General Consent for Treatment

I hereby voluntarily consent to receive behavioral health services, including psychiatric evaluations, medication management, psychosocial assessments, psychotherapy, and follow-up care from GREAT VALLEY TELEPSYCHIATRY PLLC.

I understand that I may withdraw consent at any time in writing.

Telehealth / Telemedicine Consent

I understand that telehealth involves the use of electronic communication to provide behavioral health services.

I acknowledge the following:

• I understand the purpose, risks, and benefits of telehealth services.
• I understand that confidentiality laws (HIPAA, 42 CFR Part 2) apply to telehealth sessions.
• I understand I may refuse or discontinue telehealth at any time.
• I understand technical failures may occur.

HIPAA Privacy Practices Acknowledgment

I acknowledge that I have received and reviewed the Notice of Privacy Practices outlining how my health information may be used or disclosed.

Include the Notice of Privacy Practices

Psychotropic Medication Consent

I give consent to my provider to prescribe psychotropic medication if needed, based on his or her professional judgment.

Financial Responsibility and Insurance Billing Consent

I understand that:

• Insurance may be billed for services rendered.
• I am responsible for copays, deductibles, and non-covered services.

Emergency Contact and Crisis Consent

I authorize the provider to contact the emergency contact/case manager and emergency services (911) in the event of a crisis or if I am a danger to myself or others.

Patient Rights & Responsibilities Acknowledgment

Patient Rights

As a patient, I have the right to:

• Be treated with dignity, respect, and without discrimination.
• Receive services in a safe, clean, and supportive environment.
• Participate in the development of my treatment plan and goals.
• Be informed of my diagnosis, treatment options, medications, and potential risks/benefits.
• Refuse treatment or medication (unless court-ordered or in an emergency), and be informed of possible consequences of refusal.
• Confidentiality of all personal, medical, and mental health information as protected by HIPAA and 42 CFR Part 2.
• Access my medical records within a reasonable time (as allowed by law and agency policy).
• Report grievances or complaints without retaliation.
• Receive humane care — no verbal, physical, or psychological abuse.
• Practice my religion or spiritual beliefs, as long as it does not interfere with others.
• Have access to medical and psychiatric care in a timely manner.
• Be free from seclusion or restraint unless medically or legally justified for safety.
• Receive information regarding discharge planning and community resources.

Patient Responsibilities

As a patient, I agree to:

• Participate honestly in my treatment and recovery process.
• Follow facility rules, schedules, and staff instructions to maintain safety.
• Take medications as prescribed and inform staff of any side effects or refusal.
• Respect staff, peers, property, and the privacy of others.
• Avoid violence, threats, stealing, or possession of weapons.
• Abstain from alcohol, illicit drugs, or non-prescribed medications while in treatment.
• Attend groups, therapy sessions, and medical appointments and actively engage in treatment.
• Provide accurate information about my health, history, allergies, and medications.
• Report unsafe conditions, harassment, or abuse to staff immediately.
• Participate in discharge planning and follow-up appointments.

Acknowledgment of Understanding

I acknowledge that I have received, read, or had explained to me my Patient Rights and Responsibilities.

I understand these rights and agree to follow the responsibilities while receiving services at GREAT VALLEY TELEPSYCHIATRY PLLC.

Consent for Recording Sessions (if applicable)

Client Rights and Information

By signing this form, I acknowledge that:

• My session will not be recorded without my explicit consent.
• I have the right to refuse recording and this will not affect my ability to receive services.
• If I consent, I understand the recording may capture audio, video, and/or screen content during my session.
• All recordings will remain confidential and protected under HIPAA and 42 CFR Part 2 (if substance use treatment applies).
• Recordings will be stored securely and deleted once no longer needed for the stated purpose.
• I may withdraw my consent at any time, and no further recordings will be made.
• I understand that I am not permitted to record sessions unless I have written approval from my provider.

Consent for Controlled Substance Monitoring (if prescribing stimulants/benzodiazepines)

Client Acknowledges and Agrees to the Following

1. Medication Use & Safety
   • I understand controlled substances may be addictive, habit-forming, or misused.
   • I agree to take the medication exactly as prescribed and not change the dose without my provider’s approval.
   • I will not obtain similar medications from another provider without notifying Great Valley Telepsychiatry.
   • I will not share, sell, or misuse my medication.
2. Monitoring & Compliance
   I consent to the following monitoring practices if clinically indicated:

   ☑ Random or scheduled urine drug screens (UDS)

   ☑ PMP (Prescription Monitoring Program) review of my medication history

   ☑ Pill counts or medication reconciliation

   ☑ Verification with pharmacies or other providers

   ☑ Safe storage of medications to prevent theft, misuse, or los

3. Lost or Stolen Medications
   • Lost, stolen, or damaged medication may not be replaced early.
   • A police report may be required for any reported theft.
4. Single Prescriber & Pharmacy
   • I agree to use one prescribing provider and one pharmacy for controlled medications unless otherwise approved.

Consent Statement

I understand and consent to controlled substance monitoring as part of my treatment. I agree to follow this plan to ensure safe and appropriate use of medication.

Safety Contract / No-Harm Agreement

Client Agreement

I agree to the following:

1. Safety from Self-Harm
   • I agree not to harm myself or end my life in any way.
   • If I experience thoughts of self-harm or suicide, I will:
     • Use coping skills (deep breathing, music, journaling, grounding, exercise)
     • Inform staff, my provider, or a trusted person immediately
     • Request crisis support if needed (988 Suicide & Crisis Lifeline)
2. Safety from Harm to Others
   • I agree not to harm others, threaten others, or engage in violent behavior.
   • If anger or urges to harm others become overwhelming, I will notify staff or remove myself from the situation and use coping strategies.
3. Communication and Support
   • I agree to tell staff or my provider if I feel unsafe or unable to control harmful thoughts.
   • I will accept help from crisis services, emergency services, or hospitalization if necessary to maintain safety.
4. Crisis ResourcesIf I cannot ensure my own safety, I agree to contact one of the following:
   • 911 (Emergency Services)
   • 988 Suicide & Crisis Lifeline
   • Nearest Emergency Room

Provider / Staff Commitment

Great Valley Telepsychiatry agrees to:

• Provide a safe environment and emotional support
• Offer coping strategies and crisis intervention
• Ensure immediate assistance if the client expresses unsafe thoughts or behaviors
• Involve emergency/crisis services when necessary for client safety

Release of Information (ROI) Consent

I Authorize the Release of My Protected Health Information (PHI):

Client Rights & Confidentiality Notice

• I understand this authorization is voluntary.
• I may revoke this consent at any time in writing, except for information already released.
• Unless revoked earlier, this authorization will expire 12 months from the date signed.
• This form protects information under HIPAA and 42 CFR Part 2 (substance use confidentiality).
• I understand information disclosed may not be re-released by the recipient without my written consent.
• My treatment, payment, or services will not be denied if I choose not to sign this form.