Consent to Treatment
Please read and attest below:
I acknowledge that I have had all my questions about treatment answered fully and to my satisfaction.
I seek and consent to take part in treatment with mental health provider Jodianne Ingersoll, PMHNP of Psychiatric Empowerment Services, PLLC. I understand that developing a treatment plan with this mental health provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I understand and agree to paly an active role in my treatment processes.
I understand that no promises have been made to me about the results of treatment or of any procedures provided by this mental health provider.
I am aware that I may stop my treatment with this mental health provider at any time. If I do, I will have to pay for the services that I have already received. I understand that I may lose other benefits or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)
I know that I must call to cancel an appointment at least 48 hours (two business days)before the time of appointment. If I do not cancel and show up, I will be charged for that appointment.
I am aware that my health insurance company or other third party payer may be given information about my diagnose(s) and life functioning, as well as the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understnaat that if payment for the services I receive here is not made, the mental health provider may stop treatment.