Pondworks Psychiatry & Psychotherapy

Available Forms

Compliment A Pondworks Employee New Patient Form 1 of 7: Patient Contact Information New Patient Form 2 of 7: Practice Policies New Patient Form 3 of 7: Privacy Practices New Patient Form 4 of 7: Patient Portal Agreement New Patient Form 5 of 7: Review of Systems New Patient Form 6 of 7: Medications List New Patient Form 7 of 7: Consultation Informed Consent Questionnaire # 1 of 3: PHQ-9 Questionnaire # 2 of 3: GAD-7 Questionnaire # 3 of 3: Q-LES-Q-SF Telemedicine Consent Telemedicine Practice Policies

New Patient Form 7 of 7: Consultation Informed Consent

Pondworks Consultation Informed Consent

Please read, sign and complete this document. Your provider will complete their sections after your evaluation appointment(s)

Welcome to our office! Your first visit with us is a "consultation to treat," or what we refer to as a "consulting relationship." In a consulting relationship we assess your psychiatric symptoms and determine what type and level of care would be most appropriate, and also if we can provide this care. We also assess whether we have a good therapeutic rapport. This consultation period may last more than one encounter. At the conclusion of the consulting period we will decide whether we should enter into a therapeutic, treatment relationship.

By signing this informed consent, I understand that we are entering into a consulting relationship for the purpose as described above. I further understand that the consulting relationship is not a treatment relationship. A consulting relationship is of limited duration and purpose. The consulting relationship may be terminated at any time by either of us.

I have been given the opportunity to review this informed consent in full and to ask questions. *

Yes

Name *

Date *

* Required field