Consent Forms and Policy

This page includes what is written in consent forms and includes policies you will agree to in advance prior to being seen. 

Welcome and thank you for choosing Normal Psych for your psychiatric healthcare needs. We look forward to providing you with personalized, comprehensive psychiatric care. Our provider employs a variety of treatment strategies based on your individual needs. These strategies include psychiatric medication management, as well as various therapeutic modalities. Our goal is to partner with you to formulate a treatment plan and work toward achieving full remission of your symptoms while maintaining the highest level of functioning and quality of life possible. General practice policies are outlined for your review.

The initial intake appointment does not establish a patient-provider relationship. It is a diagnostic interview and assessment of your mental health needs. Together, we will work towards a treatment plan, including goals and recommendations. Past medication successes and failures will be taken into consideration, but we cannot guarantee that your medication will be continued after assessment.

Your autonomy is important to us and will be respected. You are under no obligation to adhere to a course of treatment. Our goal is to determine a treatment plan that will lead to improvement in your mental and physical health utilizing current evidence-based practices.

As partners in the treatment process, you will be expected to:

• Follow through and be compliant with mutually agreed upon treatment plans. If you have concerns about therapy or a particular course of treatment, please communicate this with your prescriber.
• Make and keep follow up appointments at the recommended interval.
• If we are having difficulty achieving a therapeutic alliance, we can discuss options and alternatives.

Failure to comply can result in treatment delays including medication gaps.

Termination of treatment and transfer of care may be considered for:

• Lack of participation in treatment.
• Inappropriate use of medications, including not taking medications prescribed, changing, or discontinuing medications without consultation.
• Displaying aggressive, destructive, or threatening behavior. Verbal or physical abuse of staff will not be tolerated. 

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.   You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.   By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: • Protected health information may be disclosed or used for treatment, payment, or  

        health care operations.

 • The Practice has a Notice of Privacy Practices and that the patient has the opportunity 

        to review this Notice.

 • The Practice reserves the right to change the Notice of Privacy Practices. 

• The patient has the right to restrict the uses of their information but the Practice does 

        not have to agree to the restrictions.

 • The patient may revoke this Consent in writing at any time and all future

 • The Practice may condition receipt of treatment upon the execution of this

 • The patient acknowledges that he/she has received a copy of our HIPAA practices 

        brochure. 

As a patient at this practice, I acknowledge the following:

   1. I have informed the provider of all medications that I am taking, including prescriptions, over-the-counter medications including supplements, nicotine and/or caffeine containing drinks, pills, gums or patches and also illegal/recreational drugs and alcohol use.

   2. I understand that some medication therapy may require periodic lab tests and that I may be asked to have labs done at random times between appointments.

   3. I understand that extended use of controlled substances may produce psychological and/or physiological dependence and that ongoing use must be regularly evaluated and justified.

   4. I understand that prescriptions of controlled substances that have run out early will not automatically be renewed early which can result in being without medication for a period of time.  This may, in certain conditions, lead to physical and physiological withdrawal.  Prescriptions of controlled substances, which have been lost or stolen, will not be replaced without a police report of theft.

   5. I understand that using controlled substances not as prescribed (such as increasing the dose without the provider's instruction) may be considered substance abuse.  I understand that sharing of controlled substances with any other person (including family) may be considered diversion of a controlled substance and is illegal.

   6. I understand that improper use of prescribed medications, repeated missed appointments and harassment or assault of staff are grounds for immediate discharge from this practice and may not be subject to a 30-day supply of medication and a referral list.  

Normal Psych believes in paying nursing education forward and prides itself on providing quality clinical experiences for graduate level psychiatric nurse practitioner students. At times, interns may be present during appointments or you may be asked to meet with an intern first to begin your session. Interns are closely supervised by licensed providers.  You will be asked at the beginning of every session if you are comfortable with this. If you are not, please let the staff know.  

Urine drug screens are done at every initial visit and may be requested throughout treatment by your provider. This is to ensure safe prescribing, treatment compliance and avoid diversion of certain medications.  You may be contacted between appointments to go to a lab location for a random drug screen. Please note that failure to come in when requested for a random drug screen may result in a delay in refilling your prescription. If you have any questions or concerns, please address them with your provider. 

There is vast literature available detailing the detrimental effects of long-term benzo use (Xanax, Ativan, Klonopin, Valium). This class of medication is not indicated for anything other than short-term management of anxiety while a therapeutic dose of a non-benzo is being established, along with active engagement in therapy.  Long-term use of benzos lead to rebound anxiety, poor sleep and insomnia, increased tolerance and early onset Alzheimer’s and dementia. A taper will be initiated by your provider along with other treatments to prevent withdrawal seizures, lessen discomfort in symptoms and better manage anxiety. If you are on a benzo and do not want to explore other alternatives, you may wish to consider finding another provider.  

At Normal Psch, we strive to provide the best possible clinical care with the latest evidenced based practice methods. If you are dissatisfied with your treatment, please address this with your provider or the office staff.  Negative reviews will be grounds for discharge from this practice. If you choose to leave a negative review, you forfeit your right to privacy and confidentiality. Negative reviews will be addressed professionally with a reminder to contact the office.  

We respond to all voice mail messages within 24 business hours. Please be aware that calls of non-urgent matters made on weekends or holidays may not be addressed until the next business day.  Please be aware that texts and emails are not for emergent concerns and may not be addressed for more than 24 business hours. Please do not call and leave multiple voicemails about the same issues, as multiple messages delay staff from addressing both your, and other patients’, needs.  If you are calling between appointments to speak with your provider, please be advised that they may not be able to speak to you directly when you call, as they are with other scheduled patients. Please communicate your needs to the office staff, who will relay your message to your provider. It is up to the provider to return your all or to direct staff with next steps, which may include scheduling an appointment. Your provider can not help you in a timely manner if you do not communicate your needs to staff.  

***If you are experiencing a medical or psychiatric emergency, call 9-1-1 or go to your nearest emergency room.***  

If your phone number changes, it is your responsibility to let the office know in a timely manner. We can not confirm or call your for appointments if we do not have a current number. If you are expecting a call from the office, it is your responsibility answer, or to ensure that your voicemail is set up and that your mailbox is not full. We can not leave messages if your mailbox does not allow us to. 

Appointments are booked on a routine basis only. We are unable to accommodate walk-in appointments at this time.  If you require an urgent appointment between your scheduled appointments, please call the office and we will make our best effort to accommodate you at the earliest, mutually convenient time possible. For an urgent or missed appointment, you will be given the option to schedule with a different provider with sooner availability.  Providers do their best to alert patients of vacations and adjust scheduling. However, emergencies arise. If your provider is unable to keep your scheduled appointment, you may be scheduled with a different provider. Unfortunately, we may not be able to notify you ahead of time if you will have a different provider.  Your appointment time is reserved for you. Please provide the office at least 24 hours in advance if you need to reschedule or cancel an appointment. You may be charged for no-shows or cancellations with less than 24 hours’ notice at the rate of the scheduled appointment. No-show fees are not reimbursable through insurance. A medication bridge may be called in as a courtesy if you reschedule your appointment with sufficient notice to the office but cannot be guaranteed. On occasion, appointments may run over the allotted time. While we try to keep to the schedule, there are times when clients are in crisis and are given extra time as needed. We ask that you respect this, as you may also need extra time at some point in your treatment. We try our best to resolve what we can in session and leave an appointment mid-crisis.  

Insurance is taken through Headway (please check in advance if your insurance is accepted). If paying a deductible or copay out of pocket, payment is expected at the time of service. We accept debit and credit cards, through Headway.

Initial Psychiatric Evaluation: $450.00 (45-60 Minute) 

Therapy Session with Medication Management: $250.00 (40 Minutes) 

Therapy Session with Medication Management: $200.00 (20 Minutes) 

Medication Management with limited therapy: $150.00 

Lab Handling: $25.00 

Dictated Letters: $25.00 

Dictated Reports and/or Evaluations: $100.00 

***No-shows and cancellations of less than 24 hours’ notice may be subject to the posted service fee.***  

Sliding Scale available. (

Insurance is accepted through Headway.co where we accept Aetna, Oscar Health, United Healthcare, Oxford, Cigna, and Horizon. Please check with Headway and your insurance before booking appointments to confirm that your insurance is accepted.

We do not accept insurance directly at this time other than through Headway.co, but you can submit the bill to your insurance for reimbursement if your insurance is not covered under Headway.co . We are not responsible if insurance rejects part or all of your claim. It is your responsibility to confirm your insurance coverage prior to your appointment as well as fill out all Headway.co forms.  Please check with your carrier prior to scheduling an appointment. This can also change throughout the year as plans change. Some insurance plans offer out of network benefits after a deductible is met.  It is your responsibility to know your insurance benefits, as we cannot guarantee your copay, that you will be reimbursed for services or the amount of reimbursement. Fees are due at the time of visit.  A receipt will be provided at the end of each appointment for your records and possible reimbursement. It is your responsibility to keep receipts for insurance and tax purposes, as we do not keep copies. Receipts can be duplicated for an additional charge.   

Requests for MedOne and other forms for social services will be completed at the discretion of the provider.   We have the right to refuse to fill out MedOne and social services forms for individuals who fail to keep their appointments, are not following the treatment recommendations, or for patients whom we do not feel comfortable performing this service. Patients are expected to be engaged in treatment at this practice for at least three months before MedOne paperwork can be completed.  Patients are also expected to be engaged in treatment during disability beyond monthly medication management, including but not limited to, outpatient therapy, an intensive outpatient or partial hospitalization program or other higher level of care as determined by your provider.

 • We do not backdate disability forms. 

 • If regularly scheduled appointments are not kept, we will notify social services.

 • Social services paperwork is subject to the fee schedule.

 • Social services paperwork requests can take 7-10 business days to complete. 

If you are requesting assistance in the completion of a disability claim, please be advised of the following:

 • We do not "give" disability. We will report symptoms and your response to treatment 

        to the company that handles your disability insurance or your lawyer. We have the 

        right to refuse to fill out disability forms for individuals who fail to keep their 

        appointments, are not following the treatment recommendations, or for patients whom we do not feel comfortable performing this service.

 • Patient are expected to be engaged in treatment at this practice for at least three 

        months before disability paperwork can be completed.

 • Patients are also expected to be engaged in treatment during disability beyond 

        monthly medication management, including but not limited to, outpatient therapy, 

        an intensive outpatient or partial hospitalization program or other higher level of care 

        as determined by your provider.

 • We do not backdate disability forms.

 • If regularly scheduled appointments are not kept, we will notify your disability carrier. 

        Disability paperwork is subject to the fee schedule.

 • Disability paperwork requests can take 7-10 business days to complete. 

Prior Authorization  

On occasion, your insurance company will require a prior authorization to cover a prescribed med. We do not know this until after you take your prescription to your pharmacy.  If a prior authorization is needed, the pharmacy will alert the office and a staff member will complete the necessary forms.  Please note that this can sometimes take several days.  Please be aware that when a medication is approved, your insurance company does not always notify the office.  The quickest way to see if your medication has been approved is to call your pharmacy and ask them to try your prescription again. 

Medication Refills   

If you are prescribed medication, it is important that you take your medication as directed and keep appointments for medication refills. Appointments are typically scheduled every 28 days and prescriptions are typically written for 30 days, therefore you should not run out of medications between appointments unless you are taking more than prescribed. Should an issue arise where you will not be able to attend a scheduled appointment and you anticipate running out of medication before your rescheduled appointment, please make your request 7 days prior to the expiration of the prescription.  Please be advised if you are an existing patient and have not been seen in the office within the past 3 months, an appointment may be required prior to refilling your prescription. It is your responsibility to secure your medications. Lost or stolen medications will require a police report to be considered for an early refill, but this cannot be guaranteed by your provider, pharmacy or insurance plan.   **Please be advised that your failure to plan does not constitute an emergency for this practice.**