Leaf Psychiatry, LLC – Consent for Services and Patient Agreement

Leaf Psychiatry, LLC – Consent for Services and Patient Agreement

This form outlines your rights, responsibilities, and expectations when receiving care from Leaf Psychiatry, LLC (“Provider”). Please read this agreement carefully. If you have any questions, please ask your Provider before signing.

1. Consent for Services

By signing below, I voluntarily request and consent to receive behavioral health services from my Provider. These may include psychiatric assessment, psychotherapy, medication management, nutritional counseling, laboratory testing, and other appropriate interventions. Treatment will begin with an initial assessment and collaborative treatment planning.

I understand that:

- I may ask questions and provide feedback at any time.

- No guarantees have been made about the outcome of treatment.

- I may stop treatment at any time, but agree to discuss this with my Provider.

- Treatment is typically provided over several sessions and reviewed regularly.

- I have the right to be informed about my diagnosis, the nature and purpose of proposed treatment, risks and benefits of treatment alternatives, and the probable consequences of not receiving treatment.

- I acknowledge that I have been given the opportunity to ask questions about my treatment and have received answers I can understand.

- I understand that my provider is licensed in Michigan, Arizona, and Hawaii, and telehealth services may only be provided when I am physically located in a state where the provider is authorized to practice.

2. Confidentiality and Limits

Your Provider will protect your privacy to the fullest extent of the law. Information is confidential except in the following circumstances:

- Danger to self or others: If you pose an imminent risk, your Provider may act to prevent harm.

- Abuse/neglect: Suspected abuse of children, elders, or dependent adults must be reported.

- Court order: Your Provider must comply with valid legal requests for records.

- Professional consultation: Providers may seek peer consultation while omitting identifying details.

- Insurance use: Information shared with insurers may not remain confidential.

- Communicable disease reporting as required by Michigan public health laws

- court-ordered evaluations or treatments
- investigations of healthcare fraud

- if you file a complaint or lawsuit against your provider

- worker's compensation claims, where relevant information may be disclosed under MCL 418.315

Duty to Warn:

• Under Michigan law, if you communicate an actual threat of physical violence against a reasonably identifiable third person, your provider may be required to take action, which may include warning the intended victim and notifying law enforcement.

For patients aged 14-17 receiving mental health services under mcl 330.1707, certain information may be kept confidential from parents/guardians unless disclosure is necessary to prevent serious harm or is otherwise required by law.

Refer to the Notice of Privacy Practices for a full explanation of privacy rights under HIPAA.

3. Appointments, Payments, and Cancellations

- Appointments are scheduled via the patient portal, by phone, or by email.

- Payments are due at the time of service via card or ACH transfer.

- Cancellation Policy: Appointments must be canceled ≥24 hours in advance. Late cancellations or no-shows incur a $120 fee.

- Appointments may be considered no-shows after 15 minutes of tardiness.

4. Emergency and After-Hours Care

Leaf Psychiatry is not an emergency service. If you are in crisis:

- Call 911 or go to the nearest ER.

- Call 988 (National Suicide & Crisis Lifeline) or 1-866-488-7386 (Trevor Project).

Messages are typically returned within one business day, but may be delayed during provider leave.

5. Communication and Technology

- Secure communication via TherapyPortal is preferred.

- By using email or text, you consent to responses via those same methods, even without separate consent forms.

- Providers do not accept social media requests to protect your confidentiality.

- Therapy sessions may be supported by HIPAA-compliant transcription tools (e.g., Freed AI or Twofold Health). You may opt out at any time without penalty.

6. Practice Policies and Expectations

· Response Timeframe: Messages are usually returned within one business day. Urgent concerns should not be sent via email or portal.

· Prescription Refill Policy: Refill requests require 3 business days. Early refill requests may not be granted.

· After-Hours Coverage: For urgent needs after hours, please contact 911, 988, or visit the nearest emergency department. We do not provide on-call services but may coordinate with trusted providers when needed.

7. Telehealth and In-Person Visits

I consent to receive psychiatric services via telehealth technology. I understand that:

• technical difficulties may interrupt or terminate our session

• telehealth may not be appropriate for all psychiatric conditions

• my provider must be licensed in the state where I am physically located during each session

• I am responsible for ensuring privacy on my end during sessions

• emergency protocols differ from in-person care

• I have the right to refuse telehealth services and request in-person care

Telehealth requires a secure internet connection. You agree to:

- Ensure privacy during sessions.

- Not record without written permission.

- Notify your Provider of your location before each session.

In-person visits require adherence to public health precautions. Do not attend in-person appointments if experiencing symptoms of illness.

8. Dual Relationships and Boundaries

You may encounter your Provider in non-clinical settings. To protect your privacy, the Provider will not initiate contact. Dual relationships are discussed transparently, and referrals will be offered if the relationship impacts treatment.

9. Students and Interns

You may encounter students observing clinical care. You may always request to be seen without student participation.

10. Legal Testimony and Records

- Your Provider does not serve as a forensic or court expert.

- Legal testimony is billed at $1,000/hour with an 8-hour minimum plus expenses.

- Records are maintained in TherapyNotes, a HIPAA-compliant platform with robust security features.

11. Financial Terms and Insurance

Good Faith Estimate:

Under federal law, if you are uninsured or not using insurance, you have the right to receive a “good faith estimate” of expected charges before receiving services. This estimate will be provided when you schedule services or upon request. If your actual charges exceed the estimate by $400 or more, you may have the right to dispute the charges.

A. Private Pay Rates (No Insurance)

| CPT Code | Service | Rate |

|----------|---------|------|

| 90792 | Initial Psychiatric Evaluation (60 min) | $230 |

| 99212–99215 | Med Management (15 min) | $130 |

| 99212–99215 + 90833 | Med + Therapy (30 min) | $150 |

| 99212–99215 + 90836 | Med + Therapy (60 min) | $185 |

| 90834 | Psychotherapy (45 min) | $185 |

| 90836 | Psychotherapy (60 min) | $185 |

| 90847/90846 | Family Therapy (50 min) | $185 |

| 90839 | Crisis Session (60 min) | $200 |

| 90840 | Additional Crisis (per 30 min) | $100 |

B. Insurance

- It is your responsibility to verify benefits, coverage, and out-of-pocket costs.

- You are responsible for all fees not covered by insurance (copays, deductibles, uncovered services).

- Out-of-network services must be paid in full at the time of service.

11. Discharge from Care

You may be discharged for:

- Mutual agreement that treatment is complete or no longer beneficial.

- Inappropriate behavior, non-payment, repeated no-shows, or poor communication.

- If discharged, you will be offered appropriate referrals and, when necessary, short-term continuation of care for safety.

If discharge becomes necessary for non-emergency reasons, the provider will:

• provide written notice when possible

• offer 30 days of transitional care or until alternative care is established, whichever comes first

• provide appropriate referrals

• prescribe necessary medications during the transition period to avoid interruption of care

• document the reasons for discharge in your medical record

12. AI Appointment Transcription and Documentation

These AI tools assist with documentation only. All clinical decisions, diagnoses, and treatment plans are made by your provider based on professional judgment, not AI recommendations.

To enhance quality of care and reduce administrative burden, your Provider may use HIPAA-compliant artificial intelligence (AI) tools (e.g., Freed AI or Twofold Health) to assist with transcribing and summarizing session content. These tools are optional, and you may decline their use without any negative impact on your care.

A. Freed AI

Freed transcribes sessions in real time and generates clinical summaries. These summaries are reviewed and signed by your Provider. Freed does not allow third parties access to your session content. Freed is HIPAA-compliant, and data is securely stored and encrypted. You may opt out at any time by informing your Provider.

B. Twofold Health – Patient Consent

General Notice

Your Provider has a legal and ethical responsibility to protect communications. Twofold Health is a HIPAA-compliant tool that automatically generates summaries of clinical sessions using encrypted and secure technology. By signing this consent, you agree to allow Twofold Health to process and summarize your session content.

1. Data Collection and Use

- Transcription and Summarization: Session audio is transcribed and summarized by Twofold Health. Recordings are not retained.

- Retention of Notes: Your Provider may retain summaries in your confidential medical record.

- Anonymized Data: Twofold Health may retain depersonalized data (with all identifiers removed) to improve its software.

2. Risks and Mitigations

- Confidentiality: As with all technology, there is a small risk of unauthorized disclosure. Twofold Health mitigates this risk through encryption and storing minimal identifying data.

- Summarization Bias: AI-generated summaries may contain bias. Your Provider will review and revise summaries using clinical expertise.

- Support Access: In limited cases, Twofold Health staff may access depersonalized transcripts for customer support purposes.

3. Benefits

- Improved Focus on Care: Your Provider can focus more directly on you during sessions.

- Reduced Administrative Burden: AI summaries reduce the need for live note-taking, which can improve attention and reduce burnout.

- Enhanced Clinical Insight: Summaries may support clinical insight and continuity of care.

Consent

By signing this agreement, you consent to the use of Twofold Health software to transcribe and summarize your sessions.

13. Standard of Care

Your provider will exercise reasonable professional judgment and deliver services according to the applicable standard of care for psychiatric practice in Michigan. This agreement does not limit any rights you may have under Michigan law regarding professional negligence or malpractice claims.

14. Minors And Parental Rights Under Michigan Law (MCL 330.1707)

Minors aged 14 and older may consent to mental health treatment without parental involvement. Parents/guardians may have limited access to treatment records of minors 14-17, except when disclosure is necessary for the minor's safety. In cases of divorced/separated parents, the parent with legal custody has decision-making authority unless court orders specify otherwise. The provider will use clinical judgment in determining what information to share with parents/guardians, always prioritizing the therapeutic relationship and patient safety.

15. Complaints

If you believe your Provider has acted unethically or improperly, you may:

- Discuss it directly with your Provider.

- File a complaint with the state licensing board or your insurance.

- Contact the U.S. Department of Health and Human Services for HIPAA concerns.

Acknowledgment and Signature

I have read and understand this Consent and Patient Agreement. I agree to its terms and understand the risks, benefits, and responsibilities of behavioral health treatment. I acknowledge that I have had the opportunity to ask questions and have them answered.