This form explains the nature of care and your choices. Consent is an ongoing conversation and can be revisited as your care changes.
What treatment may include
Care may include psychiatric assessment, diagnosis, medication management, psychotherapy, education, monitoring, laboratory orders, coordination with other clinicians, and referrals when appropriate. The plan is based on your needs, preferences, and the clinician’s judgment. A consultation or request for a particular medication does not guarantee a diagnosis, prescription, service, or outcome. If this practice cannot meet your needs, alternatives and referrals will be discussed.
Benefits, risks, and alternatives
Possible benefits include understanding symptoms, improving functioning, and reducing distress. Results vary. Discussing difficult experiences may temporarily increase distress. Medication may cause side effects, interactions, or other risks and may require follow-up or testing. Before starting or materially changing treatment, we will discuss its purpose, expected benefits, important risks, reasonable alternatives, and the option of declining it. This general consent does not replace a medication-specific discussion or any additional consent required for a particular service.
Your participation and choices
Share accurate information about your symptoms, health history, medications, supplements, allergies, substance use, and other care. Report changes, side effects, safety concerns, and pregnancy or pregnancy plans when relevant. Attend agreed follow-up and monitoring. You may ask questions, seek a second opinion, decline a recommendation, or withdraw consent for future care. Discuss a safe transition or discontinuation plan; abruptly stopping some medications can be harmful.
Privacy and coordination
Information is handled under the Notice of Privacy Practices and applicable law. Permitted or required uses may include treatment, payment, practice operations, required reports, and steps to address serious threats. Additional protections apply to some mental health, HIV-related, substance use disorder, and psychotherapy-note information. This form does not authorize unrestricted sharing with employers, relatives, referral sources, or others. Separate permission will be obtained when required. Signing does not waive privacy rights or release the practice from legal duties.
Telehealth
Visits may use live audio and video. Telehealth can improve access and convenience, but the clinician may be unable to perform a physical examination, technology can fail, and privacy cannot be guaranteed in every environment. In-person evaluation or a different level of care may be needed.
- Confirm your actual physical location and callback number at each visit. At launch, you must be physically in New York.
- Use a private, safe location and a secure connection when possible. Do not attend while driving. Identify anyone else present.
- If the connection fails, try the link again and call 646-549-4694. The clinician will determine whether telephone contact, rescheduling, or another arrangement is appropriate and permitted.
- You may decline telehealth and discuss available alternatives. This practice does not add an in-person requirement beyond what applicable law or your clinical needs require.
- Neither party will record a visit without a separate discussion and appropriate consent. AI-assisted documentation requires its own permission and the practice’s no-retained-recording standard.
Urgent needs and fees
The practice is not an emergency service. Messages are not continuously monitored. In an emergency, call 911 or go to the nearest emergency department. Fees, insurance, attendance charges, and payment permissions are explained separately. Treatment consent does not authorize a payment-card charge.