering or talking about unpleasant events, feelings, or thoughts can result in considerable discomfort or strong feelings of anger, sadness, worry, fear, or experiencing anxiety, depression, insomnia, etc. Therapy may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed.

Additionally, attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. The experience of you changing while in therapy will sometimes happen quickly, but more often it will take time and patience on your part. There is no guarantee that psychotherapy will yield positive or intended results.

During therapy, our therapists will utilize various psychological and motivational approaches according to the problem that is being treated and the assessment of what will best benefit you. These approaches include but are not limited to behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family, and couples), psycho-educational, solution-focused, or coaching techniques.

PROCESS OF PSYCHOLOGICAL TESTING/EVALUATION

Psychological services may include psychotherapy, consultation, assessment, and/or treatment planning. Therapy involves working together with a psychologist to address emotional, behavioral, cognitive, or social difficulties. The goal is to foster personal growth, improve functioning, and address concerns you may be experiencing.

Psychological testing and assessment are designed to help understand your (or your child’s) emotional, cognitive, behavioral, and developmental functioning. The results of these assessments may be used to inform diagnosis, treatment planning, and recommendations for academic, occupational, or social functioning.

Participation in psychological services can result in several benefits to you or your child, including diagnosis, accomodations at schools, improved learning outcomes, and resolution of the specific concerns that led you to seek psychological services. Working toward these benefits requires effort on your part. Psychopsychological services requires active involvement, honesty, and disclosure of current and past experiences affecting you.

For the psychological services process to be successful, your commitment to the process is essential. This commitment includes attendance, active participation, and completion of the process through the planned termination of psychological services services. During the evaluation and assessment process, be mindful that remembering or talking about unpleasant events, feelings, or thoughts can result in considerable discomfort or strong feelings of anger, sadness, worry, fear, or experiencing anxiety, depression, insomnia, etc. psychological services may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed.

Nature of Psychological Testing and Assessment

Psychological assessments involve the use of standardized tests and other evaluation methods to obtain information about various aspects of functioning. This may include:

Intellectual functioning (IQ)
Academic performance and learning abilities
Memory and attention
Behavioral and emotional functioning
Social and developmental skills

The assessment process generally includes:

Initial Interview: A detailed interview to gather information about your (or your child’s) history, concerns, and current functioning.
Testing Sessions: Administration of psychological tests, which may include paper-and-pencil tasks, computerized tests, questionnaires, or interviews. Sessions typically last 1-3 hours, but the length may vary depending on the type of assessment.
Scoring and Interpretation: After the assessment, your psychologist will analyze and interpret the results.
Feedback Session: You will be scheduled for a feedback session to discuss the results, diagnosis (if applicable), and recommendations.

Risks and Benefits

Benefits: The results of the assessment can provide valuable information about your (or your child’s) strengths and areas of difficulty. This information can be used to guide treatment, educational planning, and interventions to improve functioning.

Risks: While testing is generally considered safe, there are some risks to be aware of:

Emotional Distress: Some individuals may experience discomfort, frustration, or anxiety during testing, especially if they struggle with certain tasks.
Misunderstanding Results: Without professional interpretation, test results may be misinterpreted. It’s important to discuss all findings with your psychologist.
Confidentiality Limitations: If test results are shared with schools or other professionals, they may become part of a permanent record that could impact future evaluations or decisions.

Voluntary Participation

Every child is eligible for a free evaluation through their local public school district. This is a right protected by law under the Individuals with Disabilities in Education Act (also called IDEA). While schools are required to consider the results of an outside evaluation, they are not required to fully accept those results in lieu of their own evaluation. Participation in psychological testing and assessment is voluntary. You may choose to withdraw from the process at any time, though doing so may limit the ability to reach diagnostic conclusions or make recommendations. If you have concerns during the assessment process, you are encouraged to discuss them with your psychologist

Client Rights

You have the right to:

Be treated with respect and dignity.
Receive services that are appropriate to your needs.
Request information about your treatment, diagnosis, and progress.
Decline or refuse treatment at any time without judgment.
Seek a second opinion from another mental health professional.
Ask any questions regarding the therapy process.

OFFICE POLICIES

All clients are required to read and sign the Therapy Treatment Team, LLC informed consent and policy documents before their first visit. Please note that you may schedule an appointment by calling our offices. Your scheduled appointment indicates acceptance of our HIPAA and informed consent policies which are regularly updated.

If you are in crisis or this is a life-threatening emergency, go to the nearest emergency room for assistance. Office and online appointments are NOT appropriate for acute and crisis situations. If you are a current client, please contact the office and/or your therapist, psychologist or psychiatric prescriber and we will discuss what happened AFTER you are seen by someone in the emergency room.

Confidentiality is key in counseling, psychological services and psychiatric care sessions. Your confidence is safeguarded, with the exception of what is outlined in the informed disclosures below. You will be seen according to your confirmed appointment. We use an online scheduling system that will send a reminder email, text, and/or voice message. To schedule or reschedule an appointment, please call one of our offices at 239-537-9646. All appointments (first-time and recurrent) MUST check in with the front desk before starting your appointment with your therapist, psychologist or with your psychiatric prescriber.

DUAL RELATIONSHIPS

This is a small world, and you and your therapist, psychologist or psychiatric prescriber may see each other in the community. If you see each other outside of the office, your therapist, psychologist or psychiatric prescriber may smile and say “Hi” in a generally friendly way, as they might do with everyone in our community. The therapist or the psychiatric prescriber will wait for you to initiate the interaction with them before they directly address you.

In addition, we will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, we will preserve the integrity of our working relationship. For this reason, we will not accept any invitations via social media sites such as Facebook, Twitter, Linkedin, or Pinterest, nor will we respond to blogs written by clients or accept comments on our blog(s) from clients.

Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist, psychologist or psychiatric prescriber and client is never part of the therapy process as well as other actions or dual relationship situations that might impair your therapist’s Psychologist’s or your psychiatric prescriber’s objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature.

TERMINATION AND REFERRAL

During the initial intake process and the first couple of sessions, the psychologist, therapist, or psychiatric prescriber will assess if they can be of benefit to you. If you have requested online consultation, their assessment will include your suitability for psychological services, psychotherapy, or psychiatric care delivered via technology.

Therapy Treatment Team, LLC does not accept clients who, in our opinion, we cannot help. An example of this may be, but is not limited to, the client having symptoms that we are not trained to work with, or the situation the client is experiencing can no longer be helped by members of our team. In such a case, your psychologist, therapist, or psychiatric prescriber will give you several referrals that you may contact.

If at any point during the treatment, your psychologist, therapist, or psychiatric prescriber assesses that he/she is not effective in helping you reach your treatment or therapeutic goals, your provider is obliged to discuss this with you up to and including termination of treatment. Your responsibility is to make a good-faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about our treatment recommendations, you are strongly encouraged to express them so the provider can resolve any possible differences or misunderstandings. In such a case, the provider would give you several referrals that may be of help to you.

If you request and authorize it in writing:

The psychologist will talk to the psychologist of your choice to help with the transition.
The therapist or psychiatric prescriber will talk to the psychotherapist of your choice to help with the transition.

Deciding when to stop working together is meant to be a mutual process. Before termination, the provider will discuss how you will know if or when to come back or whether a regularly scheduled “check-in” might work best for you.

Noncompliance with treatment recommendations may necessitate early termination of services. Non-compliance can include, but is not limited to, repeated cancellations, no-shows, or showing up late to your appointments. If you do not show up, repeatedly cancel your appointments, and/or show up late to your appointments, we reserve the right to terminate your treatment unilaterally and immediately.

If at any time you want another professional’s opinion or wish to consult with another psychologist, therapist, or psychiatric prescriber, we will assist you in finding someone qualified, and if we have your written consent, we will provide her or him with the essential information needed. You have the right to terminate psychological services, therapy, or psychiatric care at any time. If you choose to do so, we will offer to provide you with names of other qualified professionals whose services you might prefer. Please see the cancelation and no-show policy below for more information on how we reserve to terminate services due to multiple cancellations or no-shows.

If you commit violence to, verbally or physically threaten, or harass a psychologist, therapist, psychiatric prescriber, or other personnel in our offices, or your provider, or the family of anyone else in our offices, we reserve the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. Please contact the office to make arrangements any time should your financial situation change.

MEDICATION/PRESCRIPTION RESPONSIBILITY

To provide the best quality psychiatric care, there will be an agreement between the patient and/or consumer and the Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner (PMHNP).

I understand, agree, and acknowledge that I am entitled to the following information before making an informed decision regarding medication administration:

My condition or diagnosis. Targeting symptoms of the condition and reasons for medication(s). Alternative treatments with benefits and potential risks involved.
Medication name, dosage, frequency, route of administration, and expected duration of use.
Psychotropic medication therapy may include regular lab and/or diagnostic tests and monitoring potential effects.
I will inform the Psychiatric Prescriber or the Psychiatric Mental Health Nurse Practitioner – (PMHNP) of all my known allergies.
I will inform the Psychiatric Prescriber or the Psychiatric Mental Health Nurse Practitioner – (PMHNP) of all medications I am currently taking, including prescriptions, over-the-counter remedies, herbal therapies, supplements, and any other recreational drug or alcohol use.
I should avoid drinking alcoholic beverages when consuming psychotropic medication(s).
I am aware that, at the discretion of my provider, if it is deemed appropriate that I be prescribed a medication considered a controlled substance, a contract may follow.
I understand that certain medications, at the provider’s discretion, may require monitoring parameters to be started/ continued. This may include but is not limited to ongoing lab work, drug screening, blood pressure, and weight.
I understand that my Psychiatric Prescriber or PMHNP participates in the Prescription Monitoring Program and, by law, may access information about me and/or report information about me, as applicable.
I understand that my Psychiatric Prescriber, or PMHNP, participates in systems cooperation with other community entities. Still, not limited to other providers/health systems/laboratories/pharmacies, etc., and may access information about me as applicable to my care.
I understand that my Psychiatric Provider or PMHNP must be informed if I am receiving, or plan to acquire psychiatric medication management from another provider. I can receive care from up to one provider concurrently. My Psychiatric Provider or PMHNP is happy to coordinate a transition to a new provider if/when I choose to make a change.
I understand it is my responsibility to read or will be read to all the drug labeling information for all my medications, including prescriptions, over-the-counter remedies, herbal therapies, supplements, and any other medicine or drug.
It is also my responsibility to ask questions of my pharmacist regarding any questions or concerns I have regarding any or all of my medications.
I am aware and accept that no treatment results have been guaranteed. I acknowledge I will be advised of the probable consequences of declining recommended or alternative therapies.
The Psychiatric Prescriber or Psychiatric Mental Health Nurse Practitioner Board-Certified (PMHNP) will answer and will continue to respond to any or all of my questions regarding the treatment plan. Common medication side effects may occur, as well as rare, potentially life-threatening side effects and fetal risk during pregnancy.
I understand and accept the possible side effects of any prescribed psychotropic medication or drug, and I will continue to ask my pharmacist questions regarding any questions or concerns I have.
I acknowledge, agree, and understand immediate discontinuation of certain medications can risk additional side effects; therefore, some medicines should be discontinued gradually under the guidance of the Psychiatric Prescriber or the Psychiatric Mental Nurse Practitioner – (PMHNP).
I understand that it may take up to 72 business hours for a refill request to be completed and that it will only be considered once a follow-up appointment has been scheduled as soon as possible (not to exceed 30 days or more shortly at the discretion of the provider), and that there is no guarantee that my Psychiatric Prescriber or PMHNP will approve the request between appointments. If approved, a $15 fee will be applied (see fee information on the reverse side).
Some Schedule II-IV medications will not be authorized to be filled early. Please discuss this with your Psychiatric Prescriber or PMHNP.
Controlled substances may require a hard copy prescription and will not be authorized to be filled early.
Unless approved by my Psychiatric Prescriber or my PMHNP’s discretion, no changes to medication will be made outside of scheduled appointments.
I may only request a medication refill once before attending my next appointment, and I must allow for up to a 72-hour turnaround.
Medication changes, refill requests, and questions concerning your medication will not be addressed on evenings or weekends but will be handled the following business day within a 72 business hour timeframe. Please refer to the emergency protocol.
Please plan and schedule an appointment before running out of your medication. Refills may not be filled, but every effort will be made to prepare you as soon as possible upon your appointment request.
I understand that if I am a no-show or late or cancel my appointment and require medications, no changes will be made, and prescriptions will be refilled for seven days until I have an appointment scheduled.
I understand that my medications will not be refilled if I have not attended an appointment for over six months. I will be scheduled for a new intake at the discretion of my Psychiatric Prescriber or PMHNP’s discretion.
If I am discharged for any reason by the Therapy Treatment Team, a 30-day supply of most medications will be provided to me by the Psychiatric Prescriber or PMHNP’s discretion.

By reviewing this document and signing the accompanying informed consent, the patient asserts that all the following statements are factual:

I understand that the primary treatment goal in prescribing medication is to improve my ability to function, quality of life, and/or work. Considering these goals, I agree to help myself by following better health habits, including but not limited to exercise, eating healthy, and avoiding the use of alcohol and tobacco.
I understand that when my insurance may require a pre-authorization for the medication prescribed, staff will submit appropriate paperwork as required by my insurance for any pre-authorization. I know that my insurance company may take between 24 hours and up to 14 days to approve a pre-authorization, which could delay receiving my prescribed medication.
I am responsible for my controlled substance medication. If the prescription medication is lost, misplaced, or stolen, or if I need it refilled sooner than prescribed, I understand it will NEVER be replaced.
I will not request or accept the same class of medication from any other physician/prescriber while I am receiving medication from this office.
Refills of medications will only occur at scheduled medication management appointments. Refills will not happen over the phone unless otherwise arranged with your prescriber. In these cases, prescriptions may take up to 72 business hours to be sent to the pharmacy.
Refills will not be authorized early because of vacations or personal plans.
I am responsible for taking my medication at the dose and time prescribed.
I will not share, trade, or sell my medications. I understand that doing so will result in my immediate discharge from this office.
I will disclose fully, to the best of my knowledge, all other medications I am taking.
I understand that driving a motor vehicle may not be allowed at times while taking a controlled substance, and it is my responsibility to comply with the laws of this state and in accordance with my prescriber.
I understand that any criminal charges for receiving, possessing, or selling illegal substances and/or a controlled substance prescription will be reviewed by my prescriber and may result in my discharge.
I understand it is the responsibility of the Psychiatric Mental Health Nurse Practitioner – (PMHNP) to explain to me the nature of any diagnostic, therapeutic, medical, and/or psychiatric-mental health treatment plan necessary to treat me and to explain the risks and consequences associated with the services.
I understand that the Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) does not prescribe or dispense addiction treatment medications such as, but not limited to, Naloxone and Methadone but may refer a patient to a treatment center/provider as needed. I understand the Psychiatric Prescriber or the Psychiatric Mental Health Nurse Practitioner – (PMHNP) does not prescribe opioid pain medications, and there are no medication samples at the Therapy Treatment Team premises.
While treating me, I understand that my The Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) may refer me to a specialist for some medical diagnosis. It is typical and expected for you to be under the care of a primary care physician or medical specialist when you have certain medical conditions. For example, pregnant patients are also being seen and treated by an appropriate healthcare professional, and patients seeking adjunctive cancer support are also under the care of an oncologist.
I understand that Therapy Treatment Team, LLC psychiatric prescribers do not conduct detox procedures and Therapy Treatment Team, LLC is not a detox facility.

PATIENT CONFIDENTIALITY NOTICE

The patient record (“designated record set”) and all subsequent or additional protected health information maintained by the Agency is protected by Federal and/or State laws and regulations.

Generally, the Agency may not disclose to a person outside the Agency that I attended treatment or disclose any information identifying myself as an alcohol or drug abuser unless:

A) I consent in writing and/or

C) The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, program evaluation, or for the purposes for supervision with the collaborative physician.

The disclosure is otherwise permitted or required pursuant to HIPAA and our policies and procedures. Federal and/or State laws and regulations concerning confidentiality do not generally protect or restrict information about a crime committed by a person, including a patient, either at the Agency, against any person who works for the program, or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child, vulnerable adult abuse, or neglect from being reported under Federal and/or State laws to appropriate State or Local authorities.

As a participant of Therapy Treatment Team group practice, you acknowledge that the healthcare team, including both psychotherapy and psychiatry, assigned to you maintains a shared record on our Electronic System. Therefore, you understand and consent to the fact that all documentation related to your care will be accessible to the providers within your care team. You understand the importance of confidentiality within the group practice setting and acknowledge that your information will be handled according to the established protocols and legal requirements.

I understand the Clinical Director, the Psychiatric Prescriber, the Psychiatric Mental Health Nurse Practitioner – (PMHNP), the Collaborative Physician, and administrative staff may review my patient record and any lab and diagnostic reports, but all my records will be kept confidential and will not be released outside of the Agency without my written consent.

I understand that I have voluntarily chosen to seek treatment; I am of legal age and authorized to execute this addendum. I will immediately alert the Psychiatric Mental Health Nurse Practitioner (PMHNP) of any medical conditions that may adversely affect my health or the effectiveness of the medication, including new prescriptions from other providers or over-the-counter medications, including herbal supplements.

I understand that if I experience any side effects, I am responsible for following up with the Psychiatric Prescriber or Psychiatric Mental Health Nurse Practitioner (PMHNP) prescriber at my expense.

I understand that receipt of this medication is subject to reporting, by my Psychiatric Mental Health Nurse Practitioner (PMHNP) to my primary care physician and/or the manufacturer, if required, and I will authorize these disclosures. Medical recommendations may be made to my Primary Care Physician related to physical symptoms and diagnostic findings related to my mental health state.

I understand that treatment options are available for my condition other than the Psychiatric Prescriber or Psychiatric Mental Health Nurse Practitioner – (PMHNP) recommended procedures. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

I understand that no guarantees are being made to me as to the results of evaluation or treatment.

I am aware that I am an active participant in this endeavor and that I share the responsibility for treatment by providing all accurate information about my history or my child’s history.

I understand that our work will be kept confidential, with the exception of disclosures required by law and when necessary in connection with my care. In particular, I am aware that, although my Psychiatric Nurse Practitioner (PMHNP) is a clinically independent practitioner, consultations with associates are at times clinically advisable, and my signature below gives my PMHNP permission to do that. The associates also provide emergency coverage for each other when one is out of the office. I understand that an associate providing coverage for my PMHNP may need access to relevant information to provide the best interim care possible. My PMHNP works collaboratively with my therapist when I am in therapy to ensure that everyone is working together to best support my needs.

I authorize the release of any information necessary to process any insurance claims or to help get a preauthorization or reauthorization for visits and/or medications. I understand that it may be necessary for my TTT psychiatric prescriber to provide information included in my health record to obtain a preauthorization or reauthorization for medication and that TTT will not obtain a separate or unique release of information for the purpose of prescriptions or medication management.

A patient’s authorization to disclose records is not required for the following purposes:

For the treatment of a patient including TTT (providers/staff) obtaining pre authorizations and reauthorizations of medications or labs on your behalf.

For payment of or billing for services.

For health care operations (for example, quality assurance, credentialing, audits, compliance monitoring).

In addition, there are laws and standards, which can require such disclosures under certain circumstances:

Clinicians and other health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

It is the Agency’s duty to warn any potential victim, when a significant threat of harm has been made. In the event of my death, my spouse or my child(ren)’s parent or legal guardian may have a right to access my records.

Professional misconduct by a clinician must be reported by other clinicians, in which case related patient records may be released to substantiate disciplinary concerns. Legal custodial parents or legal guardians of non-emancipated minor patients may have the right to access my records.

Informed Consent for Teletherapy (if applicable)

In cases where teletherapy services are provided, you acknowledge the following:

Teletherapy involves the use of electronic communications (video, phone) to conduct therapy sessions.
There are risks associated with teletherapy, including the potential for technical difficulties and security breaches. Every effort will be made to use secure, HIPAA-compliant platforms.
You are responsible for maintaining privacy on your end (e.g., using a private, quiet space for sessions).
Teletherapy may not be appropriate for every condition, and it will be up to the discretion of your psychologist to determine if teletherapy is suitable for your needs.

PRIVACY & CONFIDENTIALITY

All information disclosed within sessions and the written records about those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and psychologist or therapist remain the property of Therapy Treatment Team, LLC. Verbatim material from psychological services or therapy sessions remains in the client’s record and should never be revealed publicly unless both client and the provider agree. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with these forms.

As a participant of Therapy Treatment Team group practice, you acknowledge that the healthcare team, including both psychological services/psychotherapy and psychiatry, assigned to you maintain a shared record on our Electronic System. Therefore, you understand and consent to the fact that all documentation related to your care will be accessible to the providers within your care team. You understand the importance of confidentiality within the group practice setting and acknowledge that your information will be handled according to the established protocols and legal requirements.

Generative Technology

As part of our commitment to providing accurate and efficient documentation, our providers use artificial intelligence (AI) transcription services during appointments. These services help transcribe conversations to create detailed and accurate treatment notes. The recordings are used solely for this purpose; no permanent recording is generated, and the transcription is not stored anywhere. Once the transcription is completed, the treatment note is drafted and securely saved in our electronic health record system.

The transcription process follows strict confidentiality protocols to safeguard your privacy and comply with HIPAA and other applicable privacy laws. While the AI service processes the voice recordings, no identifiable information is shared with external providers beyond what is necessary for the transcription. By signing this informed consent, you acknowledge your understanding and agreement to the use of these technologies during your treatment sessions.

FOR PARENTS

At Therapy Treatment Team, LLC we work hard to gain your child’s trust so that the therapeutic or testing and assessment process can have the utmost benefit to them. For this reason, we do not consult with parents in person during the first appointment. We may talk to parents or consult with a parent in person in front of the child at the office in some circumstances if we determine this will benefit the progress and wellbeing of your child.

After the first appointment with your child, please expect the following: a. the psychologist or therapist will consult with parents on the phone or over video without the child being present, b. we request that you maintain any information discussed about your child between you and the child’s psychologist or therapist, c. please communicate with your child’s psychologist or therapist about your desire to have other consultation calls after future appointments, and d. our psychologists or therapists are glad to schedule a consultation call after an appointment with your child at your request.

If you would like to consult regarding your child every week, the psychologist or therapist will end the sessions with your child anywhere from 30 to 40 minutes to give time to consult with you on the phone at a different time.

Generally, the treatment of a minor (under the age of 18) must be authorized by a parent or someone else with legal authority. Parental control over a minor’s treatment includes parents without residential responsibility for a child who retains decision-making authority over the child’s treatment and treatment records because a court has ordered it. When parents with decision-making authority cannot agree on access to or release of their child’s confidential treatment information, a court will decide that matter following a hearing.

Please note that by signing this document, you agree that Therapy Treatment Team, LLC is not legally or ethically liable for reviewing, understanding, or assessing legal documents regarding child custody cases. If a parent who has shared custody makes an appointment without the consent of the other parent, Therapy Treatment Team, LLC is not legally or ethically liable for the misconduct of the parent who is violating the legal agreement. Therapy Treatment Team, LLC reserves the right to terminate treatment for your child if your initial treatment consent was not properly or legally signed by both parents.

We believe it is best to identify and resolve potential parental agreements before treatment begins. Therefore, it is our policy to involve both parents when treating minors to the extent both are available. If both are available but cannot reach an agreement about treatment and access to records, it is the responsibility of the parents to resolve their differences through a court hearing before continuing treatment with Therapy Treatment Team, LLC.

If one parent is unavailable and we determine that it is appropriate to proceed with the consent of only one parent, the absent parent will have the right to the child’s treatment records upon request while the child is a minor unless there is a court order to the contrary. If the continuation of treatment becomes an issue, it is the responsibility of the parents to resolve the disagreement in court, and Therapy Treatment Team, LLC has the right to terminate and provide both parents with three different referral sources for the continuation of treatment if desired.

Consistent attendance is especially important for effective psychological services or therapy. Therapy Treatment Team, LLC will schedule follow-up sessions directly with your child. It is your responsibility to check in with your child or Therapy Treatment Team, LLC to know when the next scheduled psychological services or therapy session takes place.

Please note that upon turning 18, the child gains control over treatment, information, and records.

WHEN DISCLOSURE MAY BE REQUIRED

Some of the circumstances where disclosure is required by the law without consent are: a. when there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and b. when a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form), or c. when subpoenaed by a court of law.

Disclosure may be required according to a legal proceeding or other matters. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy or psychological services records and/or testimony by your therapist or psychologist. In couple and family therapy or psychological services, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.

The Therapy Treatment Team will use clinical judgment when revealing such information. We will not release records to any outside party unless we are authorized to do so by you or in the case of children/family by all adult family members who were part of the treatment. In most situations, we can only release information about your treatment to others (teachers, primary care doctors, other professionals working with you) if you sign a written Authorization to Release Information form. You have the option to either give or decline consent to release information at any time.

There are some situations where we are permitted or required to disclose information without your consent:

Court order. If you are involved in a court proceeding and a request is made for information concerning your treatment or your child’s treatment, we will not disclose that information without your consent, unless there is a court order to do so.

Communication for protection. If you threaten to harm yourself, we may be obligated to contact family members or others who can help provide protection.

Legal complaint. If you file a complaint or lawsuit against one of our therapists or psychologists, Therapy Treatment Team, LLC may disclose relevant information to defend our case.

Periodic consultation with mental health colleagues, all of whom are legally bound to maintain confidentiality. During these case reviews, every effort will be made to avoid revealing your name/identity.

Communication with your insurance company, at your request. The information we submit under your claims will become part of the insurance company’s files, which the Therapy Treatment Team, LLC has no control over.

It is important that you discuss any questions or concerns you may have about confidentiality with your therapist or psychologist. If such situations arise, your therapist or psychologist and Therapy Treatment Team, LLC will make every effort to fully discuss them with you before acting, and we will limit my disclosure to what is necessary.

HARM TO SELF OR OTHERS-BAKER ACT 52

If there is an emergency during your work with Therapy Treatment Team, or in the future after termination, in which one of the therapists, psychiatric prescriber or psychologists becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, the therapist will do whatever can be done within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the police, hospital, or an emergency contact whose name you have provided.

NON-VOLUNTARY DISCHARGE FROM TREATMENT

I acknowledge I may be discharged from the Agency non-voluntarily if:

A) I exhibit any physical violence, verbal abuse, carry weapons, or engage in illegal acts at the Agency and/or,
B) I refuse to comply with stipulated treatment rules, refuse to comply with treatment recommendations, do not provide the appropriate forms upon initial treatment, or do not make payment or payment arrangements in a timely manner and/or,
C) I do not attend my scheduled appointment for two (2) consecutive sessions without notifying the Agency twenty-four (24) hours prior to the scheduled appointment, indicating I can attend the appointment.

CONFIDENTIALITY OF ONLINE, CELL PHONE, AND FAX COMMUNICATION

Therapy Treatment Team communicates via email for scheduling and basic informational purposes only. All therapeutic, testing and assessment, or psychological services topics, concerns, or questions are discussed in the office or during a scheduled appointment. If you choose to email your therapist, your psychiatric prescriber, or your psychologist from your email account or by text, please limit the contents to issues such as cancellation or change in appointment time. Email and text messages are not guaranteed to be confidential. If you choose to communicate with your therapist, your psychiatric prescriber, or your psychologist this way, you do so, understanding that we cannot guarantee that these modes of communication are confidential.

Additionally:

Text messaging via mobile phone is acceptable for appointments and housekeeping issues only.

If you call your therapist, your psychiatric prescriber, your psychologist, or someone else in our team, please be aware that unless we are both on landline phones, the conversation is not confidential.

If you send a fax to the Therapy Treatment Team, LLC, our fax is secure.

Our therapists, our psychiatric prescribers, or our psychologists will not respond to personal and clinical concerns via email.

If you wish to use email as a way to “journal” information between sessions, you understand that your therapist, your psychiatric prescriber, or your psychologist may not have the opportunity to review your journal emails until your next scheduled session.

You understand that emails between sessions that contain confidential information may be intercepted in transmission.

Therapy Treatment Team, LLC makes every effort to keep all information confidential. Likewise, if we are working online together, Therapy Treatment Team, LLC asks that you determine who has access to your computer and electronic information from your location, including: family members, co-workers, supervisors, and friends, and whether or not confidentiality from your work or personal computer may be compromised. We encourage you to only communicate through a computer that you know is safe i.e. wherein confidentiality can be ensured. Be sure to exit all online counseling, psychological services, or therapy sessions and emails fully.

If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place our practice as a check-in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, others may surmise that you are a therapy or psychological services client due to regular check-ins at our office weekly. Please be aware of this risk if you are intentionally “checking in,” from our offices or if you have a passive LBS app enabled on your phone.

It is not a regular part of the practice to search for client information online through search engines such as Google or social media sites such as Facebook. Extremely rare exceptions may be made during times of crisis. If your therapist, psychiatric prescriber, or psychologist has a reason to suspect that you are in danger and you have not been in touch with them via usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if Therapy Treatment Team, LLC ever resorts to such means, Therapy Treatment Team, LLC will fully document it and discuss it with you at your next session.

COUPLES

Treatment records of couples’ sessions contain information about each person. Both clients should be aware that either person has a right to obtain treatment records. If one of you requests your records, it is the Therapy Treatment Team, LLC policy to notify the other member of the couple and to afford that individual an opportunity to receive a copy of the records as well. Additionally, the couple’s treatment is done with the couple, and with the relationship being the goal of each treatment session. A couple’s session is for the couple, not for each individual in the relationship.

GROUP THERAPY

Unlike individual treatment, the confidentiality of group therapy is not privileged and, therefore, not protected by law. Group members must sign and abide by a written confidentiality agreement prior to participating in the group. Clients with concerns about confidentiality should discuss them before beginning treatment.

PARENT CONSULTATION VS. COUPLES OR FAMILY THERAPY

Parent consultation with both parents is not considered couples or family therapy. If you received couples or family therapy through a provider at TTT, please know that treatment records of couples’ sessions contain information about each person. Both or all clients should understand that either person has a right to obtain treatment records. If one of you requests your records, it is the Therapy Treatment Team, LLC policy to notify the other member of the couple or the family and to allow that individual to receive a copy of the records. Additionally, couples and family treatment is done with the couple or the family, with the relationship being the goal of each treatment session. A couple’s or family session is for the couple or the family, not for each individual in the relationship.

COURT-ORDERED TREATMENT

If you are seeing one of our providers or psychiatric prescribers due to a court order requiring you to seek treatment, it is our policy that we do not proceed with treatment until we have received a copy of the court order and have had the opportunity to review it. Because you have been ordered by the court to obtain treatment, there are limits to confidentiality in addition to the ones described in the paragraph entitled Confidentiality. For example, we may be obligated to file a report with the court that ordered you to seek treatment or with someone else. By signing below, you understand that your limits of confidentiality are different if you are seeking treatment from one of the Therapy Treatment Team, LLC providers or psychiatric prescribers because you were court-ordered to do so. Court-ordered evaluations, reports, letters, summaries, travel, and subpoenas may have different fees from the ones listed below and may not be covered by health insurance. Please call the office to obtain more information regarding court-ordered fees for services.

MEDICAL EMERGENCIES

If I encounter a personal emergency that requires prompt attention, I may contact a crisis hotline such as 988, crisis unit, or 911. I can choose to leave a message for the Psychiatric Prescriber or Psychiatric Mental Health Nurse Practitioner – (PMHNP) through the office number 239-537-9646. (Please allow at least twenty-four (24) hours for a follow-up phone call.)

If an emergency arises and you require prompt attention, or you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room.

CONTROLLED SUBSTANCES PRESCRIBING STANDARDS

The psychiatric prescriber can make independent clinical judgments regarding the prescription of controlled substances. Clinical best practices, safety standards, and a comprehensive assessment of potential benefits and risks will inform the prescriber’s approach. This discretion allows the prescriber to determine the most appropriate course of treatment, including whether controlled substance medications are clinically indicated, the specific type and dosage, and any necessary adjustments over time. Here are the medication treatment guidelines that TTT psychiatric providers follow:

A patient must have an adequate trial (at least one month) of at minimum two non-stimulant medications for ADHD prior to starting stimulant therapy unless otherwise contraindicated.
A patient should have an adequate trial (at least one month) of at minimum two non-benzodiazepine anxiolytics prior to the initiation of a benzodiazepine for anxiety or panic symptoms unless otherwise contraindicated.
If a patient has any cardiovascular risk, they will need to be cleared by primary care or cardiology prior to starting stimulant therapy; the patient must also obtain an ECG or have had one completed within the last six months.
Adult patients with no prior history of ADHD will be referred for formal neuro-psych testing prior to initiating ADHD treatment.
If a patient is being treated with opioids for acute/chronic pain, benzodiazepines will not be prescribed unless absolutely necessary. The patient will be given a prescription for Narcan if this occurs. This patient will be given a maximum seven-day supply of benzodiazepines at a time if this occurs.
A patient with a history of substance abuse will be asked to obtain a urine drug screen (UDS) if they are prescribed a controlled substance.
A patient will not be prescribed a CNS stimulant and CNS depressant (e.g., amphetamine and benzodiazepines) concurrently unless absolutely necessary. If this is a continuation of previous treatment, a plan to taper off on one of these medications must be documented during the initial visit.
A patient with difficulty controlling alcohol consumption will not be prescribed a C-II controlled substance.
A patient who regularly consumes marijuana (medical or medicinal) will not be prescribed a C-II controlled substance.
A patient with a history of opioid addiction will not be prescribed a C-II controlled substance.
Refills for controlled substances will not be authorized early under any circumstance (e.g., medication is stolen, lost, or thrown away).

GROUP psychological services

Unlike individual treatment, the confidentiality of group psychological services is not privileged and, therefore, not protected by law. Group members must sign and abide by a written confidentiality agreement prior to participating in the group. Clients with concerns about confidentiality should discuss them before beginning treatment.

DIAGNOSIS

Therapy Treatment Team, LLC providers will diagnose based on the discussions, disclosures, and symptoms you share during sessions. Insurance companies require diagnosis and treatment planning, which can dictate treatment. If you do not want your diagnosis to be shared with your insurance company, you have the option of being self-pay, which will not require your diagnosis to be shared with the exceptions listed above under the section called WHEN DISCLOSURE MAY BE REQUIRED.

You have the right to know your diagnosis and to discuss any questions you have about it with your psychiatric prescriber, psychologist or therapist. Therapy Treatment Team, LLC will only discuss your diagnosis in person or via video Telehealth appointments. Therapy Treatment Team, LLC will not respond, answer, or engage in conversations regarding your diagnosis or other details of your session via email, text, or other forms of communication.

To discuss your diagnosis or any other questions you have about the treatment we provide or provide you, please schedule an appointment with your psychiatric prescriber, psychologist or therapist. If your psychiatric prescriber, psychologist or therapist is not available, an appointment can be made with one of our clinical directors.

LEGAL LITIGATION AND FORENSIC LIMITATIONS

It is the stated philosophy and policy of Therapy Treatment Team, LLC (TTT) that we do not participate in lawsuits, court proceedings, or litigations of any type on a plaintiff’s behalf unless compelled to do so by a court order signed by a judge. We do not participate or get involved in litigation matters unless we have been hired as an expert witness and agree to be in the role from the start of the first appointment and initial assessment of the client. We only testify, if we choose to and we deem it appropriate. On rare occasions, if we choose to assist in a legal matter, you will be billed at three times the rate of your appointments per hour. A minimum of three hours is reserved and you must pay that up front.

TTT is hereby making a full disclosure concerning legal matters that may be of a confidential nature. a). It is agreed that should there be legal proceedings such as, but not limited to, divorce and custody disputes, civil matter, injuries, lawsuits, etc., neither you (client) nor your attorney, nor anyone else acting on your behalf will subpoena, depose, or call on a TTT provider to testify in court or at any other legal proceeding. b). If you and your legal representation requests a formal (subpoena for records) or informal (by signing a release of information), you understand that TTT will release your records as requested. c). If TTT or a TTT provider is given a lawful subpoena, you hereby give us permission and waive your HIPAA rights for us to respond.

If you become involved in legal proceedings and your TTT provider’s deems it necessary to participate in your case, you will be expected to pay for all of the provider’s professional time, including but not limited to: preparation, documentation, report writing, evaluation writing, communication with legal council and others, deposition, telephone time, transportation costs, court appearance, report writing, consultation, and supervision, even if we are called to testify by another party. Because of the complexity of legal involvement, any court appearance or telephone contact with the court during a court case regarding the client or the client’s family members in a civil or criminal matter will be charged $2800.00 per day, payable two weeks in advance and non-refundable. Travel time will be billed at an hourly rate of three times the amount of the treatment hourly rate, plus mileage from portal to portal. Depositions will be billed at an hourly rate of three times the amount of the treatment hourly rate, plus mileage from portal to portal. If records or other materials are subpoenaed, the office’s regular fees for records will be charged for copying and file preparation. It is also possible that TTT may not be able to bill your health insurance because they may not cover any treatments related to your legal case and your appointments will have to be paid out of pocket.

The therapists of Therapy Treatment Team, LLC consult regularly with other professionals, including other TTT team members, regarding clients. During a consultation, we make every effort to avoid revealing any identifying information about clients. The consultant, supervisor, or expert is legally bound to keep the information confidential. Considering all of the above exclusions, if it is still appropriate, upon your request, we will release information to any agency/person you specify unless we conclude that releasing such information might be harmful in any way.

PROFESSIONAL RECORDS

The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of your records unless we believe that viewing your records would be emotionally damaging, in which case we will be happy to send them to a mental health professional of your choice. Alternatively, we can prepare a summary for you instead. Because these are professional records, they can be misinterpreted by and/or upsetting to untrained readers. If you wish to see your records, we recommend you review them in our presence so that we can discuss the contents. A client’s authorization to disclose records is not required for the following purposes:

For the treatment of a client including TTT (providers/staff) obtaining pre authorizations and reauthorizations of medications or labs on your behalf.
For payment of or billing for services.
For health care operations (for example, quality assurance, credentialing, audits, compliance monitoring).
Certain disclosures may also be made by a health care provider without client authorization to accomplish public health activities and other permitted uses as set forth in the Privacy Rule.

Here is the TTT protocol for a record request:

Adult Individual Records

The individual requesting the record calls the TTT office and speaks to the TTT Client Care Coordinator, has a third-party company send a record request via fax, or informs their TTT psychiatric prescriber, therapist, or psychologist. TTT is not responsible for the way a third-party company chooses to deliver a record request (fax, secure email, or mail).
The TTT Records Request coordinator will inform the provider about the request. The provider will speak to the TTT client about the implications of this request and explain we will need 7 to 15 business days to provide the records.
The TTT Records Request coordinator will send a Release of Information consent (ROI) to the TTT client via DENmaar, as well as a set of instructions to fill it out properly via DENmaar Messages and email (To the email address we have on file for the TTT client). The client is responsible for understanding and knowing which third-party company requested records and states the name of that company or organization in the record release form. We will provide records in person, via fax, or secure mail. We do not provide records for walk-ins or stopping by or unsecure mail and we do not provide records without a consent completed and signed in DENmaar. By signing a release of information, the client understands that the company or organization reviewing the records may use the information in the notes and/or treatment plan to deny claims, litigate against them, or deny services previously requested. TTT providers do not conduct evaluations for legal or civil litigations, therefore, we will not be able to refute, evaluate, or change decisions made by a company that reviewed the records you agreed to release.
The TTT client signs the Release of information consent in DENmaar or reaches out to the TTT Records Request coordinator if they are unable to complete this step in the portal. If needed, the Records Request coordinator will send a copy of the ROI via email, or arrange for the client to pick up a copy in the closest office.
The TTT Records Request coordinator confirms the ROI has been completed properly.
The Records Request coordinator prepares records and gives them to the client or requesting third-party in the way they desire or approve per request in the record request form (mail, in person, fax, DENmaar messages).
If a client has any questions about records, the client must make an appointment in person or via Telehealth to discuss the record with the psychiatric prescriber, therapist, or psychologist.
The client understands that a record request is a request to provide progress notes and a treatment plan. A record request is NOT an initiation or expectation that your psychiatric prescriber, therapist, or psychologist will engage or get involved in a litigation, disability claim, evaluation, or court proceeding on your behalf.

Minors Records

The parent or parents requesting the record calls the TTT office and speaks to the TTT Client Care Coordinator or sends a request via fax, or informs their TTT provider.
The provider will speak to the parent/s about the implications of this request and explain we will need 7 to 15 business days to provide the records.
The TTT Records Request coordinator will send a Release of Information consent (ROI) to the parent/s via DENmaar, as well as a set of instructions to fill it out properly via DENmaar Messages and email (To the email address we have on file for the TTT client). The parents are responsible for understanding and knowing which third-party company requested records and states the name of that company or organization in the record release form. We will provide records in person, via fax, or secure mail. We do not provide records for walk-ins or stopping by or unsecure mail and we do not provide records without a consent completed and signed in DENmaar.
The parent/s signs the Release of information consent in DENmaar or reaches out to the TTT Records Request coordinator if they are unable to complete this step in the portal. If needed, the Records Request coordinator will send a copy of the ROI via email, or arrange for the client to pick up a copy in the closest office.
The TTT Records Request coordinator confirms the ROI has been completed properly.
The Records Request coordinator prepares records and shares them with the parent/s in the way they desire or approve per request in the record request form (mail, in person, fax, DENmaar messages).
If the parent/s have any question about records, they will have to make an appointment in person or via Telehealth to discuss the record with the provider.

Couples Records

The partner or both partners requesting the record calls the TTT office and speaks to the TTT Client Care Coordinator or sends a request via fax or informs their TTT provider.
The provider will speak to the partners about the implications of this request and explain we will need 7 to 15 business days to provide the records.
The TTT Records Request coordinator will send a Release of Information consent (ROI) to the partners via DENmaar, as well as a set of instructions to fill it out properly via DENmaar Messages and email (To the email address we have on file for the couple). Only one partner can sign the release to request the couple’s therapy or psychological services records, but both partners will be provided with the record per the TTT policy. We will provide records in person, via fax, or secure mail. We do not provide records for walk-ins or stopping by or unsecure mail and we do not provide records without a consent completed and signed in DENmaar.
The partners sign the Release of information consent in DENmaar or reaches out to the TTT Records Request coordinator if they are unable to complete this step in the portal. If needed, the Records Request coordinator will send a copy of the ROI via email, or arrange for the client to pick up a copy in the closest office.
The TTT Records Request coordinator confirms the ROI has been completed properly.
The Records Request coordinator prepares records and shares them with the partners in the way they desire or approve per request in the record request form (mail, in person, fax, DENmaar messages).
If the partners have any question about records, they will have to make an appointment in person or via Telehealth to discuss the record with the provider.

All Records Fees

If you want to request a copy of your records, there is a fee depending on the number of pages, please contact our office to find out more about the fee for providing your records. Please note that Therapy Treatment Team, LLC will provide your record using the following methods: electronic Denmaar portal, secure fax, or in-person pick-up. We do not provide records to you or to a third party via unsecure email, text messages, or mail. To release your record to a third party a release of information consent must be completed using our electronic, secure, and HIPAA-compliant software. Please note that Therapy Treatment Team provides only the following records to you or a third party you requested (you may choose to release all, some, or none of these):

Treatment or Session Notes
Facesheet or generalized report
The treatment plan
The basic information you provided when you filled out the initial paperwork
Letter/s that we wrote on your behalf
Evaluation/s if one was completed and paid for prior to the record request

MENTAL HEALTH BILL OF RIGHTS:

Pursuant to the Florida Mental Health Bill of Rights, clients have certain rights. A copy of the Mental Health Bill of Rights is included here:

https://www.flsenate.gov/laws/statutes/2022/394.459

Please review the bill of rights carefully and let your therapist know if you have any questions. In addition, here is the code of ethics for mental health professionals at http://www.apa.org/ethics/code/

CONSULTATION VS. COUNSELING

Mental Health Counseling Services:

Our counseling services include Individual, Couples, and Family focuses. During your counseling sessions, you can expect your counselor to build a trusting relationship in order to help you cope and build skills in order to reduce the symptoms that brought you into counseling. Our clients and counselors work together to identify patterns that may be the cause of distress. Through counseling, we gain a better understanding of ourselves and build healthier, more effective ways of coping through lives challenges. Counseling is a directive approach, which means that you will be working directly with the problem. Counseling is for the client(s) present in the session to find ways to navigate and adapt their skills in order to find meaning and fulfillment. Counseling services can be provided in-person and through telehealth.

Due to the depth and therapeutic process of therapy, Clinicians will only provide Counseling to clients residing in the same State where Clinicians hold licensure.

Mental Health Consultation Services:

Our consultation services are recommended for individuals who are seeking Professional knowledge and information regarding specific challenges. Consultants are able to meet with you to assist with sharing suggestions or information directly related to a specific problem. During the consultation, the Clinician may provide teaching or training and can work with families, groups, or organizations. During consultation, services are able to be communicated directly or indirectly. Consultation services are helpful for an individual, family or group that is seeking advice or gathering input related to Mental Health issues and provide strategies to a person so they are able to deal with the problem independently. Consultation services may be limited to a few sessions. They may result in a referral for psychological treatment, processing techniques, crisis intervention, or other recommendations your mental health consultant may have.

CONSULTATION VS. PSYCHOLOGICAL TESTING OR TREATMENT

Psychological Testing and Treatment Services:

Our psychological services include Individual, Couples, and Family focuses. During your psychological services sessions, you can expect the psychologist to build a trusting relationship in order to help you cope and build skills in order to reduce the symptoms that brought you into psychological services. Our clients and psychologists work together to identify patterns that may be the cause of distress. Through psychological services, diagnosis, treatment recommendations, and planning are made in-person and through telehealth.

Due to the depth and complex process of psychological services, psychologists will only provide psychological services to clients residing in the same State where providers hold licensure.

Mental Health Consultation Services:

Our consultation services are recommended for individuals who are seeking professional knowledge and information regarding specific challenges. Consultants are able to meet with you to assist with sharing suggestions or information directly related to a specific problem. During the consultation, the psychologist may provide teaching or training and can work with families, groups, or organizations. During consultation, services are able to be communicated directly or indirectly. Consultation services are helpful for an individual, family or group that is seeking advice or gathering input related to Mental Health diagnosis and issues. The psychologist can provide strategies to a person so they are able to deal with the problem independently. Consultation services may be limited to a few sessions. They may result in a referral for further psychological treatment, processing techniques, crisis intervention, or other recommendations your mental health consultant may have.

THIRD-PARTY PAYER RIGHTS

In order for the Agency to contact the applicable insurance company on behalf of my clinician, this consent must be signed by me to enable the Agency pre-authorization to request eligibility and benefit information, to file any insurance claim or process necessary paperwork. Patient data of clinical outcomes may be used for program evaluation or with your insurance company. Still, Protected Health Information (PHI) as stipulated by the Department of Health and Human Services, will only be disclosed to outside sources with an Authorization To Release Information form, except as permitted or required.

I hereby consent to the disclosure of patient records to any listed third-party payer for the purpose of receiving payment reimbursement. This includes a health insurance company and Employee Assistance Program (EAP) providers. The Agency is not responsible for any patient disclosure (i.e. diagnostic information, date of service, billing information, etc.) from a health insurance company to the primary insured.

DISCLAIMERS AND LIMITATIONS OF LIABILITY

I understand, agree, and conclusively stipulate that the Agency does not direct or control the services provided by its independent contractors, has no duty to direct, control, supervise, or train its independent contractors, and the Agency is not responsible for the acts or omissions of its independent contractors.

All independent contractors are properly licensed and insured and are employees of their own independent legal entities. It is expressly understood and agreed that the Agency’s liability is limited to the fees paid for services, and in no event will the Agency be liable for any special, incidental, consequential, or indirect damages. It is intended that this limitation apply to any and all liability or cause of action, however, alleged or arising, unless otherwise prohibited by law, including but not limited to negligence, breach of contract, or any other claim whatsoever.

APPOINTMENTS

Please arrive promptly for all appointments. Our practice management systems will send out (unless you decide to opt-out of it) an email, and/or text, and/or voice message reminder for all appointments 24-48 hours in advance. It is your responsibility to read the reminder or reminders you received.

Service Duration:

Psychological services / Therapy sessions are 45-50 minutes long.
Double sessions are 90 minutes.
Evaluations are typically 90 to 120 minutes per session and may take several sessions.

Provider Lateness and Client Contact: As with many other medical providers, psychiatric care appointments can run late; we kindly ask you to patiently wait for your psychiatric prescriber or therapist and contact 239-537-9646 ext 301 if you have questions about your session.

Client Lateness Policy (Maximum Wait Time): For both first-time and follow-up care appointments, we have a policy of a maximum wait time of 5 minutes. If you arrive more than 5 minutes late to your appointment (Telehealth or In-person), your provider will cancel the appointment. This policy is in place to ensure you get the most out of your appointment time, and we will work with you to reschedule your appointment as soon as possible. This policy is also in place because our providers are scheduled back to back and must be on time and responsible for the other upcoming appointments.

FEE FOR SERVICES

Current rates for therapeutic, psychiatric, testing, or assessment services vary per psychiatry prescriber, therapist, or psychologist, treatment technique, insurance copay, deductible, co-insurance, and time spent in a session. Therapy Treatment Team, LLC is “fee for services” and that means that fees are due at the time of your appointment. Most health insurance plans provide for some outpatient mental health benefits. Therapy Treatment Team, LLC participates on some insurance panels as either a preferred or in-network provider. Therapy Treatment Team, LLC will do a double verification of your insurance plan to understand your mental health benefits.

Quoted benefits are not a guarantee of benefits, and the client is ultimately responsible for verifying their insurance benefits. It is possible that Therapy Treatment Team, LLC will be given the wrong information by the insurance company regarding your benefits (copay, deductible, etc). If this happens, by signing below, you understand that you are financially responsible for paying any outstanding balance your insurance plan did not cover. Equally, if Therapy Treatment Team, LLC overcharged you because your insurance plan covered more than initially stated in the verification process, we will reimburse you the overcharged money. Insurance can take 2-4 weeks to process. Once Therapy Treatment Team, LLC has received an Explanation of Benefits (EOB) from your insurance company, you may be sent an invoice for any remaining balance due. Payment is expected within 15 days of the invoice date. After 15 days, your credit card on file will be billed for any remaining balance.

If Therapy Treatment Team, LLC is out of network with your insurance plan and you choose to schedule an appointment with us regardless, please note the appointments will be self-pay until we receive authorization from your insurance plan. Therapy Treatment Team, LLC may help you fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not the insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. We reserve the right to refuse an out of network insurance provider.

Not all services provided by Therapy Treatment Team, LLC are covered by insurance. Meetings, consultations, additional reports, paperwork, cancelations, lateness, and absences (that do not conform to our cancellation policy) are not covered services and will not be billed to private insurers.

You will need to have a card on file to secure your first appointment. We will obtain your credit card information while we are making your appointment on the phone with you.

Therapy Treatment Team, LLC has a first-time appointment paperwork policy. If you have not filled out your required initial paperwork 24 hours before your appointment, your psychiatry prescriber, therapist, or psychologist reserves the right to cancel your appointment and reschedule it when your paperwork is completed. Please note, we cannot see you, treat you, or consult with you until your initial paperwork is filled out and all required documents are signed.

Please note that a credit card on file is required for any telehealth or distant psychological services, therapy, or psychiatric care session. Therapy Treatment Team, LLC will collect telehealth or distant session fees using the credit card you have on file. If you are scheduled for an online synchronous chat, audio, or video conference and you are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If re-connection is not possible due to technology (this does not apply to lateness, no-show, or last-minute cancellations), contact us to schedule a new session time. If your psychiatry prescriber, therapist, or psychologist is experiencing a technical issue, Therapy Treatment Team, LLC will not charge for your appointment and will reschedule your appointment.

Please note that the co-payment, deductible, co-insurance payment, or self-pay fees for in-person and telehealth appointments are all due at the time of service. We currently accept cash and all major credit cards. If you wish to pay by credit card, Therapy Treatment Team participates in a HIPAA compliant payment system. Please note a 3.5% processing fee will be applied to all credit card payments. Unpaid fees could be eligible for referral to a collection agency contracted with Therapy Treatment Team, LLC.

Services will be suspended if there are unpaid invoices past 30 days without any communication to us regarding your balance. Additionally, bills that remain unpaid following 60 days will be forwarded to an outside collection agency.

GOOD FAITH ESTIMATE

You have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services when an appointment has been scheduled 3 or more days in advance. The GFE is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from Therapy Treatment Team or the provider you are scheduled to see. This information is an overview of potential charges when a patient is seen at our office. The GFE is only an estimate of items or services reasonably expected to be furnished at the time it was issued and that actual items, services, or charges may differ from the GFE. The patient may initiate the patient-provider dispute resolution process if the actual billed charges are “substantially in excess of” the expected charges included in the Good Faith Estimate, as specified in 45 CFR 149.620.

You may contact our office to let us know the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. Initiating the patient-provider dispute will not adversely affect the quality of healthcare services furnished to the patient. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Below is a list of potential charges for you, your family, or your child’s upcoming visit to our office:

Therapy Service	Phd or PsyD Fees	Licensed Mental Health Counselor Fees	Registered Mental Health Counselor Intern Fees	Master’s Level Mental Health Counselor (Not registered for Licensure) Fees	Bachelor’s Level Counselor (Student working on a master’s degree in counseling or related field) Fees
Individual 50 minute session	$200	$175	$150	$125	$40
Couples 50 minute Session	$200	$175	$150	$125	$40
Family50 minute Session	$200	$175	$150	$125	$40
Therapy Service	Phd or PsyD Fees	Licensed Mental Health Counselor Fees	Registered Mental Health Counselor Intern Fees	Master’s Level Mental Health Counselor (Not registered for Licensure) Fees	Bachelor’s Level Counselor (Student working on a master’s degree in counseling or related field) Fees>
Children or Minors50 minute session	$200	$175	$150	$125	40
15 minute phone consult (Existing clients only)	$40	$40	$40	$40	$0
15-30 minute phone consult (Existing clients only)	$55	$55	$55	$55	$0
15 minute phone consult(New clients only)	$0	$0	$0	$0	$0
Letters	$65	$65	$65	$65	$65
Documentation completion (Per Hour)	$200	$175	$150	$125	$30
Evaluations and Reports	$200	$175	$150	$125	N/A

Psychological Service	Phd or PsyD Fees	Licensed Mental Health psychologist Fees	Registered Mental Health Counselor Intern Fees	Master’s Level Mental Health Counselor (Not registered for Licensure) Fees	Bachelor’s Level Counselor (Student working on a master’s degree in psychological services or related field) Fees
Individual 50 minute session	$200	$175	$150	$125	$40
Family 50 minute Session	$200	$175	$150	$125	$40
Service	Phd or PsyD Fees	Licensed Mental Health Counselor Fees	Registered Mental Health Counselor Intern Fees	Master’s Level Mental Health Counselor (Not registered for Licensure) Fees	Bachelor’s Level Counselor (Student working on a master’s degree in psychological services or related field) Fees
Children or Minors 50 minute Session	$200	$175	$150	$125	$40
15 minute phone consult (Existing clients only)	$40	$40	$40	$40	$0
15-30 minute phone consult (Existing clients only)	$55	$55	$55	$55	$0
15 minute phone consult (New clients only)	$0	$0	$0	$0	$0
Letters	$65	$65	$65	$65	$65
Documentation completion (Per Hour)	$200	$175	$150	$125	$30
Evaluations and Reports	$200	$175	$150	$125	N/A

Psychiatric Care Service Fees	Fees
Psychiatric Diagnostic Evaluation/Assessment (60-90 min) Simple/Complex	$325
Medication Management w/ psychiatric care (30 min) Simple/Complex	$175-$225
Medication Management w/ Psychiatric care (45 min) Simple/Complex	$250-$375
Medication Management Only (20 min) Simple/Complex	$150
Psychiatric care Only (45-55 min)	$180

Miscellaneous Fees	Fees
Late Cancel or No Show (not covered by insurance) /td>	$100
Late Cancel or No Show Initial Evaluation (not covered by insurance)	$150
Returned Check Fee	$30

I am aware that there is no charge for brief telephone calls, however calls regarding treatment or medication issues lasting more than 5-10 minutes will be prorated and billed at the regular hourly rate ($330).
I understand that if I arrive more than 5 minutes late for my appointment, I may not be able to be seen that day. Please arrive a few minutes early for your appointment to check in.
I understand that outside of violation of RCC policies and with explanation and reasonable timing, my provider may determine it is appropriate to terminate the practitioner-patient relationship. I understand that my provider may be aware of extenuating circumstances (including but not limited to conflict of interest) that may prevent them from providing me with treatment. However, they may not be able to give details due to confidentiality.
I am aware that all balances must be paid prior to scheduling my next appointment. This includes billed charges such as those for no shows, late cancellations, completion of forms/letters, phone calls, etc.
I understand that I will be charged additional fees for the following services:
- Professional Forms: Completion of forms for employment, school, return to work, disability, retirement, legal action, etc. Forms can take up to 10 business days to complete from the time of the request, and fees are prorated at the hourly rate of $330.
- Letters: incur a prorated hourly fee of $330, billable in 15-minute increments, and payment is due prior to completion of the letter. This includes but is not limited to, forms pertaining to insurance, employment, return-to-work status, school, disability, retirement, and legal action. Letters may take up to 10 business days to complete from the time of the request.
- Medical Records: Request can take up to 14 business days to complete from the time of receipt. All requests for copies of medical records must be received in writing, dated and signed, and must include a reasonable description of the records sought. Records produced via a method other than the patient portal are subject to the following fees:
  - $20.00 for hard copies provided by fax or in person.
  - Subpoena for Witness: If my Psychiatric Prescriber or PMHNP is subpoenaed for court, the fee is $500 per hour, plus additional fees (see RCC Court Appearance Policy).
  - Refill Requests Between Appointments: A $15 fee will be incurred for refill requests outside of an appointment.

FEES NOT COVERED BY INSURANCE

There is an additional charge for services required outside a typical psychological services, therapy, or psychiatric care session. This would include but is not limited to additional reports or summaries. Fees may vary depending on the time required to complete.

Social Security Disability, Disability Claim Forms, and FMLA paperwork all require a time commitment and detailed commitment to complete. Surgery Evaluations, Short and Long Term Disability forms, and treatment Summaries for Attorney and Schools all require fees to be paid prior to initiation of paperwork. Phone consultations with Attorneys and Disability Staff also require a fee to be paid in advance. Disability paperwork requires 2-3 visits to assess the client’s needs best.

Important Note on Disability Specialization:

(Psychological Services) explicitly states: “Not all providers specialize in disability assessments, treatment, or documentation (please check with the Therapy Treatment Team admissions staff before scheduling an appointment for a disability related need).”

There is no charge for telephone consultations to other mental Health professionals, physicians, or educators.

Specific Fees for Administrative and External Consultations (Based on $120.00 Therapy/Psychological Rate):

Claim forms are a one-time fee $120.00 depending on time duration involved.
Phone consults with Attorneys and other professionals are charged $120.00 per hour with a one-hour minimum.

Fees for Administrative and External Consultations:

Service Type	Service	Fee (Therapy – Base)	Fee (Psychiatry – Base)
Forms/Claims e	Claim forms are a one-time fee	$120.00 depending on time duration involved.	$325.00 depending on time duration involved.
Phone Consults	Phone consults with Attorneys and other professionals are charged	$120.00 per hour with a one-hour minimum.	$325.00 per hour with a one-hour minimum.

CANCELLATIONS

Once a given time is allocated for a session, if you cancel or do not show up, we cannot easily fill this time slot with another client on short notice. If you must cancel your appointment, please contact our office as soon as possible. Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48-hour notice is required for re-scheduling or canceling an appointment.

Unless we reach a different agreement, the full cancellation fee will be charged for sessions missed without such notification. You will be charged, using the credit card we have on file, the full fee for appointments that are scheduled and missed or canceled with less than 48 hours’ notice.

Cancellation Fees:

Service Type	Appointment Type	Fee
Psychological Services / Therapy	All sessions	$75
Psychiatric Care	First-time visits	$150
Psychiatric Care	Follow-up visits	$100

All cancellation fees are due before scheduling continuing appointments with your existing therapist or psychiatric prescriber or another psychologist, therapist or psychiatric prescriber on our team. Please note this is our policy to provide our offices and the psychologist, therapist or psychiatric prescriber working with you with an opportunity to be able to fill the appointment you canceled. Repeated cancellations of your appointments via email may result in termination because your therapist or psychiatric prescriber did not have enough time to review your correspondence. The best way to effectively cancel an appointment 48 hours prior is by calling our offices and speaking to our front desk. Please note that payment for missed appointments is not reimbursed by your insurance provider. Repeat cancellations, even with notice, might signal the need to end therapy or psychiatric care. Our office typically allows for a maximum of three cancellations with a 48-hour notice; after that, Therapy Treatment Team, LLC reserves the right to discontinue, discharge, or not reinstate therapy or psychiatric care services due to repeated cancellations. NO SHOWS Once a given time is allocated for a session, if you do not show up, we cannot easily fill this time slot with another client on short notice. If you No Show to your appointment you will be charged the full fee for appointments that are scheduled and missed. Please note this is our policy to provide our offices and the psychologist, therapist, or psychiatric prescriber working with you with an opportunity to be able to fill that appointment you missed. Please note that payment for missed appointments is not reimbursed by your insurance provider. If you do not show up to an appointment due to an emergency or a mistake, please call our offices to reschedule. Unless we reach a different agreement, the full no-show fee will be charged for sessions missed without such notification. Please note that a No-Show fee will be collected using the credit card we have on file.

NO SHOWS

Once a given time is allocated for a session, if you do not show up, we cannot easily fill this time slot with another client on short notice. If you No Show to your appointment you will be charged the full fee for appointments that are scheduled and missed.

Please note this is our policy to provide our offices and the psychologist, therapist, or psychiatric prescriber working with you with an opportunity to be able to fill that appointment you missed. Please note that payment for missed appointments is not reimbursed by your insurance provider. If you do not show up to an appointment due to an emergency or a mistake, please call our offices to reschedule.

Unless we reach a different agreement, the full no-show fee will be charged for sessions missed without such notification. Please note that a No-Show fee will be collected using the credit card we have on file.

No-Show Fees:

Service Type	Appointment Type	Fee
Psychological Services / Therapy	All sessions	$75
Psychiatric Care	First-time visits	$150
Psychiatric Care	Follow-up visits	$100

Therapy Treatment Team, LLC reserves the right to discontinue, discharge, or not reinstate psychological services, therapy, or psychiatric care services due to No Show. Please note a 3.5% processing fee will be applied to all credit card payments. All No-Show fees are due before scheduling continuing appointments with your existing psychologist, therapist, or psychiatric prescriber or another psychologist, therapist, or psychiatric prescriber in our team.

LATENESS

If you arrive late for a scheduled appointment, only the remainder of the 45 to 50-minute session will be available. If your therapist is running late with a prior appointment for some reason, you will still receive the full 45 to 50 minutes. It is the office policy that if you arrive 15 minutes late to more than one of your scheduled appointments without notice, the next time you arrive more than 15 minutes late will be considered a no-show and you will be responsible for the missed appointment fee. The fee for being more than 15 minutes late, which is considered a no-show, is $75.

BALANCES

Therapy Treatment Team, LLC does not permit patients to carry a balance of more than two appointments. If you are unable to pay this balance, we will discuss whether it makes sense to pause your care or develop another strategy to avoid incurring additional debt. Please let us know if any problem arises during psychiatric care regarding your ability to make timely payments.

INITIAL APPOINTMENT FEE POLICY

Given the limited availability of our therapists, psychologists or psychiatrists and the value of their time, we have a reservation policy for an initial appointment. Therapy Treatment Team, LLC requires you to place a credit card on file to secure your initial appointment. If you do not show or cancel your initial appointment within the 48-hour policy stated above, you will be charged a $75 no-show fee for missing the scheduled appointment.

FEES FOR LETTER, FORMS, TREATMENT REPORTS, AND EVALUATIONS

Due to the amount of time that it takes to prepare, write, and share requests for letters, evaluations, forms, and treatment reports, Therapy Treatment Team, LLC will charge a flat rate for these requests. Your therapist will discuss these fees with you at the time you make your request. Please note we do not share letters, forms, evaluations, or records with a provider or company outside of Therapy Treatment Team unless you sign a release of confidentiality statement. Please call our offices to have one of these consents sent to you via a secure portal for you to complete and sign prior to us sharing or releasing the document or documents you requested. Please note that fees due for the document you requested are due prior to us releasing the document or record to you or a third party that you requested on your release of information. There is no charge for requesting a treatment plan, face sheet, session notes, or treatment plan.

DELINQUENT ACCOUNTS AND COLLECTIONS

You are responsible for payment of your therapy, psychological or psychiatric care services fees, regardless of whether or not your insurance carrier covers them. Outstanding balances of more than 60 days will be charged to the credit card on file. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Therapy Treatment Team, LLC has the option of using legal means to secure the payment. This may involve hiring a collection agency, and this could affect credit. You agree to the costs of any action necessary to collect your portion of the fee due, including court and attorney fees that might accrue. You will receive appropriate notice of efforts to obtain this debt.

ASSIGNMENT OF BENEFITS

By signing this agreement, you authorize payment of all medical insurance benefits, which are payable under the terms of your insurance policy, to be paid directly to Therapy Treatment Team, LLC, for services rendered. You further authorize the release of any information needed for the purposes of treatment, payment, and healthcare operations, including, but not limited to, the processing of these insurance claims. A copy of this authorization may be used in place of the original. You understand that you are financially responsible for charges not paid by your insurance company.

POLICY CHANGES

If there are material changes to our privacy policies, we will notify you by posting the updated policy on our website. We will not resend you the Therapy Treatment Team policy when it has been modified. We reserve the right to modify this privacy policy at any time, so please review our website at www.therapytreatmentteam.com frequently for any changes. Amendments to this privacy policy will be effective at the time they are posted. You will be deemed to have been made aware of, will be subject to, and will be considered to have accepted the changes to any amended or revised privacy policy by your continued use of our services or the sites.

PAYMENT DUE AT TIME OF SERVICE

I hereby acknowledge that all fees are due at the time of service and are to be made payable to: Therapy Treatment Team. Payment can be made either by: cash, authorized credit/debit card, or HSA insurance card.

The Agency is not responsible for any HSA insurance card that doesn’t approve my clinical treatment. As such, any declined HSA insurance card is my responsibility, and I must provide another form of payment at the time of service.

Any non-sufficient funds (NSF) received via a bank/debit card will result in a fee of Thirty Dollars ($30.00). When appointment fees are not paid in a timely manner, I understand a collection agency may be given appropriate billing and financial information about me, but will not receive any clinical information.

If my insurance company doesn’t provide financial reimbursement for my treatment or is canceled during treatment, I am responsible for any outstanding balance.

CONSENT

I confirm that I have read, or have been read to me, the above consent. I understand that recommended treatment may include medication therapy, including psychotropic medications, and these medications will be explained to me generally to my satisfaction. I will have the opportunity to ask questions, and I can continue to ask questions to ensure I’m fully informed regarding each and all medications, including their interaction or potential interaction. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment. I consent to treatment and agree to abide by the above-stated policies and agreements with the Agency. Even after signing, I understand I can still refuse any medication or withdraw my agreement entirely at any time.

I understand that either party (the prescriber or me) may discontinue treatment at any time when not prohibited by applicable professional standards. The Agency encourages this decision to be discussed with the Psychiatric Prescriber or Psychiatric Mental Health Nurse Practitioner (PMHNP) and myself. This will help facilitate a more appropriate discharge plan.

The treatment information is handled with the utmost care to ensure privacy. This document is for consent and agreement for clinical treatment integrative healthcare, and to understand patient rights and the Agency’s rights.

I hereby attest that I have voluntarily entered into treatment and give my consent for myself at Therapy Treatment Team, hereby referred to as the “Agency”. Further, I consent and agree to have treatment provided by the Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) , who I acknowledge, understand, and agree is an independent contractor of Therapy Treatment Team, and acts pursuant to his or her own professional license and professional judgment, which is not subject to the judgment or control of Therapy Treatment Team.
Any person providing services is a third-party beneficiary to this agreement and may enforce any rights hereunder. I understand that any Addendum to this consent will be found in the Therapy Treatment Team website at www.therapytreatmentteam.com.
I understand that the Psychiatric Prescriber or PMHNP-BC-Adult, and I will have the opportunity to ask any questions regarding the informed consent and will have all of my questions, if any, addressed.
I also understand, agree, and warrant that I will meet and discuss the treatment and risks of treatment with the Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) , and provide written consent for the healthcare prior to the start of my treatment.

I request and authorize the TTT Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) to provide and perform an assessment, diagnose, care, and evaluate my emotional and physical health, which also may include ordering medical diagnostic tests and/or procedures, services, and education that are considered advisable for my health and wellbeing. Following an initial assessment, the Psychiatric Prescriber or The Psychiatric Mental Health Nurse Practitioner – (PMHNP) and I develop a treatment plan jointly. The frequency and duration of treatment vary and will depend on my needs.

I hereby request and consent to the performance of healthcare services (or on behalf of the patient named, for whom I am legally responsible) by Psychiatric Prescriber or the Psychiatric Mental Health Nurse Practitioner – (PMHNP) at the Therapy Treatment Team providing services to me now and in the future. I consent to treatment and agree to abide by the above-stated policies and agreements with the Agency.

HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

I HAVE REVIEWED AND BEEN PROVIDED A COPY OF THE HIPAA NOTICE OF PRIVACY PRACTICES. I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS ABOUT THESE POLICIES, AND I UNDERSTAND THAT I MAY ASK QUESTIONS ABOUT THEM AT ANY TIME IN THE FUTURE. I CONSENT TO ACCEPT THESE POLICIES AS A CONDITION OF RECEIVING MENTAL HEALTH SERVICES.

INFORMED CONSENT TO TREATMENT

I HAVE READ, UNDERSTOOD THE INFORMED CONSENT TO TREATMENT, AND SIGNED IT. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS. IF THE PATIENT IS UNDER THE AGE OF EIGHTEEN OR UNABLE TO CONSENT TO TREATMENT, I ATTEST THAT I HAVE LEGAL CUSTODY OF THIS INDIVIDUAL AND AM AUTHORIZED TO INITIATE AND CONSENT FOR TREATMENT AND/OR LEGALLY AUTHORIZED TO INITIATE AND CONSENT TO TREATMENT ON BEHALF OF THIS INDIVIDUAL.

I AGREE TO THE ABOVE CONDITIONS AND POLICIES. I AGREE AND CONSENT TO PARTICIPATE IN BEHAVIORAL HEALTH CARE SERVICES OFFERED AND PROVIDED AT THERAPY TREATMENT TEAM, LLC.