Informed Consent for Services
We are grateful to have the opportunity to work with you. Please read this document carefully, as it contains important information about our healthcare services and business policies. Before signing, please feel free to ask any questions.

Services
Wilson Clinical Services, PLLC. provides various psychiatric healthcare services, including prescription medication, psychotherapy, neuropsychological, and psychological examinations. We can prescribe medication if you and your provider agree this is a necessary and appropriate treatment. All treatment requires an active effort on your part. After your initial consultation, we will offer you some impressions of what our work may entail, along with treatment recommendations. You should assess this information and your initial impressions to decide whether you feel comfortable working with us. If you have questions regarding our clinical procedures at any time, please feel free to bring them to our attention.

Confidentiality
Trust and safety are paramount in the treatment of your mental health. Therefore, we take confidentiality very seriously. Moreover, federal law prohibits us from releasing information about our work without your written permission. However, there are a few exceptions:

• If we believe you could harm yourself or others
• If we suspect child or elder abuse
• If a court subpoenas your records
• If an on-call provider in this office needs information to treat you appropriately in the absence of your primary provider

Please refer to the Notice of Privacy Practices or the Consent for Telemedicine for more information.

Emergencies
During business hours, please get in touch with our office at (253) 200-0234 or [email protected]. After business hours and on weekends, please call 911, or seek immediate care at your nearest emergency department. The emergency department staff can involve the on-call provider as needed.

Prescription Refills
If you begin taking a medication, you must be safely monitored for its effectiveness and side effects. You will be given ample medication and refills until your next appointment. You are responsible for scheduling follow-up appointments before you run out of your prescription. In return, you will find that we are conscientious about the cost of medical care and do not request unnecessary visits. If we refill a medication between visits, it is usually our policy to prescribe only enough medicine until the next visit. If our initial appointment is performed via telepsychiatry, you must complete and sign all intake forms before any medication is prescribed.

Contacting You
It is your responsibility to keep your contact information up to date. We cannot be your treatment provider if we cannot contact you or your PCP. If your information changes, please contact our office at (253) 200-0234 or [email protected] and update our staff as soon as possible.

Contacting Us
We encourage you to contact us if you have questions or concerns about your treatment. You may call during office hours and leave a non-confidential message with our office staff, or you may call and leave a confidential voicemail with your provider. We will not interrupt appointments to take calls except in absolute emergencies. We will make every effort to return calls as soon as possible. You may email, but please understand that we may not respond in a timely way.

Payment
Payment is expected at each session, and your card on file will be charged. We will strive to complete all work during our scheduled sessions. However, we may charge on a prorated basis for other professional services you may require, such as report writing, email correspondence, telephone conversations, prior authorizations, and consultations with other professionals that you have requested. Our office accepts cash, check, credit card, and many HSA cards for your convenience.

Cancellations & Missed Appointments
Cancellations must be made by calling the office at least 48 business hours before your appointment. Failure to do so will result in a full charge for the missed appointment. Repeated no-shows or late cancellations will be carefully discussed and may be cause to discontinue treatment. Missed appointments must be rescheduled in a timely way for us to continue our treatment effectively.

Insurance
We accept most insurance plans. If you are insured under a plan we do not work with, we can provide you with the necessary information to file your claim with your insurance company. It is your responsibility to understand what your insurance company will cover for the cost of the appointment.

We greatly appreciate the opportunity to be of service to you. If you have any questions, concerns, or suggestions regarding our practice, please discuss them with us. We are always eager to hear your comments and will gladly answer any questions. Your signature below indicates that you have read the above and consent to the terms of this contract.