Tranquility Behavioral Health Patient Portal

Tranquility BHC PATIENT REGISTRATION

What type of services are you seeking? * FIRST & LAST NAME: * Preferred Name D.O.B. * Phone * Email Address: * Home Address * SSN Have you been vaccinated for COVID-19 * How would you describe your gender identity?

If other, Please specify

Other: Preferred Pronouns * Occupation Highest Level of Education

Insurance Information

Insurance Name: * Policy Holder First & Last Name * Policy Holder D.O.B. * Subscriber ID Number: * Group Number * Relationship to Subscriber: * Do you have Secondary Insurance *

If answered yes, please input your Secondary insurance information

Secondary Insurance Name Subscriber ID Number Group Number

Nature of the Therapeutic Relationship:

Your plan of care may include supportive psychotherapy and/or medication management. This relationship is strictly professional and therapeutic, ensuring your provider can address your mental health needs effectively. You are expected to actively participate in treatment and adhere to the prescribed plan. If issues arise, it is important to address them with your provider.

INITIAL *

Appointments:

Cancellation Policy: Notify the office at least 48 hours in advance for follow-up appointments and 72 hours for new patient appointments to avoid fees. No-Show Fees: A fee of $300 will be charged for new patients and $125 for follow-up visits if you do not show up or fail to cancel within the required timeframe. Late Arrival Policy: If you arrive more than 15 minutes late for your appointment, you may be rescheduled to ensure timely care for other patients. Discharge Policy: Consistent no-shows or multiple missed appointments may result in a referral to another provider and discharge from the practice.

INITIAL *

Notice of Privacy and Confidentiality:

Privacy and Confidentiality Policy Conversations between the provider and client are confidential and protected. Information will only be disclosed with your written consent or as required by law, including situations involving: Suspected abuse or neglect of vulnerable individuals. Legal or regulatory matters, such as criminal cases, child custody disputes, or licensing board complaints. By signing, you: Authorize necessary disclosures as mandated by law or for your care and payment. Release the provider from liability for any legally required confidentiality breaches.y.

INITIAL *

Uses and Disclosures of Information:

Under federal law, your provider may use and disclose personal health information (PHI) for treatment, payment, and health care operations without authorization. State laws may require your consent for certain disclosures. Other Uses and Disclosures: Abuse, Neglect, or Domestic Violence: PHI may be disclosed to report suspected abuse or neglect as required by law. You will be notified if feasible. Minors: PHI must be disclosed to parents, guardians, or legal representatives to make medical decisions for minors.

INITIAL *

Confidentiality and Third-Party Payers:

Information shared with insurance or managed care companies is beyond our control once released. Insurers may share data with entities like the Medical Information Bureau, potentially affecting future eligibility for life, disability, or other insurance. Employers may also access identifiable health data through insurance administrators, and Medicare or other insurers can review medical records for claims. While such events are rare, they are possible. To best protect your privacy, consider avoiding third-party involvement in your treatment. Certain privacy breaches may also occur if required by law or necessary to prevent serious harm.

INITIAL *

Duty to Warn (DO NOT SKIP THIS SECTION)

If your provider reasonably believes that you are a danger, physically or emotionally to yourself or to another person, he or she will warn the person in danger and CONTACT THE FOLLOWING PERSONS, in addition to medical and law enforcement personnel. By signing this consent form, you give your consent to make these contacts in these circumstances.

EMERGENCY CONTACT NAME: * Relationship to Patient * PHONE NUMBER * EMERGENCY CONTACT NAME PHONE NUMBER

Phone, Text, or Email Policy:

Routine calls for profile updates, office policies, or medication questions are free. Calls of a therapeutic or non-therapeutic nature will be charged $250/hour after the first 5 minutes. Calls are returned during business hours only. Texting is not used for ongoing discussions due to confidentiality concerns. Non-urgent matters should be addressed at your next appointment. For urgent matters or emergencies, do not text or email. Call 911 or go to the nearest emergency room. Non-urgent emails are welcome but confidentiality cannot be guaranteed. For questions, contact the office during business hours or leave a voicemail after hours.

INITIAL *

Tele-psychiatry Policy:

Tele-psychiatry provides secure, HIPAA-compliant mental health services via video conferencing, reducing the need for travel and allowing greater convenience. Potential Risks: Poor video quality, technology issues, or privacy breaches. Limited information compared to in-person visits, possibly affecting judgment. Your Rights: Privacy laws apply to telepsychiatry. You may withdraw consent for telepsychiatry at any time. In-person visits may be required if your provider deems them necessary. Your Responsibilities: No recording sessions without written consent. Notify your provider if others are present during sessions. Texas residency and in-person initial consultation are required for controlled substances only Bi-annual in-person visits and access to a blood pressure cuff, scale, and email are mandatory for Texas Residents Follow UPDOX and/or Doximity prompts to connect to sessions. By signing, you consent to telepsychiatry services and acknowledge your rights and responsibilities.

INITIAL *

Legal Proceedings/Court-Related Services:

We do not provide evaluations or reports for custody, visitation, or other forensic matters. We cannot and will not offer testimony or reports regarding custody, visitation, or parental fitness in legal or administrative proceedings. If such services are needed, you must hire a mental health professional specializing in forensic cases. Reasons for This Policy: A provider-client relationship may create a perception of bias. Testimony could compromise the therapeutic relationship and the confidentiality of your mental health treatment. Forensic evaluations are best conducted by professionals trained in court-related matters. By signing below, you waive the right to request our participation in legal proceedings. If a subpoena is issued, a $5,000 retainer fee is required in advance for any court-related involvement.

INITIAL *

After-Hours On-Call Provider Policy:

We are not a crisis center. This policy provides 24-hour emergency contact for clients experiencing a crisis or adverse medication reactions. For emergencies requiring immediate attention, dial 911 or go to the nearest emergency room. Do not leave messages regarding medication refills or appointment changes; these will not be returned. Contact us during normal business hours (Mon-Thu: 8:00 AM?5:00 PM, Fri: 8:00 AM?3:00 PM) for medication refill appointments or non-urgent issues. Weekend and holiday coverage is limited; try to address concerns during business hours. For crises or medication side effects, we may schedule same-day emergency appointments if necessary. If hospitalization is required, go to the nearest emergency room. By signing, I confirm that I have read and understand the After-Hours Policy.

INITIAL *

Prescription Refill Policy

To ensure effective care, clients must attend scheduled appointments for medication refills. Medications will not be refilled if you miss, cancel, or reschedule your appointment. It is your responsibility to schedule refill appointments promptly and check your medications before each visit. Office visits with the provider are required for all prescription medications, with intervals based on your needs. We reserve the right to refuse refill requests. Contact our office directly to schedule your appointment.

INITIAL *

Controlled Substances

Controlled substances require an appointment for refills and must be taken as prescribed. Early refills will not be issued. Missed appointments will result in no refills. If you are receiving similar medications from another provider, sharing medications, taking non-prescribed medications, or altering dosages, you will be referred out of the practice. Schedule II Medications: Refills require an appointment. Prescriptions expire 21 days from the earliest fill date. If your pharmacy cannot fill the prescription, contact our office with a secondary pharmacy. Allow up to 72 hours for re-sending prescriptions. Clients prescribed controlled substances must complete a urine drug screen at initiation and quarterly thereafter.

INITIAL *

Medication Refill Policy: Medications will not be refilled over the phone or email; a scheduled visit is required. Lost prescriptions require a police report. Controlled substances can only be refilled 30 days after the last fill; no early refills are allowed. Medication adjustments require an appointment. For severe reactions, go to the nearest emergency room or call 911. Same-day emergency visits may be available during business hours. Use the patient portal to message your provider directly. Contact us immediately to reschedule if needed, as we offer flexible options to facilitate your visit.

INITIAL

Drug Screen Fee

Urine Drug Screen (Mandatory): $25.00

INITIAL *

PRESCRIPTION REFILL DISCLAIMER

Medications will not be refilled without an appointment, including partial refills. Adjustments or new medications require an appointment with your provider and cannot be done via email. For medication side effects, send a nurse message through our website at www.tranquilitybhc.com to schedule an appointment. Emails to the business address will not be answered. A $15 fee applies to switch pharmacies if your medication is unavailable at your current pharmacy. Thank you for adhering to our policies to ensure safe and effective care.

INITIAL *

Paperwork Policy

We understand the need for completed forms for disability or work-related purposes and have outlined the following guidelines to streamline this process. FMLA Paperwork: Sign a release of information. Schedule an appointment to complete your paperwork. Allow 10-14 business days for completion. Social Security/Disability/Attorney Paperwork: Sign a release of information. Schedule an appointment. Allow up to 15 business days for completion. Formal Letters (504/School/Emotional Support/Service Pet): Sign a release of information. Schedule an appointment. Allow up to 15 business days for completion. VA Paperwork: Sign a release of information with the VA and provide your counselor?s fax number. Schedule an appointment. Allow up to 15 business days for completion. FMLA Limitations: FMLA is limited to a maximum of two weeks per year. We do not provide 12 months of intermittent FMLA. Short-Term/Long-Term Disability: We do not complete short-term or long-term disability paperwork due to its complexity. By signing below, you acknowledge and agree to this policy.

Initial *

Terms of Payment

INITIAL *

Consent to Treatment

I voluntarily agree to receive mental health evaluation, medication management, psychotherapy, psychiatric care, treatment, and/or other services and authorize the undersigned provider to provide such care, treatment, or services as they are considered necessary and advisable. I understand and agree that I will actively participate in my plan of care, treatment, or services provided. I am aware that I can be referred out of the practice at any time, if I am not adherent to the plan of care or have missed more than 2 consecutive appointments or 3 appointments in one calendar year. By signing this treatment information and consent form, I the undersigned client, acknowledge that I have read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. Initial Treatment Plan: By signing and initialing the policies and procedures in this information and consent form, I agree to the initial treatment plan and understand all policies and procedures of the clinic. I also understand that I must communicate any questions or concerns about my treatment plan. I understand all the policies and procedures and I have the right to revoke my consent or refusal to any treatment. Questions, Concerns and/or Complaints: If you have any questions, concerns, and/or complaints about the nature of your treatment or about your billing statement, please ask or talk to us about it. We will do our best to answer your questions promptly, address your concerns openly, respond respectfully, and take your criticism seriously. I have read and agree with the Prescription Refill Policy and understand that I am required to submit a urine drug screen and must request a refill 7 days in advance. I have read and agree with the Terms of Payment and understand that I am responsible for any and all outstanding fees, co-payments, deductibles, and/or co-insurance that is not covered by my insurance. I have read and agree with the office policy and procedures for paperwork. I have initialed the bottom of each page to acknowledge that I have read this document in its entirety.

INITIAL *

Patient/Guardian/Parent Signature:

By inputting your FULL NAME, you are consenting that all information entered above is true and correct, and that you agree to the terms/conditions of establishing a therapeutic relationship with Gero-Psychiatric Behavioral & Mental Health Consultants LLC DBA Tranquility Behavioral Health LLC outlined above.

Printed Signature * DATE * HOW DID YOU HEAR ABOUT US? *

Medication Management Consent

I, the undersigned,

First & Last Name * *

I understand that I am being prescribed one or more medications by my provider. I acknowledge that diagnoses made using DSM-V criteria are based on clinical assessments rather than objective tests, such as lab work or imaging. While medical theories suggest conditions like "chemical imbalances" or "brain abnormalities" may contribute to my distress, such theories are not verified by specific diagnostic tests. I am aware that any objective data, if obtained, does not determine DSM-V diagnoses except for drug-induced conditions, such as tardive dyskinesia. I consent to the treatment plan with this understanding.

My authorized prescribing clinician met with me and we talked about Condition(s), for which treatment is being recommended; Dosage of medication, and how I will take it (by mouth or injection); Duration of treatment (no more than one year at a time); e) desirable outcomes of the proposed treatment (prognosis with treatment); Risks, benefits and side effects of the treatment; Dangers of abruptly discontinuing medications and how to safely discontinue medications; Feasible alternative treatments, including benefits, risks, and probable effectiveness of each medication; Possible outcomes if no treatment is received.

RISKS AND BENEFITS OF THE MEDICATIONS

The risks, benefits, side effects, and alternatives of the prescribed medications have been discussed, and I understand and agree to the treatment plan. Key points include: Safety Plan: Abstain from illicit drugs, alcohol, and mind-altering substances. Seek help immediately (call 911, 713-HOTLINE, or visit the nearest ER) if experiencing suicidal thoughts, psychosis, or severe side effects. Risks and Side Effects: Potential side effects: worsening suicidal ideation, weight gain, metabolic syndrome, life-threatening rash, tremors, EPS, tardive dyskinesia, chest pain, arrhythmia, seizures, thyroid or renal issues. Medications may cause drowsiness and impair activities like driving. Monitoring: Regular lab testing will monitor for side effects such as elevated blood sugar, lipids, liver enzymes, and prolactin. Antipsychotics (Mood Stabilizers): Risks include acute dystonia, which may be irreversible but treatable. Other side effects include headache, restlessness, nausea, and sensitivity to heat. FDA Black Box Warning: Reviewed concerning increased suicidality in children and adolescents. Off-Label Use: I understand the meaning and potential risks of off-label medication use. By signing, I acknowledge these risks and understand I will not hold my clinician liable for tardive dyskinesia or other long-term side effects.

I have been counseled on the importance of medication adherence and the outcomes of not adhering to the medication regimen. I have been counseled extensively about medication adherence and stopping the medications may lead to negative outcomes and symptom exacerbation. I have been counseled on abstaining from illicit drug use and abstaining from alcohol intake. If a female, she has been told about the use of contraception as they should not get pregnant while taking these medications without informing the prescribing provider.

The information I was given for each treatment is summarized below. I have also received a voided copy of all medications sent to the pharmacy electronically and information about the proposed treatment. I understand the risk and benefits of the medications and agree with my treatment plan.

Patient/Guardian Print Full Name: * Date *

MEDICATION HISTORY

List Current Medications * * List Medication Allergies * * List Tried & Failed Medications * * Patient/Guardian Initial * DATE: * If you are signing on behalf of a patient, please print name and state relationship to the patient

NO SUICIDE CONTRACT

Patient First/Last Name: *

I hereby agree that I will not harm myself in any way, attempt suicide, or die by suicide. Furthermore, I agree that I will take the following actions if I am ever suicidal:

1) I will remind myself that I can never, under any circumstances, harm myself in any way, attempt suicide, or die by suicide.

2) I will call 911 if I believe that I am in immediate danger of harming myself.

3) I will call any or all of the following numbers if I am not in immediate danger of harming myself but have suicidal thoughts: Tranquility BHC EMERGENCY LINE: 984-377-3386; OR and 1-800-SUICIDE.

A. Text my provider or call this Phone Number 1) Dr. Henrietta Evans DNP APRN PMHNP-BC, GNP-BC 984-377-3386;

B. 1-800-SUICIDE -- 24-hour suicide prevention line that can be called from anywhere in the U.S.

4) I will TEXT "I'M ALIVE" three times a day to ensure that I am safe to the Google Voice number. I will continue to talk on the phone with as many people as necessary for as long as necessary until the suicidal thoughts have subsided

Patient/Guardian Initial * Date of signing: *