CNS

CONSENT FOR SERVICES

This letter of agreement confirms that CNS has been asked by you to provide mental health services.

General Policies

General

We intend to help you feel and function significantly better. There is an expectation, but no guarantee, that you will benefit from treatment. In order for your treatment to be effective, we must work cooperatively. Try to talk as freely as you can about the difficulties that are affecting you and try to approach the session as open-mindedly as possible.

Confidentiality

What is discussed during appointments will not be revealed to anyone outside of CNS without your permission except where disclosure is required by law, such as if there is concern for 1) abuse or neglect of a child, dependent, or elder adult, 2) danger of harm to yourself or others, 3) grave disability to one’s functioning or survival, or 4) pursuant to legal proceedings. I may ask you to sign a “Release of Information” to coordinate care with other health care professionals of yours. Your information will not be disclosed to your health insurance carrier without prior written consent.Please note that this agreement authorizes clinicians of CNS to discuss your confidential information internally with the other staff of CNS.

Risks and Benefits

Medications and psychotherapy each have risks and benefits. Risks of medication will be discussed in appointments before starting new prescriptions. Risks of psychotherapy include experiencing uncomfortable levels of emotion. In the worst case scenario, risks of psychotherapy may include temporary worsening of psychiatric symptoms. Treatment often requires recalling unpleasant aspects of your history as well as the experience of emotional pain in the present. Medications as well as psychotherapy have been shown to have benefits for people who undertake them, often leading to a significant reduction of feelings of distress, reduction of symptoms, better relationships, and resolutions of specific problems.

Limits of Service

In the event of a medical emergency, call 911 or go to an emergency room immediately. Call CNS as soon as is practical and possible. CNS does not provideinsurance, disability, or workman's compensation evaluations. In the event that you intend to apply for medical or life insurance or file a claim for disability orworkman's compensation while under the care of CNS, please discuss this first with your clinician because authorization must be provided by your clinician as well as CNS.

Nature of Practice

CNS Health is a California Medical Corporation. Alternative names include CNS, CNS Los Angeles, and CNS Integrated Behavioral Health.

Office Policies

Cancellation Policy

The scheduling of an appointment involves the reservation of a clinician’s time specifically for you. If you need to cancel or change an appointment, please inform us at least48 business hours in advance, otherwise you will still be billed and payment is required.For Nursing shifts, cancellation must occur 5 business days in advance, or you will be billed.

Reaching Us

Clinicians or staff at CNS try to answer calls live or return routine phone calls within one business day.Although you may feel free to email CNS, we do not routinely use email for professional communication. Important information should be conveyed to us in person, ideally in appointments.

Records

CNS keepsconfidential records of your treatment that include appointment times, billing records, indications for medication use and response, and certain content of the appointments. You, or a future treating clinician, can request copies of your medical record. Copies for patients are assessed fees which are average for the community. Psychotherapy notes belong to CNS and are not a part of the medical record, therefore they cannot be requested to be viewed. Clinicians at CNS do not give testimony in court. In the unfortunate circumstance that you sue CNS, you thereby waive your confidentiality and CNS is allowed to present your records without your consent.

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