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Amethyst Holistic Health provides high-quality, compassionate mental health care that is accessible to everyone. Do you have mental health concerns? If so, let’s chat! Request a FREE 15-minute consultation by filling out the form below:

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I understand that I am voluntarily engaging in a telepsychiatry consultation with Amethyst Holistic Health, PLLC.

I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

I understand that a telepsychiatry consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

I understand that the alternative to a telepsychiatry consultation is to forgo evaluation and treatment with Amethyst Holistic Health, PLLC and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telepsychiatry consultation.

I understand that telepsychiatry has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through Amethyst Holistic Health, PLLC will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

Telepsychiatry services offered through Amethyst Holistic Health, PLLC is not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

To maintain my privacy, I will not share telehealth login information or video conferencing links with anyone unauthorized to attend the appointment.

I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.to the terms & conditions

I have had the opportunity to ask questions and have had them answered to my satisfaction.

By signing below, I agree that I have read, understood, and agree to the items contained in this document.

By signing below, I am also consenting to the use of telepsychiatry as a delivery method for my medical and psychiatric care and authorize Amethyst Holistic Health, PLLC to use telemedicine to diagnosis my condition and provide appropriate treatment.

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At Amethyst Holistic Health, we use a holistic approach to manage mental health symptoms and empower our patients to overcome the challenges that they face in their daily lives.

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(980) 277-4475

(949) 655-7873

amethysthhnc@gmail.com

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