The Custodial Parent or Legal Guardian should REVIEW AND SIGN this Consent to Treat Minor IF Patient is under 18 years of age or has a legal guardian.
If the patient is under the age of eighteen or unable to consent to treatment, a legal custodian of the Patient will be required to authorize and consent for the initial evaluation and on-going treatment on behalf of the Patient.
I voluntarily consent that my child, or ward, will participate in a mental health evaluation (e.g. psychological or psychiatric) and/or treatment by staff from the Nashville Center for Hope & Healing. The evaluation and treatment will be made by a licensed mental health clinician (a psychotherapist, psychologist, psychiatric nurse practitioner, psychiatrist, or licensed therapist). I understand that following the evaluation and/or treatment, complete and accurate information may be provided concerning each of the following areas:
1. The benefits of the proposed treatment 2. Alternative treatment modes and services3. The manner in which treatment will be administered4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).5. Probable consequences of not receiving treatment 6. Expectations regarding the length and frequency of treatment
It may be beneficial to my child, or ward, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s, or ward’s, daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. As a parent or guardian of the patient seeking evaluation and treatment, I may have useful information for the professionals doing the evaluation and ongoing treatment, because of this fact, please disclose all information which can be helpful to the treatment team at any point in the care process. Information can be given verbally, or in written communication.
Treatment will hopefully give benefits, which may include improved cognitive or academic performance, emotional and physical health status, quality of life, and awareness of strengths and limitations.
Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. As the parent or guardian of the patient, I will be responsible for charges. Fees are available to me upon request and may be referenced in the new patient packet.
Information from my child’s, or ward’s, evaluation, and/or treatment is contained in a confidential medical record at the Nashville Center for Hope & Healing, and I consent to its use by staff for the purpose of continuity of my child’s, or ward’s, care. Per Tennessee mental health law, the information provided will be kept confidential with the following exceptions: 1) if my child, or ward, is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise, or 3) if a court order is issued to obtain records.
I have the right to withdraw my consent for evaluation and/or treatment of my child, or my ward at any time by providing a written request to the treating clinician. I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child or my ward. I also attest that I am the legal guardian and have the right to consent for the treatment of this child or ward. I understand that I have the right to ask questions of my child’s, or my ward’s service Clinician about the above information at any time.
Please read the following letter about our clinic and then, begin the application:
Hello and Welcome!
As the medical director of the Nashville Center for Hope & Healing, I want to welcome you and thank you for inquiring about an appointment. Once you submit your application, we will review the application to make sure we can provide the care you are seeking; if we cannot we will refund your deposit and make an appropriate referral.
I am board-certified in psychiatry with the American Board of Psychiatry and Neurology and have trained and seen patients in Nashville and Middle Tennessee since 1992. I have recruited the finest mental health professionals in the area to help you with your needs. In our office, we care for patients from ages 14 & up.
We perform Comprehensive Team Evaluations* and have a reputation for thoroughly evaluating and helping patients get well. The team evaluations include a psychiatric nurse practitioner, a therapist, and a supervising psychiatrist. These evaluations are long and thorough and are more expensive than a typical doctor’s visit. The evaluations generally last 3 to 3.5 hours and are comprehensive and well worth the price. A psychiatrist supervises the comprehensive evaluation and the follow-up care after the initial visit and is consulted by the team as needed in the follow-up. This delegation of service allows you to receive excellent, cost-effective care.
We are a TEAM, and we meet as a team weekly to review cases that we share. Most clinics are just independent clinicians who market the practice together; this is not the case at Nashville Center for Hope & Healing. Further information about our team can be found on our website, www.healnashville.com.
While we offer Comprehensive One-Time Consultations in our clinic for patients and other clinicians in the Middle Tennessee community, we do offer our Comprehensive Team Evaluation at a discount, if you are continuing your care with us following the first visit. Recently, because of the 2020 financial hardships, we started offering Psychiatric Nurse Practitioner-Only evaluations and Therapist-Only. These Psychiatric Nurse Practitioner-Only and Therapist-Only Evaluations are NOT the same as Comprehensive Team Evaluations. There will only be one clinician (a Nurse Practitioner or a Therapist) in the visit.
The Team Evaluation, the Psychiatric Nurse Practitioner evaluation, the therapist evaluation, and all follow-up services are “out-of-network” services in the Nashville Center for Hope & Healing (NCHH), and, as so, patients are asked to pay the full charge of the visit. We are able to file insurance claims for our patients to all commercial insurance companies, but we cannot file with governmental plans such as Medicare, Medicaid, and TennCare as we are not in contract with these entities.
After each encounter, our billing staff can file your claim with your insurance to help you get some reimbursement. Insurance payments typically take a few weeks and will be reimbursed to you directly or if you choose, you can apply any reimbursement as a credit to future visits to our clinic. As all insurance arrangements with patients are unique, insurance reimbursement from your plan is NOT guaranteed. Payment from an insurance company is dependent on the terms of your specific health insurance policy.
In addition to our services, we offer Transcranial Magnetic Stimulation (TMS) and now Esketamine, through an arrangement with the NeuroScience and TMS Centers; we can refer you for a TMS consultation and treatment. Please inquire at the initial appointment scheduling if you are interested in TMS.
We cannot book time for any of the initial evaluations until this application and the deposit payment are complete. The new appointment deposit is the entire fee of the appointment and covers for the potential of a Missed Appointment or Late Cancellation as our clinicians set aside significant time for each evaluation.
Here are the steps to complete the process:
STEP 1: Complete this private, HIPAA compliant questionnaire Sign all Policies, Select Service(s), & Submit the form with a deposit payment*
STEP 2: Staff will send an email for you to complete your Medical History Questionnaire
STEP 3: Staff will email, or call you with options to schedule your first appointment
* If you are unable to submit the deposit with a credit card payment, print the form, and contact our office manager for an alternative payment form.
We look forward to helping you get a complete comprehensive evaluation, diagnosis, and treatment plan; we believe this is the key to getting well. If you have questions about the process, our clinic, or our team, visit our website www.healnashville.com, or email Whitney Patton, our Front Office Manager, firstname.lastname@example.org.
Michelle Cochran MD, DFAPA, Director of Nashville Center for Hope & Healing
We are out of network with insurance at NCHH.
If you would like us to submit your claim to insurance when you see other clinicians in the office, we will need information about your policy. If you are privately paying for the appointment (not filing insurance) or using insurance which we are not in-network clinicians, then you do NOT need to fill out this section, and can write NA or NONE in the sections below.
Dr. Cochran does not see in-network patients in this clinic.
*Please note: If the patient continues in our office for at least three follow-up appointments following the Comprehensive Team Evaluation the $695 charge will be honored. The remainder of the one-time Consult fee will be billed if the required follow-ups are not made within 12 weeks following the Comprehensive Team Evaluation.
****Read all of the NCHH Policies (Privacy, General Office, and Insurance & Payment Policies), www.healnashville.com, then sign below.****
The policies, below, are highlighted for emphasis:
Late Cancellation/Missed Appointment Policy
Notification must be received by 4:00 pm CDT, five (5) business days before the scheduled appointment in order to avoid charges.
If you have to cancel or reschedule my new patient appointment, you must give five (5) business days' notice prior to the date of the appointment in order to receive a full refund. A large block of time is booked for the new appointment, and we must have a 120-hour (five business-day) notice in order to potentially reschedule the time. If you cancel the new patient appointment or miss the appointment you will be responsible for the full fee for the appointment scheduled and this can not be billed to insurance.
For all follow-up appointments, we also have a 72-hour cancellation policy. If you miss an appointment OR do not cancel with a three (3) business-day notice, you will be obligated to pay the full fee of the service (e.g. a late cancel or missed Nurse Practitioner session/30-minute appointment would cost $120.
Again, Late Cancellations and Missed Appointment fees are not covered by insurance.
Prescription Refill Policy
The policy in the office is to refill all medication within an appointment, and because of this we generally, do not prescribe medication outside office visits.
Medication refills are handled during office hours, during scheduled appointments, when an assessment can be made of the patient. We refill medications only for patients currently under our care.
If you are prescribed medication, you will be given enough medication to cover you until your next scheduled appointment. If you have to cancel please reschedule quickly to avoid running out of medication. Contact us directly if you need a refill of prescribed medication, and allow 72 hours for refills to be sent.
Prescription refills outside of an office visit will be charged $30. This fee is not billable to your insurance.
If your appointment is rescheduled because of unforeseen circumstances, on our part, there will not be a charge.
Payment of Charges Policy
All charges must be paid at the time of service. The office staff will collect for the booked amount of time with the Clinician (or co-pay and deductible if applicable).
You are agreeing to allow Nashville Center for Hope & Healing (NCHH) to charge the credit card on file for any fees due that are outstanding following the appointment or outside of an appointment.
The following are a few common examples of when this might happen:
• If you have insurance coverage for your appointments and we incorrectly collected a lower estimated co-pay, co-insurance and/or deductible, and then later receive an Explanation of Benefits (EOB) from your insurance showing that we did not collect enough money from you, then we will notify you and charge the balance to your card on file.
• If your appointment goes beyond the originally booked time, then the clinician will bill for the additional amount of time in the session, and this could mean that you might have a larger charge than you paid when you arrived for the appointment.
• The clinicians charge their hourly rate for any service on your behalf (letter writing, review of medical records, calls to outside therapists/or clinicians caring or you, review of labs/tests, completing special insurance forms, emergency call after hours, refills outside of your appointment, late cancellations/no-show charges, etc.).
Likewise, if we overcharge you, we will immediately apply the credit to your account. If you prefer, notify us and we can refund the charge.
By signing below, I am acknowledging that I have read all of the policies on the Nashville Center for Hope & Healing website.
I agree with my cardholder policy and I authorize the full fee charge of the appointment scheduled as a deposit, as well as, all outstanding fees, non-covered fees, and late cancellations or missed appointment fees to be charged to my credit card as explained in the Insurance & Payment policies and the General Office policies.
I have read & agreed to all policies of the Nashville Center for Hope & Healing website (Privacy, General Office, and Insurance & Payment) and any and all of those policies that may be amended and published on www.HealNashville.com.