Informed Consent

Last updated August 12, 2024 

It is our obligation to provide you with the information you need in order to decide whether to consent to the treatment that you will be receiving. The purpose of this form is to verify that you have received this information and give consent to treatment. Please read this form carefully before acknowledging. 

Treatment Information  

Defina Health Care Professionals offer therapy and medication management services. Therapy involves assessing, evaluating, and treating mental health issues and disorders. Various techniques may be employed to alleviate or address these issues, each with its own set of benefits and risks. During your appointments, you or your child will discuss the mental health concerns, treatment goals, and any recommended therapies or medications. This discussion will cover the potential benefits, risks, and side effects of these treatments, including any medications that might be used alongside therapy. 

Possible risks may include experiencing uncomfortable emotions such as sadness, guilt, anxiety, anger, frustration, loneliness, or the recollection of distressing events. On the other hand, potential benefits could include significant reductions in distress, improved relationships, enhanced problem-solving and coping skills, and the resolution of specific issues. Since therapy outcomes can be unpredictable, your provider will strive to manage risks and benefits effectively. They will discuss the likelihood of achieving your treatment goals and explore reasonable alternatives, ensuring that you are actively involved in your mental health journey. 

You acknowledge that the success of therapy depends on your active participation and progress. However, no specific outcomes can be guaranteed. You have the right to refuse any recommended treatments or withdraw your consent at any time. Your relationship with your Health Care Professional will always be professional and respectful. You have received information about your provider’s qualifications and credentials (available in the provider profile) and may inquire about these during appointments or by contacting Defina Health. If you have any concerns or complaints about your treatment, you are encouraged to address them with your Health Care Professional or Defina Health.   

Telehealth   

Mental health services can be delivered through various methods, including telehealth, which enables you to receive care using secure audio or video technology instead of visiting an office for in-person appointments. Telehealth involves real-time communication between you and your Health Care Professional during scheduled sessions via audio or video platforms. 

Telehealth offers several advantages, such as more convenient access to services and the comfort of receiving care from your home or workplace. However, there are also potential risks, such as technological issues, response delays, and the limitations of remote therapy. This section aims to inform you about these risks and benefits so you can make an informed choice about using telehealth services. 

You understand that with telehealth, your Health Care Professional will be at a different location and not physically present with you. They will interact with you through video, audio, or messaging via Defina Health’s secure platform. Despite these security measures, there is a risk that your information could be disrupted or accessed by unauthorized individuals. To enhance security, it is recommended that you avoid using public computers or shared networks. 

Telehealth serves the same purpose as in-person psychotherapy or counseling but may offer a different experience due to the technology used. Your provider will regularly evaluate whether telehealth is suitable for your treatment needs. It’s important to have a plan in place for handling any technical issues or mental health crises that may require in-person care. 

- If you experience a disconnection due to technical problems, your Health Care Professional will use your contact information on file to reach you. 

- In the event of a mental health crisis leading to a disconnection, your Health Care Professional will attempt to contact you, or if they are unable to, your emergency contact. Please ensure that your contact information and that of your emergency contact are always current. 

For emergencies, call 911 or go to the nearest hospital emergency room. If you are having suicidal thoughts or plans to harm yourself, you can reach out to the National Crisis & Suicide Lifeline at 988 for free, 24-hour support. 

Medication Management  

If your provider determines that medication could benefit your treatment, they will discuss this with you, including the reasons for the recommendation, proper usage, potential side effects, and what to do if side effects occur. Your provider will only prescribe medication if they are licensed to do so and if, in their professional judgment, it is medically appropriate. They will provide a written or electronically transmitted prescription to a pharmacy of your choice but will not dispense medication directly. It is crucial to adhere to the prescribed usage to ensure the medication’s effectiveness and minimize side effects. You must inform your provider of any other medications, vitamins, or supplements you are taking, and report any side effects or changes in your substance use. Do not stop taking medication without consulting your provider, as this could be harmful. Additionally, avoid sharing, selling, or improperly disposing of your medication, as doing so could result in the termination of your treatment relationship. If there are legal requirements for in-person consultations before prescribing medication, your provider will notify you. If your provider is unable to prescribe medication, they may refer you to another provider. It is your responsibility to ensure that your provider receives any necessary past records or test results, and understand that medication decisions are at the discretion of your provider. 

Confidentiality 

Confidentiality is very important at Defina Health to ensure effective services. However, there may be certain situations where your Health Care Professional is required by law to disclose certain information to certain parties such as state agencies or law enforcement agencies. These situations may include and are not limited to the following:  

  • If you are reasonably suspected to be in imminent danger of harming yourself or someone else 

  • If you tell a Health Care Professional about sexual misconduct, they are required to report it to authorities. 

  • If you talk about any abuse, neglect, or maltreatment of children and adolescents, the elderly, or disabled persons the Provider is required to report it to authorities. 

  • In criminal proceedings, in response to a subpoena, or other legal proceedings 

Policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document. Please remember that you may ask questions about confidentiality at any time during your treatment.   

If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgement of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following: 

  1. You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth and, after considering such matters, you consent to receiving telehealth services if such modality is appropriate and desired.  

  2. You understand that you have the right to withhold or withdraw your consent to the use of telehealth and/or medication treatment in the course of your care at any time, without affecting your right to future care or treatment. 

  3. You understand that it is your duty to inform your Health Care Professional of electronic interactions regarding your care that you may have with other healthcare providers. 

  4. No promises or guarantees have been made to me regarding the therapy or medication management services that you will receive. 

  5. All applicable confidentiality protections apply to our services, in accordance with Defina Health Notice of Privacy Practices. 

  6. If your Health Care Professional determines that telehealth services are not appropriate for your condition or care, your Health Care Professional may use other appropriate arrangements, including a referral.  

  7. You have provided, or will provide before treatment, Defina Health and your Health Care Professional accurate information regarding your identity and location. 

  8. You have been informed regarding how to enter appointments and communicate with your Health Care Professional via Defina Health’s telehealth platform, and will discuss a plan with your provider for how to work around technological difficulties and connections issues should they occur.