Patient-agreement

March 9, 2026

Welcome to Mental Health & Wellness Center, LLC (“Practice”). Please read the following information carefully so you have a clear understanding of our policies concerning providing services to You. Please take your time to review and fully understand this document. Please sign and date at the end to indicate that you have understood and agree. Thank you for your cooperation.

As used in this Agreement, “You” shall mean the below signed patient or the parent/guardian of a minor patient, as applicable.

Professional Services

Practice offers a thorough psychiatric diagnostic evaluation in an in-person or virtual setting, as determined by You and Your provider. At the conclusion of your first (or second) visit, we will share our thoughts on your diagnosis or working diagnosis, answer your questions, and discuss potential evidence-based treatments, which may include prescribing medications and psychotherapy services for a comprehensive treatment approach.

Services include assessment, psychiatric diagnosis, on-going psychotropic medication and treatment management, and psychotherapy. We treat a variety of mental health conditions including depression, anxiety, psychosis, trauma disorders, grief, substance use disorders, life transitions and ADHD, among other psychiatric conditions.

We do not provide:

• Forensic services such as custody evaluations, assessments recommended by probation, ability to stand trial, legal matters of medical opinion, etc;

• Interventional psychiatry services, such as ketamine, esketamine, transcranial magnetic stimulation, deep brain stimulation, vagus nerve stimulation, intravenous therapies or emerging therapies, such as psychedelics.

• Disability determinations or answer any functional questions on paperwork for any disability leave or workers compensation;

• Neuropsychological or psychoeducational testing or evaluations for bariatric surgery.

• Completed paperwork for any organization unless you have been a patient for 6 months or longer or have been seen a minimum of 6 times.

• Letters in support of an Emotional Support Animal.

In some situations, Practice may not be able to meet your mental health needs or, You may feel that Practice is not well matched for your needs. In these situations, Practice will do its best to provide You information where You can obtain appropriate care elsewhere.

Consent for Treatment/Treatment Issues

After an initial assessment, You and Your provider will discuss the type and extent of services that You will receive. You have the right and we encourage you to ask questions throughout the course of treatment. [A1] 

Practice may incorporate psychotherapy into medication management sessions. While counseling can be beneficial, there are inherent risks. You may discuss personal issues which may bring up uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh this discomfort and can lead to benefits such as improved personal relationships and reduced feelings of emotional distress. You acknowledge, however, that no warranty or guarantee can be made as to the results of therapy.

You will not become a patient at Provider until both You and Your provider decide together that this treatment relationship is appropriate at the initial visit.

All treatment is strictly voluntary, and You may choose to stop treatment at any time You wish. If You experience any problem(s) with medication and/or other aspects of Your treatment plan, it is your responsibility to inform Your provider of the problem(s).

Appointments

Prior to the initial consultation You will receive an initial intake assessment through the patient portal. This assessment includes questions around the medical and psychiatric history, history with medications and side effects, and self-report measures to collect subjective data directly from You about Your thoughts, feelings, behaviors, and attitudes. It is expected that YOU complete the initial intake assessment to the best of your ability.

Initial[A2] /consultation appointments for patients are generally 75 minutes. Often, the initial appointment provides enough time to complete the evaluation, but sometimes it is necessary for an evaluation to be divided between two or more appointments. Initiation of treatment may need to be delayed until the evaluation is complete. Please have all medication bottles available to You at Your first appointment and all follow-up appointments. If available, please submit copies of Your past medical and mental health records through the patient portal, including testing or laboratory work. Please have the contact information for Your previous mental health providers and other providers so that Practice can obtain care coordination and treatment history information, if needed.

Follow-up medication management appointment times are generally 30 minutes [A3] [A4] [A5] [A6] . In preparation for each medication management appointment. You will receive a set of self-reported measures that are tailored to your case. It is expected You complete these measures to the best of Your ability.  In some cases, Your provider will require tests be completed before Your provider agrees to continue a medication. For example, this may include urine tests or plasma level tests. The samples should be collected within the time frame directed by Your provider.

Follow-up psychotherapy appointment times are 45 minutes.

Appointments provide time with the provider. An appointment does not guarantee any specific medications, treatments, or letters.

We do our very best to be on time for Your appointment. Like any medical provider’s office, there are occasions when the provider is delayed due to patient emergencies or other urgent matters. You may choose to cancel and reschedule Your appointment with no fee if Your provider is more than 10 minutes late for Your appointment. There may also be occasions when Your appointment may be canceled by the office. We will always try to give as much notice as possible, but sometimes it may be short notice if an urgent patient need or personal emergency arises.  

No Shows/Late Cancellations/Late Arrivals

If You are not able to come to Your appointment, please reschedule through the patient portal or email the office to reschedule. If you contact the office at least 48 hours(excluding weekends and holidays) before your appointment you may reschedule with no additional cost, and the appointment will be offered to someone else.

If an appointment is not canceled or rescheduled more than 48 business hours ahead, a cancellation fee of $300 for new patient appointments or $150 for follow-up appointments will be applied to your account.  If You are scheduled for a telehealth appointment, it is Your responsibility to log on early from a private location with secure internet and test Your connection for any issues with connectivity, camera, microphone, or any other technical issues. See next section for policy on technical issues.

Should You arrive more than 10 minutes late for any appointment, You will be asked to reschedule so that an appropriate amount of time and attention may be devoted to Your care. You will still be responsible for payment of the standard appointment fee. Appointments that begin late will still end at the scheduled time.

Telehealth

Practice primarily offers in person visits. However, on a case-by-case basis, Your provider may approve telepsychiatry appointments as appropriate. Through this videoconferencing service [A7] , You will be able to attend Your psychiatric visit from the comfort of Your home.

While many people find telehealth to be convenient, it is not always appropriate for every patient. Your provider reserves the right to require that Your visits be in-person.

Please note that the patient must be located in the state of Maryland [A8] [A9] , Virginia, New Hampshire, or the District of Columbia where Your provider is licensed, at the time of all telehealth appointments. This is because state licensing laws prohibit your provider from providing therapy to a patient located in a state in which your provider is not licensed.  Appearing for an appointment while out of state will result in cancellation of the appointment, and it will be considered a late cancellation with stated fees applying.  

All patients are required to use the HIPAA compliant video telehealth platform provided by Practice.  Please note that it is Your responsibility to ensure You are in a private location with a stable internet connection and a properly functioning device. A moving vehicle is not an appropriate setting for your appointment as your internet connection will become unstable, and if you are driving, your attention should remain 100% on the road. Patients are encouraged to log on 20 minutes before your session to ensure functionality and connectivity. A test call feature is available on the telehealth platform. Please note you must email or call the practice and report any technical difficulties, including not receiving a link for your session, by 10 minutes before your appointment begins. Failure to do so may be considered a late cancellation with stated fees applying. Your provider reserves the right to cancel or reschedule visits in which connectivity problems or poor video/audio quality interferes with communication or quality of services provided, which will be considered a late cancellation with stated fees applying.  In infrequent cases, the appointment can be conducted via telephone; however, this is a case-by-case decision between the patient and provider and is not the preferred or required mode of communication for subsequent visits.

Patients who are prescribed controlled substances must be seen at least once a year in person.

Communication and After-Hours Policy

The preferred method of communication is through the secure patient portal. You may also call the office and leave a voicemail.  Please note that all communications will be added to your medical records. Messages received are checked daily during business hours Monday, Tuesday, Wednesday, Thursday, and Friday 8:00am-4pm. Messages received after hours, on weekends, or holidays are reviewed the next business day. Please allow at least 1-2 business days for a response.

Portal communication or voice mails are not for emergency or urgent issues. Please note if you need immediate assistance, are having suicidal or homicidal thoughts, a serious medication reaction, or any emergency, please call 911 or 988 or go to the emergency room or your local 24-hour mental health crisis center.

***Please note*** A fee may be charged for clinical phone calls/portal messages between appointments. This fee does not apply to phone calls or messages strictly related to scheduling, billing, or other non-clinical questions.

We do not communicate via text. We do not communicate via email outside of strictly clerical matters such as scheduling or connectivity problems. These communications are not protected and cannot be guaranteed as private. If you choose to send your protected health information through email to the Practice instead of using the patient portal, we shall interpret that as your consent to our responding to your email with protected health information. We will never initiate email communication that contains your protected health information.

Please make note of the following risks of use of unencrypted email:

• Email can be copied, circulated, forwarded, and stored in electronic files
• Email, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients
• Email is easier to falsify than handwritten or signed documents
• Backup copies of email may exist even after the client has deleted his or her own copy
• Employers and online services may have a right to archive and inspect emails transmitted through their systems
• Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information
• Email can be intercepted, altered, forwarded, or used without written authorization or detection

Patient Portal

Through the patient portal we may send you questionnaires or other information prior to your appointment. Please complete any forms/questionnaires at least 24 hours prior to being seen for a follow-up appointment. For an initial evaluation, ALL paperwork/forms must be completed within 3 days after the request is accepted, or the appointment may be canceled.

Controlled Substance Policy

We are generally inclined to prescribe non-habit-forming medications. A habit-forming medication is often described as a “controlled substance”. If a controlled substance is prescribed it may be written for a limited quantity and/or a short duration. If a controlled substance is prescribed, please be aware that 90-day supplies may not be provided.

Practice generally does not:

– Prescribe benzodiazepines to patients who are taking daily opiate pain medication or in the context of Medication Assisted Therapy.

– Prescribe benzodiazepines to patients who are taking stimulant medication.

– May not prescribe stimulant medication (Adderall, Ritalin, etc) unless appropriate diagnostic testing has previously been done and available for review.

– Prescribe controlled substances to patients who use marijuana or illicit substances.

– Will not replace lost or stolen prescriptions of controlled substances without a police report.

– Prescribe stimulant medications to patients with a history of hypertension unless blood pressure is within normal limits and consistently under good control per a written clearance from a primary care or cardiology provider.

We reserve the right to require random urine drug screens/saliva tests to obtain further refills for any controlled substance. We may also request you bring in or show your medication for a pill/strip count. If you are prescribed controlled substances and do not comply with a pill count or drug screen request within 48 hours, you may be terminated from the practice.

Please note it is a felony to accept a controlled substance prescription from the same (or similar) class from any other prescriber without both of those prescribers’ consent and notification. This is referred to as “provider shopping”. Practice frequently checks the Prescription Drug Monitoring Program (“PDMP”) platform for all patient receiving controlled substance prescriptions from a Practice provider. This is required by law.  If you receive controlled substances from another prescriber and do not notify the clinic, you will be terminated from the practice.

Professional Fees

Practice does not participate with any insurance plans. All fees for services rendered are paid by patients out of pocket.

For initial evaluations, Practice shall require full prepayment from patients in order to schedule the appointment. This will be charged to the credit card on file.

Patients may request an invoice to submit to their insurance company for possible out-of-network reimbursement. Out-of-network insurance reimbursement depends on an individual patient’s policy terms. We are not responsible for filing or ensuring insurance reimbursements for insurance plans we do not accept. Your insurance plan is a contract between You and the insurance company and does not directly involve the provider.

Please check with Your insurance company before making an appointment to determine what out-of-network benefits are available to You. Please note that You are ultimately responsible for all charges incurred for Your treatment or the treatment of those for whom You are responsible.

Credit Card

You will be required to leave a confidential credit card on file that will be billed automatically up to 8 hours before scheduled visits. Your credit card may also be billed for asynchronous care, letters, or forms that You have requested from the Practice. Your credit card is used to secure payment in the case that there is a no-show/late cancellation/non-sufficient funds fee. A test transaction may occur to verify the card on file is active prior to Your appointment. If for any reason the card is rejected, Your appointment may be canceled and may not be rescheduled.

You are responsible for fees from credit card companies, collection agencies or banks due to non-sufficient funds, payment disputes, or non-payment of fees. Please notify us if there is any change in Your payment information or if any problem arises in Your ability to make payments. Overdue accounts may be referred to collection agencies as a last resort.

Fees are subject to change and reflect the complexity and type of service(s) provided. You will be notified thirty days in advance of any changes in our fees.

Basic Fees

• Initial appointment (75 min): $ 600
• Follow up appointments (60 min): $ 500
• Follow up appointments (30 min): $ 300
• Phone calls: $100 per 10 minutes (phone calls under 5 minutes are not charged)

Asynchronous care (This refers to a model of healthcare delivery where communication between patients and healthcare providers occurs at different times, rather than in real-time. In this model, patients can send messages or requests for care through secure online portals, emails, or other messaging platforms, and healthcare providers respond at their convenience within a specified timeframe. This approach offers flexibility for both patients and providers, allowing them to communicate without the need for simultaneous availability, which can improve access to care and convenience for patients while managing providers’ workload efficiently. Fees will be charged for all time spent by the provider providing such care, whether time spent in direct contact with the patient, composing written communication to the patient or other individuals involved in the patient’s care, or in submitting lab or medication orders.): $100 per 10 minutes.

Misc. provider services per 10 minutes over the initial 5 minutes: $ 100

Bounced payment / invalid bank account / non-sufficient funds fee: $ 100

Straightforward provider letter: $ 150

Please note that you will not be billed for phone calls/messages related to scheduling, billing, or other nonclinical questions.

Please note that all services provided after business hours (outside 8 AM – 4 PM Monday-Friday) are billed at twice the standard rate. There is no guarantee that any services will be provided outside of business hours.

Forensic Affairs

If your provider is subpoenaed to appear in a court action involving the care that was delivered to you, you will be charged a fee for court appearances. Please note the fees related to court cases (preparing for depositions, travel time, court time, etc.) are billed at a higher hourly rate than basic services. For more detailed information, please contact us directly.

Medication Refills/Medication Disclosures

At Your appointment, You will be provided with enough medication until Your next recommended follow-up visit. When medications are first prescribed, patients are generally seen more frequently, and then less frequently as stability is achieved. The frequency is determined at the most recent visit with the provider. Medications are refilled only for patients who are active in treatment. The longest interval between visits is typically three months. Even if You are stable on Your medication, an evaluation of Your progress needs to take place.

If You cancel or reschedule Your appointment, it is Your responsibility to contact Your provider if You need additional medication before Your next visit. Medications may not be given if You cancel or no-show if the provider feels a clinical evaluation is necessary prior to a refill. It is the responsibility of the patient to make follow-up appointments at the recommended interval.

It is expected that You only receive psychiatric medications through your provider at Practice while You are under his or her care. If You obtain psychiatric medications through another provider, it will be assumed You have transferred Your care.

If You require additional medication before Your next appointment, please contact Practice as soon as possible. Please allow up to 3 business days to process refill requests for non-controlled medications and 5 business days for controlled substances. Refills are not processed after business hours, on weekends, holidays, or other days on which the office is closed. Please review the holiday schedule posted on the website. If You miss or cancel a scheduled appointment and require a medication refill before Your next visit a charge may apply for this service.

Before contacting Practice, please call the pharmacy directly to ensure that You do not have any additional refills on file, possibly under a different prescription.

Laboratory Studies/Additional Testing

At times, laboratory studies may be required. Please be aware that the cost of laboratory work is not included in Your visit charge and is Your responsibility. Completion of necessary lab work may be required prior to initiating or continuing medication.

In addition, You may be referred to psychological testing if warranted which may incur additional costs which are Your responsibility.

Confidentiality

Please review the HIPAA Policy provided to You. Please let Your provider know if You have any questions.

Please be aware that the audio or video recording of any session is not permitted. If an unauthorized recording is made, it is grounds for immediate termination of the therapeutic relationship.

Mental Health Records

Practice currently uses an electronic health record (EHR) to record and store patient information. This EHR system is secure and also abides by the HIPAA laws/regulations. However, as with all electronic systems, there are factors that are sometimes outside of our control. We will always strive to ensure Your information is kept confidential and compliant with HIPAA regulations. We reserve the right to change EHR systems at any time.

Discontinuation of Treatment

The provider may discontinue treatment with a patient for any non-discriminatory reason as long as the provider is not abandoning the patient. This includes termination for non-payment of services or disrespectful/ abusive behavior or harassment towards office staff or providers. If You decide to discontinue treatment, You can do so at any time in person, by phone, or in writing.

If You discontinue treatment without notifying Your provider, it will be assumed that Your therapeutic relationship with him or her terminated 90 days after Your last visit, unless You have an appointment scheduled for a future date, beyond which Practice carries no further responsibility for Your care. You may re-enter treatment with Your provider at Practice if Your treatment ended in good standing and the Practice is accepting new patients.

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this Agreement from time-to-time. We reserve the right to make the Agreement effective for information we already have about You as well as any information we receive in the future.

By signing below, You certify that You have read and understand the terms stated in this Patient Agreement. You agree to abide by the terms stated above throughout the course of the professional relationship.

PATIENT/GUARDIAN ACKNOWLEDGEMENT AND SIGNATURE:

Patient’s Signature: __________________________

Date: _______________

Parent/Guardian Signature (if applicable): __________________________

Date: _______________

 [A1]Alternatively, “You have the right and we encourage you to ask questions throughout the course of treatment”

 [A2]Prior to the initial consultation the patient will receive an initial intake assessment through the patient portal. This assessment includes questions around the medical and psychiatric history, history with medications and side effects, and self-report measures to collect subjective data directly from You about Your thoughts, feelings, behaviors, and attitudes. It is expected that YOU complete the initial intake assessment to the best of your ability.

 [A3]For medication management. How long (range) for a follow up psychotherapy session? Do you always do both?

 [A4]I want to focus on medication management instead of psychotherapy. In some cases, I will offer/agree to provide psychotherapy. I expect this to be <10% of cases.

 [A5]In some cases, I will require tests be completed before I agree to continue a medication. For example, urine tests or plasma levels. The samples should be collected within the time frame directed by the Psychiatrist.

 [A6]In preparation for each medication management appointment You will receive a set of self-reported measures that are tailored to your case. It is expected you complete these measures to the best of your ability.

 [A7]There will be cases where I do not feel comfortable or where Telepsych may not be appropriate to deliver the best possible care. I want to reserve the right to approve or deny the option of telepsych.

 [A8]Have you re-activated D.C. and Virginia licenses? If yes, I can add those

 [A9]Yes, I am reactivating these two licenses.