WELCOME TO WILMINGTON MENTAL HEALTH & MEDICAL SERVICES (WMH)

We would like to thank you for allowing US to participate in your care. We use behavioral medicine methods and prevent, diagnose, and treat psychosomatic disorders, as well as medical conditions.

Please familiarize yourself with our policies and procedures before you embark on this journey. We ask that you complete all forms in this packet and read the instructions below carefully. When you are ready, please sign and date the forms when asked to do so.

• Fill out the forms to the best of your abilities. If you are the parent/legal guardian or authorized representative of the person seeking treatment, you must provide information as it pertains to your child.
• Please confirm that you fully understand and accept the terms and conditions of your treatment (p. 2).
• Please acknowledge that you received a copy of our privacy practice notice (p. 3) as the HIPAA Privacy Rule requires that we distribute the notice to clearly explain your rights with respect to your personal health information and our privacy practices.
• Please provide a copy of your identification and insurance cards to ensure that we are offering treatment to the right person.

If you are seeking mental health assistance today, you may be experiencing some anxiety and reluctancy about the treatment you are about to receive. These symptoms are very common and may resemble the feelings people experience when seeking medical care during moments of anguish. We will make it a priority to protect your privacy and offer you a safe place where you feel heard and supported. If you have any questions or concerns regarding your treatment, we will be happy to answer those questions at any point during your care.

The first step in your care may involve the completionof a comprehensive clinical assessment or medical evaluation with a counselor or primary care provider, respectively. The information we collect during those evaluations will be used to analyze and interpret your existing problem(s), identify potential diagnoses, formulate a case, and offer treatment recommendations. You may be asked to schedule a follow-up appointment as part of your therapy, medication management, or medical care plan to review the results of your intake assessment to guide your treatment or evaluate your progress.

When appropriate, we will offer recommendations and coordinate with other professionals if additional services are required. Treatment is generally goal-directed and follows a systematic process that progresses as you and your provider build a therapeutic alliance.

In our continuous effort to offer person-centered treatment, we look forward to your thoughts, questions, and feedback on how we can better tailor your treatment and address your needs. Our main goal is to maintain communication with you during your treatment and respond to your inquiries in a timely manner. Should you experience a crisis at any point between sessions, we ask that you please contact 9-1-1, 9-8-8 or go to your local hospital emergency room.

TREATMENT PROCESS:

Unawareness-->Exploration-->Process-->Intervention-->Maintenance-->Termination

"Where the art of medicine is loved, there is also love for humanity" Hippocrates

CONSENT AND SERVICE AGREEMENT

It is important to understand the services you will receive and the terms and conditions of these services. Please review this form carefully and feel free to ask any question or share any concerns you might have.

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You have the right:

• To receive information necessary for you to give informed consent prior to any procedure or treatment, including a description of the procedure or treatment, any potential risks or benefits, the probable duration of any incapacitation, and any alternatives.
• To be treated with dignity and respect by all members of our healthcare team.
• To be free from discrimination based on your race, religion, gender, or any other unlawful category.
• To be free from exploitation for the benefit or advantage of your therapist, psychiatrist, or medical provider.
• To become educated about the nature of any symptom, condition, illness, or disorder affecting you.
• To refuse treatment to the extent permitted by law, and to be informed of the medical consequences of these actions.
• To remain under care until discharge or transfer is medically advisable. If ordered by court, refusing treatment may lead to facing legal consequences.
• To refuse to be photographed, audio-taped or video-taped, unless you give prior consent to these requests.
• To privacy and confidentiality as defined by state and federal law. All information you disclose during your treatment is strictly confidential and private and will not be revealed to anyone outside without your written permission or consentor that from an authorized representative. Exceptions to this rule include disclosures required or permitted by law, typically involving substantial risk of physical harm to oneself or to others, suspicion of child abuse or neglect, or when a subpoena by a government agency is issued to compel testimony or produce evidence.
• To expect treatment from a provider who has met the minimal qualifications of training and experience required and to examine public records about his or her credentials.
• To timely obtain and be able to have access to information pertaining to you, including your clinical records.
• To be informed of the cost of your treatment before receiving services.
• To refuse follow-up calls conducted by Wilmington Mental Health and Medical Services after your treatment ends or your involvement with our facility is discontinued - our staff may conduct courtesy calls for feedback regarding your treatment and status post-separation.
• To obtain a copy of the Ethical Code of the Mental Health, Psychiatry or Medical Profession from the Board of Licensed Clinical Mental Health Counselors, The North Carolina Social Work Certification and Licensure Board, or The North Carolina Medical Board, respectively.
• To an investigation of a complaint by calling the North Carolina Board of Licensed Professional Counselors at 844-622-3572 or 336-217-6007, the North Carolina Social Work Certification and Licensure Board at 336-625-1679, or the North Carolina Medical Board at 919-326-1109 or 800-253-9653 ext. 501.

Benefits and Risks of Therapy

Significant reduction of adverse or negative symptoms, improved interpersonal satisfaction, greater personal awareness, and insight, as well as enhanced coping and resolution skills, among others. You may also be asked difficult questions and recall unpleasant memories, which can bring discomfort to you and worsen your symptoms. Please talk to your counselorif you experience any adverse reaction during your treatment.

Notice of Privacy

Wilmington Mental Health and Medical Services must collect timely and accurate health information about you and make that information available to members of your health care team for the purpose of diagnosing and providing the care you need. It is our legal duty to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.

I have read and understand this consent and service agreement. I agree to abide by the rules and regulations of my treatment as described above and acknowledge that I have received a copy of the HIPAA Privacy Notice. I understand that the Notice is subject to change and that the most recent version can be found at www.wilmingtonmentalhealth.com or in the office waiting room. I understand that I can obtain a copy of the new Notice by contacting 910-777-5575 or by writing a letter to the Privacy Officer, Joseph Rengifo, at 3825 Market Street, Ste 4 Wilmington, NC 28403.

Unless you lack physical or mental capacity to make decisions or sign, this form must be signed by you, the patient.

Unless you lack physical or mental capacity to make decisions or sign, this form must be signed by you, the patient.

Identification
All patients 18-year-old and older are required to provide a picture ID (school ID, military ID, etc.) for verification and to prevent insurance fraud. Please keep us informed of any changes related to your credit card, insurance, or worker’s compensation information during your treatment with us.

Intake Assessment
All initial appointments begin with a brief screening, comprehensive clinical assessment, psychiatric evaluation, or medical evaluation, depending on your specific presentation. Our intake forms must be filled out and returned to the office before scheduling an appointment or starting treatment.

Patient Responsibilities
We do not allow unattended minor children in the waiting room. This includes children waiting to see their provider as well as when parents/guardians are meeting with their own provider. Minors who are old enough to be in the waiting room unsupervised are expected to conduct themselves in a manner respectful of others in the building.

Patient Responsibilities
It is your responsibility to keep track of your appointments and follow‐up with our team to confirm your appointment. Our staff will regularly contact you to ensure that your follow-up appointment is scheduled as recommended. WMH staff will also attempt to reply to all messages received in a timely manner, but we cannot guarantee an immediate response. Emergency calls are best handled by the
local crisis center by dialing 9-1-1.

Phone Consultation
Direct phone calls to our providers should be for emergency purposes only. All other matters are best discussed in session. With your permission, our clinicians may communicate with other providers or collect collateral information.

Email/SMS Requests
We do not recommend sharing confidential health information about you or any of your family members via email or text. If you initiate electronic communication with us, you are consenting to receive a response in a similar manner. We have established an email address for routine matters that do not require immediate response. Email communications will only be used with established patients
and have a 24-hour turnaround. When sending email, please include your name and telephone number in the body of the message.

Email/SMS Communication
If you wish to communicate with us electronically, please consider that emails are not a substitute for personal treatment or other mental health care and any messages sent to your provider are not part of your clinical records, unless relevant treatment information is shared. Emails and text messages can be both accessed and intercepted by hackers, putting your privacy at risk. Your confidentiality cannot be guaranteed as protected health information shared electronically can be stored online and exposed.

Social Media
To protect the patient-provider relationship built in the confinement of our clinic, “dual relationships” with your provider will be avoided. Your provider will not be able to “friend” you via social media (e.g., Facebook, Twitter, Instagram, etc.) to prevent compromising your privacy and blurring the boundaries of the patient-clinician relationship.

Telehealth
Distance health-related services are offered using a HIPAA compliant, two-way, real-time interactive audio and video software when face-to-face interaction is not possible. Telehealth services can only be provided to patients who are physically located in the state of North Carolina at the time of their visits, offering convenient access to care and reducing travel costs to many people. Please know that virtual
treatment can compromise your treatment with technical difficulties present during sessions.

Professional Collaboration
We will be happy to collaborate with any existing provider to develop a treatment plan that fits your individual needs. Just remember that a written consent must been completed first. Interactions Outside of Therapy Your provider may run into you outside of the office and not acknowledge you, especially if there is another person with you, until you acknowledge him or her first. This is done to protect your privacy and confidentiality. Any interaction in public is expected to be brief and exclude others in your company.

Inclement Weather
Appointments may need to be canceled or rescheduled during inclement weather (i.e., hurricane, snowstorm.) WMH follows the New Hanover County schedule for delays and closures, although we may still be open or operating on a normal schedule despite closings or delays in the community. If your appointment must be cancelled, we will make every effort to communicate this to you promptly.

Crisis Management
We do not provide emergency care during life-threatening situations. Our prescribers do not have admitting privileges to the hospital, therefore, if there is a crisis regarding your safety, please go to the nearest emergency department for evaluation and possible admission. In some cases, we may be able to fit you into our schedule if you are experiencing a mental health or psychiatric crisis.

Controlled Substances
Patients are responsible for sharing with their providers what substances and medications they are currently taking. Our prescribers may have set their own guidelines and restrictions as to what they are
able to prescribe to their patients.

Urinalysis and Laboratory Work
Urine and/or blood specimens may be collected during your visit as a requirement of your psychiatric treatment/medication management or to detect health-related problems during your primary care visit. We will send the samples to the lab for testing and notify you as soon as the results are back.

Patient Portal
We may send information to you through the patient portal prior to your appointment. You may also
access your medical records and monitor your appointments and billing information through the portal
for your convenience. Access to documents requires granting permission to the file from our end first.

Patient Etiquette
Disrespectful/ abusive behavior or harassment towards office staff or providers will not be tolerated. Any
patient who engages in disruptive behavior will be immediately terminated.

Forensic Affairs
We do not represent patients in court. However, if we need to spend time preparing for depositions,
traveling to the courthouse, or attending court trials, you will be billed at a higher hourly rate than what
we charge for our standard services

Conflict of Interest

Patients who have a strong preexisting relationship friends family etc with an assigned provider are encouraged to seek treatment from a different provider.

Termination of Treatment

We reserve the right to terminate your care if you make any threats or sexual advances toward any member of our staff. We may also discharge you for non-compliance with your treatment, for violating our terms and conditions, for failing to pay your bill, or if your safety is compromised.

MEDICAL SERVICES AUTHORIZATION

Any treatments or procedures, which may be performed in our outpatient practice, may include but are not limited to medications, injections, test to record the electrical activity of the heart or body, or laboratory procedures provided under the general and special instructions of the clinician, staff, or other health care providers of Wilmington Mental Health assisting with your care.

It is understood that, as a patient, you...

• May not be compelled to take any prescribed medication and may discontinue that/those medication(s) at any time. However, if medication is stopped, serious side effects may occur, therefore, discontinuing any medication(s) without the awareness and active participation of the prescribed clinician or nurse practitioner is contraindicated.
• Will be offered information regarding any potential risks and benefits associated with taking certain medication(s) while pregnant/breastfeeding.
• Are expected to pay for any services furnished to you by Wilmington Mental Health PLLC. Ultimately, you are financially responsible for any amount not covered by your insurance carrier and any unpaid balance if payment is denied for any reason by your insurance company.
• May be randomly drug tested biochemically to maintain the integrity of your care while receiving treatment with US. Drug testis provide US with assurance that all medications prescribed to you are being taken properly and are at the correct therapeutic level within your system. It is understood that you may refuse to comply with this request. However, your refusal could impact and terminate your treatment at WMH.
• Aer required to provide specific written permission to release STD results, HIV/AIDS testing, whether negative or positive, to anyone besides you. STDs are infections transmitted through sexual contact, caused by bacteria, viruses, or parasites, which may include herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (acquired immunodeficiency syndrome), and gonorrhea.
• Must notify Wilmington Mental Health if an agent is legally responsible for making healthcare decisions on your behalf due to your incapacity to make and execute healthcare decisions.
• Allow to start a dispute regarding medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered. The dispute will be determined by submission to arbitration as provided by North Carolina law, and not by a lawsuit or resort to court process except as North Carolina law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
• It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the provider including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean the mother and the mother's expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the provider, and the provider's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
• A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once proceeding. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the North Carolina Code of Civil Procedure provisions relating to arbitration.
• This agreement may be revoked by written notice delivered to the provider within 30 days, or signature. It is the intent of this agreement to apply to all medical services rendered at any time for any condition. I understand that I have the right to receive a copy of this arbitration agreement.

Please list all medications, including over the counter, physician prescribed, or any psychiatric medication (e.g., antianxiety, antidepressant, antimanic, antipsychotic, tranquilizer) you are taking now or have taken during the last six months.

Please do not wait until your last pill to call for a refill. There is a 72-hour turnaround for prescription refills If you have not seen the provider in six months the prescription will be denied.

Please check any symptoms you may be experiencing from the following list and write down any that may not be listed. Select "No Problems" if you are not having any difficulties. If you have any questions about this, please ask a staff member or your provider.

*Standard text messaging rates may apply with your current wireless plan.

APPOINTMENT REMINDERS AND OTHER COMMUNICATIONS

This request/authorization to release records and information has been explained to me and I fully understand it, including the nature of the records, their contents, consequences and implications of their release. The release of information is limited to the minimum necessary to accomplish the purpose for which the request is made. This authorization is being completed freely, voluntarily and without coercion.

I have the right to revoke this authorization at any time unless Wilmington Mental Health and Medical Services has acted in reliance upon it. Such revocation must be in writing and received by Wilmington Mental Health to be effective. Refusing to sign this form will not prevent my ability to get treatment, payment, or eligibility of care.

Once my health information is released, the recipient may disclose or share my information with others and my information may no longer be protected by federal and state privacy protections. Wilmington Mental Health and Medical Services will not share or use my health information without my permission other than by ways listed in Wilmington Mental Health and Medical Services HIPAA Privacy Notice or as required by law. I hereby discharge Wilmington Mental Health and Medical Services, its agents and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein.

If patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form - written proof may be required.

NOTICE - This information is to be treated in accordance with (HIPAA) privacy regulations This information has been disclosed to you from records the confidentiality of which may protected by federal and/or state law (45 CFR Part 164 and 164; 42 CFR Part 2 You are prohibited from making further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by G.S. 122C-53 through G.S. 122C-56. A general authorization for the release of other medical information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The circumstances under which disclosure is permitted or required by state or federal confidentiality rules are described in our Notice of Privacy Practices.