General Information

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Thank you for choosing MindFlow Mental Health (MMH) and RoyLynn Underwood, PMHNP-BC (owner/provider). I am very grateful for your trust in my care. MMH has contracted with MindEase Billing to bill for all client encounters. You will receive a bill from MindEase Billing and can ask any billing related questions to them and/or myself.

You can contact MindEase Billing at benefits@mindeasebilling.com

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how the relationship will work, and what each party can expect. This consent will provide a clear framework for working together. Feel free to discuss this and any questions you have with me. Please read this document in its entirety and sign confirming your agreement.

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The Therapeutic Process

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You have taken a very positive step by deciding to seek mental health treatment. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. In addition to psychotherapy risks, there are numerous risks with medications and supplements, both from the product itself and/or your actions with the product. I will do all that I can to ensure you have a safe outcome. However, you are responsible for sharing any concerns or questions you may have regarding recommended treatments, as well as for consuming the products as recommended or directed.

There are no miracle cures. No one can promise that your behavior or circumstance will change. MindFlow Mental Health can promise to support you and do the very best to understand you and your concerns, as well as to help you clarify what it is that you want for yourself.

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1. Consent to Treatment:

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I hereby give my informed consent to participate and/or have my child participate in the delivery of psychiatric services at the MindFlow Mental Health including the financial, legal, and ethical conditions listed below. Legal conditions listed below are based on the Oregon Revised Statutes (ORS). Ethical conditions set forth herein are based on the ethical principles of conduct of the American Psychological Association (APA), Oregon State Board of Nurses (OSBN), and/or the American Nurses Association (ANA).

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2. Definitions of Psychiatric Treatment:

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Psychiatric treatment with a provider at MMH refers to any therapeutic relationship I and/or my child may have with a provider at MMH in an effort to diagnose and/or treat a developmental, psychological, behavioral, or emotional condition(s) for myself, my child, and/or my family. This includes medications, psychotherapy, supplements, behavioral, and life style recommendations.

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3. Treatment of Unemancipated Minors:

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Pursuant to ORS 109.675, children 14 years of age and older are able to obtain diagnosis and treatment for mental or emotional disorders or chemical dependency without parental permission with the condition that the parent’s involvement will be sought before the end of treatment, unless this is not in the best interest of the minor, there is identified sexual abuse, or the parent refuses. However, in some cases (i.e., deterioration of functioning, suicidality, etc.) MindFlow Mental Health or its independent contractors or employees has the legal right to divulge information to a minor’s parent(s) or legal guardian without permission of the minor if it is in the minor’s best interest.

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4. Limits of Confidentiality:

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The content of psychiatric treatment is privileged information and shared with people outside of your provider and MindFlow Mental Health only with your consent or as authorized by law. The following are some situations in which psychiatric treatment information may be disclosed:

a.) Suspected or reported child abuse (including but not limited to physical abuse, sexual abuse, financial abuse, and neglect).

b.) Suspected or reported elder abuse.

c.) Suspected or reported animal abuse.

d.) Suspected or reported abuse of adults who are developmentally disabled and/or mentally ill.

e.) Threatened harm to self or others.

f.) Legal proceedings in which the client uses information shared in session. Progress notes based on psychiatric services are part of the patient’s mental health record. Information about ongoing or past psychiatric treatment may be exchanged or accessed by MindFlow Mental Health employees or independent contractors (i.e., a provider) for professional purposes, who also may share information with outside sources with my consent or as authorized by law.

g.) Also, minimal information will be provided to insurance companies and other parties as necessary for the provision of treatment, payment, and assessment.

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5. Responsibilities of the Nurse Practitioner:

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a.) Obtaining consent for treatment from patient or legally authorized healthcare representative.

b.) Developing a treatment plan based on up-to-date, evidence-based treatment and instruments.

c.) Monitoring progress in treatment.

d.) Terminating treatment either when sufficient progress has not occurred, a patient has not fulfilled their responsibilities (as listed below), or unresolvable communication challenges have occurred.

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6. Responsibilities of the Patient and Family, Include, but are not limited to:

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a.) The legal guardian signing this form agrees to inform all other legal guardians of the nature of the psychiatric treatment provided by an independent contractor or employee at MindFlow Mental Health, unless it is not in the best interest of the child.

b.) Show up on time or early for appointments. If you and/or your child cannot attend a scheduled appointment, we request that you tell us 48 hours before your appointment or by 5pm of the last business day before a holiday weekend or weekend prior to your appointment by calling the MindFlow Mental Health at (458) 488-1000 or by canceling via the patient/client portal. If you communicate cancelling less than 48 hours before your appointment or 5 pm of the last business day before a holiday/holiday weekend or weekend prior to your appointment it is considered a “late cancel” If you have 2 late cancel or “no-show” appointments in total, we may not be able to work with you and/or your child any longer. Late cancels/no-shows may incur a late fee.

c.) Be open and honest about the issues that bring the patient or family to treatment.

d.) Complete tasks/activities between sessions that are agreed upon during session to increase the likelihood of improved functioning.

e.) Timely payment: Bills will be sent to collections after 120 days late and 3 attempts to collect payment in person, by phone (including leaving message), mail, email, or text message. MindFlow Mental Health or your provider will withhold records until back payment is received, unless imminently necessary for treatment by another provider.

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7. Telemedicine Services:

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a.) All existing laws and MindFlow Mental Health policies regarding privacy and security of your health information and copies of your medical records apply to this telemedicine service and the audio and video information transmitted, received, and stored electronically as part of this service. Any dissemination of patient-identifiable images or information shall not occur without your authorization.

b.) During the telemedicine service details about you may be discussed with other authorized health professionals through the use of interactive video, audio, and telecommunications technology, such as in person. Visual and physical examination of you may take place, such as in person. Other MindFlow Mental Health staff may be requested to enter the area where telemedicine is being performed, such as in person.

c.) You may withhold or withdraw your consent to telemedicine services at any time before or during the consult without affecting the right to future care or treatment. You may also withdraw consent to extra personnel participating in telemedicine services. The request to revoke consent must be submitted to MindFlow Mental Health or your provider in writing and received by MindFlow Mental Health or your provider.

d.) Any dispute arriving from the telemedicine consult will be resolved in Oregon, and Oregon law shall apply to all disputes.

e.) Risks: audio and video technology has its own limitations and issues, including the potential for incomplete exchange or loss of information and potential unintended loss of confidentiality at either site involved in the telemedicine exchange.

f.) Video or audio recording of telemedicine services is prohibited. MindFlow Mental Health and its independent contractors or employees do not give consent to this.

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8. Court Subpoenas:

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a.) Providers at MindFlow Mental Health are nurse practitioners or other mental health provider, not a lawyer. MindFlow Mental Health nor any of the independent contractors or employees are not interested, under any circumstances, to appear in court for any reason for any patients or on their family’s behalf.

b.) You will be charged a fee if you request, or your attorney or one or more of their associates, request any independent contractor or employee from MindFlow Mental Health to appear in court to provide testimony and/or a deposition and/or any formal contribution to any court proceeding.

c.) Court Retainer Fee: $1500. Covers first hour only. Payment required 24 hours or more before the scheduled court appearance. Upon the initiation of the scheduled court appearance, the $1500 Court Retainer Fee payment is considered late. For example, if a provider is expected to participate in court beginning at 8:00am on June 23, 2021, the Court Retainer Fee payment is considered late at 8:00am on June 23, 2021. Late fees may incur additional charges at MindFlow Mental Health’s or your provider’s discretion.

d.) Court Preparation, Appearance, and Testimony Fee: Each additional hour is charged at a rate of $500, from the time your provider begins to review a file, leave the house or office, or do any preparatory work of any kind for the proceeding (e.g., print documents, etc.), and ending after the involvement is 100% complete. For every hour, from the top of the hour (e.g., 11:00 am), until 59 minutes after the top of the hour (e.g., 11:59 am) that is spent even 1 minute on the case, the family will automatically incur another $500 charge. For example, if a provider were to participate from 8:59 am until 10:01am, the charge would be $2500 ($1500 Court Retainer Fee covers 8:59 am-9:00 am, $500 covers 9:00 am-9:59 am, and $500 covers 10:00 am-10:01am). And if the provider has any obligations or responsibilities related to the case following the proceeding, charges will continue to accrue until they are complete. The family will receive a bill from MindFlow Mental Health or your provider following the court proceeding for the remaining balance. Note that the Court Retainer Fee should have been collected by MindFlow Mental Health or your provider by this time. MindFlow Mental Health’s or your provider’s services in the court proceeding will be treated like a charge for psychological services, but with special rates since services will not be billed through insurance. MindFlow Mental Health will use a collection agency if needed per MindFlow Mental Health’s regular office financial policies.

e.) If your provider is subpoenaed, you are responsible for the Court Retainer Fee and the Preparation, Appearance, and Testimony Fee, however it does not mean that your provider’s testimony will be solely or partially in your favor in the case. They can only testify to the facts of the case, to their professional opinion(s), and information available by memory at that time. The initials and signature below acknowledge that the patient or the patient’s responsible party has agreed to the terms set within this agreement, as well as providing consent for MindFlow Mental Health, your provider, and any contractor or employee to testify verbally and/or in writing to counseling services received in conjunction with said court appearance.

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9. Caregiver Status:

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a.) Except as stated above under “Treatment of Unemancipated Minors,” parent/legal guardians are required to give express permission for the treatment of a child before initiating a therapeutic relationship. To give such permission, the adult must be a custodial parent or noncustodial parent or legal guardian who maintains the legal right to make such decisions or another adult (e.g., grandparent, aunt, other relative) who has been given the legal right to make such a decision for the child.

b.) By initialing and signing below, you are indicating that you have the legal right to consent to treatment on behalf of the named child. And if you are consenting to treatment on behalf of the named child, you must inform other parties with legal interests in the child, such as a noncustodial parent of the child, that the child has started to receive psychological treatment, unless informing such other party is not in the best interest of the child, which is a decision to be made jointly with your provider

c.) Other parties with the legal right to make decisions about the child, such as a noncustodial parent, may have access to records about your child’s care, unless there is legal documentation preventing this.