INFORMED CONSENT FOR MENTAL HEALTH SERVICES

Medical Records
I understand that I have been informed that documentation regarding my treatment is filed in my mental health record maintained on the premises where I receive treatment; and that I may request to have a summary of my records sent to another treating facility upon my formal release of information. I understand that it is the policy of The Space Between to forward records only to other treating facilities. The process of duplicating and sending medical records requires 4 to 6 weeks. Fees for making copies are my responsibility.
Responsibility to Pay for Services Received
I understand that I am responsible for the payment of services not covered by insurance. Availability of services may be suspended due to an outstanding bill for services already rendered. Outstanding bills older than 90 days may be turned over to an outside agency for collection.
Discharge from The Space Between
I understand that if I do not attend a session for 90 days, I may be discharged as a patient from The Space Between. If I have an outstanding bill older than 90 days, I may be discharged from The Space Between. Discharged patients may be readmitted to The Space Between after 90 days.
Confidentiality
I understand that information regarding my treatment may be discussed with another clinical service provider from whom I receive services on the premises. I understand that my case may be reviewed with a clinical supervisor at The Space Between. I understand that if I am paying for psychological services through an insurance benefit, my insurance provider may have access to my diagnosis, treatment plan, and other information regarding my treatment by the treating clinical services provider.
Limits of Confidentiality
I understand that I have had the nature of the offered mental health services explained to me. I also understand that the confidentiality of this service is governed by the provisions of Maryland Annotated Code, Courts and Judicial Proceedings Article, § 9-109. Under these provisions, disclosure of mental health information without written authorization is permitted under certain circumstances including the following:

1. Confidentiality may not be honored if the clinical service provider has a reasonable suspicion of my intent to harm him/herself or another person.

2. Confidentiality will not be honored if the clinical service provider has reason to believe that there has been suspected or actual child, elderly/vulnerable adult abuse, which is not presently managed by the department of Social Services or other appropriate agency.

3. Confidentiality may not be honored if I or my representative raises my mental status as a question or issue in legal proceedings.

4. Confidentiality shall not be honored in court ordered evaluations.

5. Confidentiality does not apply to clinical supervision, case consolation or quality assurance audits.

6. Confidentiality shall not be honored if I engage the clinical service provider in malpractice litigation or in a complaint of an ethical violation.

Missed Appointments
I understand that in order for treatment to be successful I must commit to regular attendance for both psychotherapy and medication management appointments. If I need to cancel an appointment, I will contact The Space Between at least 24 hours prior to the time of my appointment. If I do not provide adequate notice, the visit will be counted as a missed appointment and I will be responsible for the $25 missed appointment fee. This fee will be paid before attending a rescheduled appointment.
I understand that if I miss three appointments, my case will be closed and I will no longer be able to schedule medication management appointments. I understand that as a new patient (I have received services for less than three months) I can only miss two medication appointments before my case is closed. There is a 90-day waiting period before clients can be readmitted to psychiatry treatment at The Space Between.
I understand that if I miss two psychotherapy appointments, my case will be closed and I will no longer be able to schedule psychotherapy appointments.
Outside Paperwork
I understand that paperwork for disability through any attorney or agency that I request to be completed by a clinician of The Space Between will only be completed 90 days after admission. I understand that the paperwork will not be completed if I have more than three “no show” appointments during the most recent 90-day period. I understand that my clinical session time will be used to complete the paperwork.