Our dedicated providers and staff are committed to ensuring that each patient receives the highest quality psychiatry services possible. This Patient Agreement establishes guidelines for your participation in treatment with us.

CONSENT FOR TREATMENT: I consent to evaluation and medically necessary treatment by the psychiatrists of Petit Psychiatry. I understand this consent does not constitute a guarantee about the results of my treatment. I understand I can terminate this consent for treatment at any time. I also understand that my psychiatrist may terminate consent for treatment at any time.

LIMITATIONS OF PETIT PSYCHIATRY: The psychiatrists at Petit Psychiatry are dedicated to providing the highest level of care for their patients in treating and addressing their mental health needs. However, there are some services not provided in this practice.

AGREEMENT TO PAY: I agree to pay my psychiatrist all charges for professional services at the time of the visit as balances are not allowed to accumulate. Any accumulated charges must be paid prior to any subsequent visit. Payments may be made via cash, debit card, and major credit card. Payments via credit card may be authorized over the phone.

FORMS AND PAPERWORK: I understand that paperwork or form that additional services such letter, forms, paperwork, etc. will result in an additional fee if it requires time outside of a scheduled appointment.

CANCELLATIONS AND NO SHOWS: I understand cancelled appointments must be made within 1 business day/24 business hours. If a cancellation is not made within that time or is missed without notification, I will be charged the full fee for the appointment, and this fee must be paid prior to rescheduling an appointment with my psychiatrist. True emergencies are taken into consideration. Medication refill requests may not be honored if the patient has just missed or cancelled an appointment. I understand that 3 cancellations of appointments and no-show appointment will result in termination from Petit Psychiatry. We reserve the right to charge a $75.00 fee for any lastminute cancellation and no shows.

INITIAL APPOINTMENT: I understand that it is the policy of Petit Psychiatry for all persons interested in seeking treatment at our office to fully complete and submit the New Patient Intake Forms. I understand that services cannot be provided without complete. Initial evaluations for all patients are 30-45 minutes session. I understand that my provider may request information from my other health care providers and school before making a definitive diagnosis and/or treatment recommendation. I understand that Petit Psychiatry may refer to comprehensive agency if patient requires frequent crisis management or has a history of requiring this.

FOLLOW-UP APPOINTMENT: Follow-up appointments for all patients will be 15 minutes

LATE ARRIVALS: I understand if I arrive late for a scheduled appointment and my provider will determine that there is enough time remaining, he/she will see me for the remainder of the appointment time. I understand that my provider may also request that I reschedule an additional appointment with him/her.

FORMS AND DOCUMENTS: I understand that medical forms will be completed by your provider while he/she meets with you in your session. I understand that it is my responsibility provider at the beginning of each session if need certain forms completed.

MEDICATIONS: I understand I will always notify your provider of any side effects or problems with medications. I understand suddenly stopping medication can cause medical problems. I understand that I am responsible for complying with my medications. I will not make any abrupt changes in my medications without first consulting with my physician. I understand I should not be consuming alcohol or any illicit substance while taking my prescribed medications. I understand that it is my responsibility to inform the physician of all other medications that other doctor’s may be prescribing to me. I understand responsibility to check on supply of medications and refills prior to their appointment.

MEDICATION REFILLS: I understand medications will only be refilled for current patients who maintain their regularly scheduled appointments and have account balances in good standing. I understand requests for medication refill should be make during schedule appointment. I understand all request for refill should make at least 7 days in prior to running out of my medications. I understand that medication refill made in less than 7 days in advance may result in a delay on filling my prescription. I am understanding that urgent/same day medication refills may be granted at a fee. I understand that in the event of a missed, rescheduled, or cancelled appointment, my medications may not be refilled

AFTER HOURS: I understand that calling the office after regular business hours, weekends, or holidays will provide me information on how to contact the on-call physician. I understand that this may not be my own psychiatrist. I understand that this service should only be utilized for urgent matters that cannot wait until the next business day. Calls placed for non-emergent issues such as medication refills, scheduling or billing issues, will result in being charged for that call.

EMERGENCIES: I understand Petit Psychiatry does not provide emergency care. I understand in the case of a psychiatric emergency, I will immediately call 911 directly or proceed to the nearest emergency room if able to do so safely, so that those trained personnel can provide immediate professional emergency services. If I am unable to reach my psychiatrist, I will call 911 or proceed directly to the nearest emergency room.

NON-EMERGENCIES: I understand that I may contact Petit Psychiatry, for nonemergent matters via the patient portal or phone call. I understand that every effort will be made by the staff to return my call within 5 business days. I am responsible for leaving a message that includes my name and date of birth, explains the nature of the call, and includes information on how to be contacted. I understand psychiatrist will respond to call via secure message your patient portal or a phone call from office staff. I understand that there may be a delay in respond from the Petit Psychiatry, if I am not subscribed to patient portal or has working phone number that accepts voice mail. I will allow my psychiatrist or designated representative to leave messages on my answering machine/voicemail unless I specifically request otherwise, with the understanding that every effort will be made to maintain confidentiality.

I understand that most significant medical or psychiatric questions will need an appointment to properly evaluate the situation.

PHYSICIAN ABSENCE: I understand that if I have an emergency while my psychiatrist is on leave, that another psychiatrist in Petit Psychiatry, may provide covering services. This psychiatrist will have access to my confidential medical information during this time.

COMMUNICATIONS: I understand that I may communication with providers of Petit Psychiatry, via telephone or secure messages via the patient portal. I understand that under no circumstances will I contact staff of Petit Psychiatry via personal email, phone, or text. I understand that Petit Psychiatry will not respond to patient via email or text in order to protect my privacy. I understand that contacting staff from Petit Psychiatry via their personal phone or email will result in termination of care after 3rd offensive

PRIVACY PRACTICES: I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

PETIT PSYCHIATRY ACKNOWLEDGEMENT OF RECEIPT OF PATIENT AGREEMENT

I acknowledge that I read and/or received a copy of the Petit Psychiatry Patient Agreement and will adhere to the agreement effective January 1, 2022