I provide consent to be assessed and/or receive treatment for behavioral health symptoms.
I/we understand the following:
- that I/we have been fully informed about the nature of the treatment, the risks and benefits, and the available treatment options, including: Group and/or Individual Psychotherapy, Psychotropic Medication, Telehealth
- that I/we have had the opportunity to have all questions answered to my/our satisfaction.
- that this consent is given voluntarily.
- that I am legally competent and have the authority to provide consent for treatment.
- that I have the right to withdraw my consent for this treatment at any time. That withdrawing consent for this treatment will not prejudice my continued treatment relationship.
I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Life Connect Health providing health care services to me via telemedicine. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Life Connect Health at 844-800-2735. As long as this consent is in force (has not been revoked) Life Connect Health may provider health care services to me via telemedicine without the need for me to sign another consent form.
I have reviewed, been provided with the opportunity to receive, or received a copy of LifeConnect Health’s HIPAA Notice of Privacy Practices.
(Note: If start date is prior to the request received date, it must be requested as a retrospective review and may be denied for non-compliance
Evaluation Services (Note: One unit equals one hour
Integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning, report writing and feedback to patient/family member:
Test Administration and Scoring (Note: One unit equals 30 minutes
Specific psychological tests being requested (full name of test written out) with specified time for each one: