To print, download the Consent form
Consent to Treat
I hereby request and authorize Lake Mental Health LLC and Jennifer Lake to provide care to me or my dependent (if patient is a minor). I am agreeing to those services that Lake Mental health, LLC is qualified to provide within the scope of the provider’s license, certification, and training. I also understand that, at any time, I can terminate this consent for treatment by putting such request in writing.
Signature of Client or Parent/Guardian (if client is under the age of 18)
______________________________________________Date: ___________
Policies and Procedures
This document contains important information about Lake Mental Health, LLC’s professional services and business policies. Please read it carefully and feel free to ask if any questions arise. When you sign this document, it represents an agreement between us.
Confidentiality
Confidentiality is a cornerstone of the provider and patient relationship. The assessment process is most effective in the context of a trusting, supportive, confidential relationship. In addition, ethical standards require that the provider’s work with you remains confidential.
The information shared by you during the assessment process will remain private. The only occasions in which the provider would disclose something without your permission are as follows:
- Child Abuse or Elder Abuse. Providers are mandated by law to report cases of suspected child abuse (of children and youth under age 18) and elder abuse (of adults over age 60) to the appropriate authorities.
- Suicide. If you are in imminent danger of killing yourself, Jennifer will need to breach confidentiality in order to keep you safe. This may include informing family member(s) or taking action to see that you are admitted to a hospital.
- Homicide. If you disclose that you planning to kill or hurt someone, Jennifer is required by law to inform the police, inform the intended victim(s), and inform any other necessary individuals in order to prevent loss of life.
- As mandated by law. For example, if Jennifer receives a subpoena she may be required to submit your records as part of a legal proceeding.
These situations are relatively rare. Should this occur in your case Jennifer will make every effort to discuss it fully with you before taking any action.
Contacting Lake Mental Health, LLC
If you need to contact Jennifer, the best way to do so is by texting, email or telephone.
Although we are often not immediately available by phone, voicemail is checked on a regular basis. Jennifer will make every effort to return your call Within 2 business days
With the exception of weekends, holidays, and vacations. If you are unable to reach Jennifer and feel that you cannot wait for your call to be returned, dial 911 or proceed to your nearest emergency room immediately.
You may also contact Jennifer by email. She will try to get back to you as soon as they can but this is not the most reliable form of communication. Texting is acceptable and preferred with your consent. Texts are erased after the information is placed in your chart.
Cancellations and Missed Appointments
If you wish to change a scheduled appointment, The requirement is that you do so at least 24 hours prior (in business days) to the appointment in order to avoid being billed for the appointment. Exceptions to this policy will be handled on an individual basis. Should two late, cancelled or missed appointments occur in a row, payment of associated fees will be required to hold an appointment in Jennifer’s schedule.
Professional Fees and Non-Covered Services
Jennifer may need to provide complementary activities outside of your appointment.
Examples include email or phone consultation with other professionals in relation to your care, review of reports and records; preparation of reports, letters, or documents for other providers or organizations; duplication of your medical records; and legal proceedings requiring Jennifer’s participation. Additional out of appointment treatment activities that total less than 15 minutes per month will not be charged. These kind activities that total more than 15 minutes per month will be billed directly to you at the pro-rated standard hourly rate. Examples include obtaining a prior authorization for a medication, writing letters for a pet in housing and other letters needed by a patient.
If you ever have difficulties with your bill, please address your questions or concerns as soon as possible. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Lake Mental Health, LLC reserves the right to use legal means to secure payment, which may include retaining the services of a collections agency or initiating a small claims suit.
Insurance Reimbursement
If you have an insurance that will reimburse you for appointments Lake Mental Health will provide you with an invoice you can submit to your insurance.
Authorizations & Acknowledgements
By signing below, I acknowledge that I have reviewed Lake Mental Health LLC’s Policies and Procedures, understand the information included in this document, and freely choose to abide by its terms during our professional relationship. I am aware that a copy of this packet will be given to me if I ask for a copy.
Signature of Client or Parent/Guardian (if client is under the age of 18)
_______________________________________________Date: _____________
I hereby acknowledge that I have reviewed a copy of Lake Mental Health, LLC’s Notice of Privacy Practices, of the Health Insurance Portability and Accountability Act (HIPAA) and understand the information included in this document. I am aware that a copy of this notice will be given to me if I ask for a copy. I understand that if I have further questions regarding the Notice or my privacy rights, I can address these questions to Jennifer Lake.
Consent to Use Email Communications
I hereby agree to sending and receiving from Lake Mental Health, LLC email communications as part of comprehensive treatment. I understand the risks of sending Protected Health Information (PHI) through email, and with this agreement I am accepting these risks. I accept that Lake Mental health, LLC has double authentication -email. You can also use the e-mail in my Electronic Medical Record.
Signature of Client or Parent/Guardian (if client is under the age of 18)
Signature: _____________________________________Date: ___________________
Consent to Text Communications
Text communication is not considered private. If Jennifer receives a text she places the information in your chart and it is then erased. It is wholly your decision whether or not you text.
Signature of Client or Parent/Guardian (if client is under the age of 18)
Signature: _____________________________________Date: ___________________
Contacting Lake Mental Health, LLC
If you need to contact your provider, the best way to do so is by email or telephone. Although we are often not immediately available by phone, voicemail is checked on a regular basis. We will make every effort to return your call on the same day you make it, or by the next business day, with the exception of weekends, holidays, and vacations. If you are unable to reach your provider and feel that you cannot wait for your call to be returned, dial 911 or proceed to your nearest emergency room immediately.
You may also contact Jennifer by email. She will try to get back to you as soon as they can. This is not the most reliable form of communication.
Cancellations and Missed Appointments
If you wish to change a scheduled appointment, we require that you do so at least 24 hours prior (in business days) to the appointment in order to avoid being billed for the appointment. Exceptions to this policy will be handled on an individual basis. Should two late, cancelled or missed appointments occur in a row, payment of associated fees will be required to hold an appointment on your provider’s schedule.
Professional Fees and Non-Covered Services
Your provider may need to provide complementary assessment activities that are not covered by insurance. Examples include email or phone consultation with other professionals in relation to your child’s assessment; review of reports and records; preparation of reports, letters, or documents for other providers or organizations; duplication of your medical records; and legal proceedings requiring your provider’s participation. Complementary treatment activities that total less than 15 minutes per month will not be charged; complementary treatment activities that total more than 15 minutes per month will be billed directly to you at the pro-rated standard hourly rate.
If you ever have difficulties with your bill, please address your questions or concerns as soon as possible. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Axon Health Associates, LLC reserves the right to use legal means to secure payment, which may include retaining the services of a collections agency or initiating a small claims suit.
In cases in which parents are divorced or separated, the parent/guardian who brings the child to the appointment will be considered financially responsible. The parent/guardian who signs the document below will assume sole financial responsibility for services rendered, including responsibility for all appointments not cancelled 24 hours in advance.
Insurance Reimbursement
Payment (co-pay/co-insurance/deductible, etc.) must be made either by check, cash, or credit card at the time of your visit. Payment from your insurance company will be made directly to Axon Health Associates, LLC.
Due to the complexity of health insurance, you are highly encouraged to call your insurance company prior to your intake to clarify all issues related to fees and financial responsibilities. Notify us immediately as to any change in your health insurance, place of employment, home address, or other information pertinent to our records.