Registration Forms
* Required Forms To Complete Intake
Client Intake information
Consent To Treat
At my own discretion I am requesting treatment with providers at City Mind NP in Psychiatry, P.C., (also DBA CityMind NP). I understand that my treatment may consist of psychotherapy or a combination of psychotherapy and pharmacotherapy. I will be educated to the benefits and potential side effects or reactions that may result from any prescribed medication. I understand that all medications have side effects and potential risks. I have the right to ask questions regarding my treatment and expect that my questions will be answered to my full satisfaction. If I do withdraw from treatment, I have the right to have a referral to another practitioner for alternative treatment. I agree to allow City Mind NP to make this document a permanent part of my patient record. Finally, I understand and will expect that all papers and documents concerning my treatment will be kept confidential. No information concerning my treatment can be released without my specific written consent except as required by law or in a situation deemed potentially life threatening. I give permission for my case to be discussed within supervision, however I understand that no personally identifiable information will be disclosed. I understand that according to Federal Regulations, licensed providers are mandated to report information that professional judgment would determine constitutes threat or serious harm to self or others, or indicates child or elder abuse or neglect. You have my consent, without reservation, to release any such information about me without further written approval.
* Forms Below Are Not Required
Medical Release Form*
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDSRELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6. 2. With some exceptions, health information once disclosed may be redisclosed by the recipient. If I am authorizing the release of HIV/AIDSrelated, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS related information, I may contact the New York State Division of Human Rights at 18883923644. This agency is responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.
Treatment Preferences
