Blossom: Online Psychiatry Covered by Insurance

It is our obligation to provide you with the information you need in order to decide whether to consent to the treatment that you will be receiving. The purpose of this form is to verify that you have received this information and give consent to treatment. Please read this form carefully before acknowledging.

A. Treatment Information

Blossom BH Opco, Inc. provides therapy and medication management services for adults. Therapy is a process where mental health concerns and disorders are assessed, evaluated, and treated. There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During appointments, you will discuss the nature of your mental health concerns, the goals of treatment, and any treatments your provider recommends. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment, including potential medication that may be used in conjunction with therapy.

Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include a significant reduction in feelings of distress, better relationships, improved problem-solving and coping skills, and resolution of specific problems. Given the nature of therapy, it is difficult to predict what exactly will happen, but your provider will use their best efforts to address the risks and benefits. The provider will discuss the likelihood of achieving your treatment goals and reasonable alternatives, and you will be actively involved in your mental health journey. You fully acknowledge that any benefit from therapy is directly dependent upon your participation and progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment or revoke your consent to the treatment altogether.

Your relationship with your provider is, and will always remain, professional. All parties will treat each other with respect at all times. You acknowledge that you have received information about your provider, including their qualifications and credentials (listed on the provider profile), and that you may ask about a provider’s qualifications and credentials either during appointments or by contacting Blossom BH Opco, Inc. If, at any time, you have concerns or complaints about your treatment, you may direct them to your provider or Blossom BH Opco, Inc.

B. Telehealth

Mental health services can be furnished using a number of different modalities, including telehealth, which allows you to seek care services using a secure audio or visual technology platform, rather than requiring you to come into an office for face-to-face appointments. Telehealth services are provided synchronously, meaning you and your provider will communicate in real time during a scheduled appointment over an audio/visual technology platform. There are many benefits to telehealth services, such as easier and more convenient access to services and receiving services from the comfort and safety of your home or workplace. However, there are also risks associated with telehealth services, including, but not limited to, technological failures, delays in response, and the limitations of therapy via electronic means. This section is intended to inform you of these risks, as well as the benefits, so that you may make an informed decision on whether or not to use telehealth services.

You understand that, in connection with telehealth services, your provider will be located at a remote location and will not be physically present with you. Your provider will communicate with you during scheduled telehealth appointments. Blossom BH Opco, Inc. has a secure platform that your provider can use to communicate with you via video, audio, or messaging communications. However, there always is a possibility that the transmission of your information could be disrupted or distorted by technical failures, or could be interrupted by unauthorized persons. To increase security, Blossom BH Opco, Inc. recommends that you avoid using public access computers or shared networks.

Telehealth has the same purpose or intention as psychotherapy, psychological treatment, and other mental health or counseling treatment that are conducted in person. However, due to the nature of the technology used, you may experience telehealth somewhat differently than face-to-face treatment appointments. Therefore, your provider will continuously assess whether telehealth is appropriate for your specific treatment needs.

It is important that you establish a plan with your provider in case you experience technological difficulties and get disconnected, or you experience a mental health crisis requiring in-person treatment.

If you get disconnected due to technological difficulties, your Blossom BH Opco Professional will contact you using your information on file with Blossom BH Opco, Inc. If you get disconnected during a mental health crisis, your Blossom BH Opco Professional will contact you, or if they are unable to reach you, your emergency contact. It is imperative that you ensure your, or your emergency contact’s, information is always up-to-date.
If you are experiencing an emergency situation, you must call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call or text the National Crisis & Suicide Lifeline at 988 for free 24-hour hotline support.

C. Medication Management

If indicated, your provider may recommend certain medication(s) that may be used in conjunction with therapy. Your provider may only prescribe medications if they are licensed to do so in the state where they are licensed to provide services and if, in their professional judgment, the use of medication is medically indicated. As with therapy, there are potential benefits and risks associated with each medication. Your provider will discuss with you your options for mental health-related medications, the reasons for recommending medication, the proper usage of the medication, the potential side effects, and what to do if you experience any side effects. You have the right to refuse medication without any impact on your treatment relationship with your provider. If you choose to proceed with your Blossom BH Opco Professional’s recommendation for medication, they will provide you with a written prescription or will electronically transmit the prescription to a pharmacy of your choosing. Neither your Blossom BH Opco Professional nor Blossom BH Opco, Inc. will dispense medication to you directly. As with any medication, compliance with the medication’s prescribed usage is important for its effectiveness and to avoid negative side effects. As such, it is important that you understand and agree to the following:

Take any medications as prescribed.
Alert your provider to all medications, vitamins and/or supplements you are currently taking and alert them if you start or stop any medications, vitamins or supplements prescribed by another provider or of your own volition.
Discuss with your provider any side effects you may experience while taking the medication.
Do not stop taking medications without consulting with your provider, as doing so may result in negative side effects.
Do not share, sell, give away, dispense, or improperly dispose of your medication. If you do so, your provider and/or Blossom BH Opco, Inc. reserve the right to terminate your treatment relationship.

Certain laws or regulations may require you and your provider to have an in-person, face-to-face meeting at some point prior to or during your use of medication. Your provider will alert you if any such laws apply and will require you to comply with any in-person requirements before issuing a prescription or refill request.

If your provider is not authorized to prescribe medication, they may refer you to another provider who can assess the appropriateness of medication in your treatment and prescribe medication based on their professional judgment.

D. Confidentiality

Interactions with your provider will be confidential. There may be situations, however, where a provider is required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. For example, your provider may be required by law to report abuse or neglect. Additionally, in the event that you are a danger to yourself or others, your provider may be required by law to take action that discloses certain information about you. Providers may also have a duty to warn anyone who may be in imminent danger as a result of your threats or frame of mind. Please ask your provider or Blossom BH Opco, Inc. if you have any questions about mandatory reporting situations.

E. Records

Your records will be stored securely for a minimum of ten years. Should you ever need access to your records, please contact Blossom BH Opco, Inc. You acknowledge that you have received the Blossom BH Opco, Inc. Notice of Privacy Practices, which outlines our record-keeping and Protected Health Information confidentiality procedures. All applicable confidentiality protections and ethical rules will apply to telehealth services in the same way as with in-person therapy.

F. Financial Information

You have received information on the fees that you will incur for services. You understand that you are financially responsible for charges that are not covered or paid by your insurance. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Blossom BH Opco, Inc. to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Blossom BH Opco, Inc. for the charges for which Blossom BH Opco, Inc. is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.

If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgment of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:

You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth, and, after considering such matters, you consent to receiving telehealth services if such modality is appropriate and desired.
No promises or guarantees have been made to you regarding the therapy or medication management services that you will receive.
You have provided, or will provide before treatment, Blossom BH Opco, Inc. with accurate and up-to-date personal, medical, and financial information necessary for your care and treatment.
You understand that you may revoke this consent in writing at any time, except to the extent that your provider has already taken action in reliance on it.

It is our obligation to provide you with the information you need in order to decide whether to consent to the treatment that you will be receiving. The purpose of this form is to verify that you have received this information and give consent to treatment. Please read this form carefully before acknowledging.

A. Treatment Information

Blossom BH Opco, Inc. provides therapy and medication management services for adults. Therapy is a process where mental health concerns and disorders are assessed, evaluated, and treated. There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During appointments, you will discuss the nature of your mental health concerns, the goals of treatment, and any treatments your provider recommends. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment, including potential medication that may be used in conjunction with therapy.

Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include a significant reduction in feelings of distress, better relationships, improved problem-solving and coping skills, and resolution of specific problems. Given the nature of therapy, it is difficult to predict what exactly will happen, but your provider will use their best efforts to address the risks and benefits. The provider will discuss the likelihood of achieving your treatment goals and reasonable alternatives, and you will be actively involved in your mental health journey. You fully acknowledge that any benefit from therapy is directly dependent upon your participation and progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment or revoke your consent to the treatment altogether.

Your relationship with your provider is, and will always remain, professional. All parties will treat each other with respect at all times. You acknowledge that you have received information about your provider, including their qualifications and credentials (listed on the provider profile), and that you may ask about a provider’s qualifications and credentials either during appointments or by contacting Blossom BH Opco, Inc. If, at any time, you have concerns or complaints about your treatment, you may direct them to your provider or Blossom BH Opco, Inc.

B. Telehealth

Mental health services can be furnished using a number of different modalities, including telehealth, which allows you to seek care services using a secure audio or visual technology platform, rather than requiring you to come into an office for face-to-face appointments. Telehealth services are provided synchronously, meaning you and your provider will communicate in real time during a scheduled appointment over an audio/visual technology platform. There are many benefits to telehealth services, such as easier and more convenient access to services and receiving services from the comfort and safety of your home or workplace. However, there are also risks associated with telehealth services, including, but not limited to, technological failures, delays in response, and the limitations of therapy via electronic means. This section is intended to inform you of these risks, as well as the benefits, so that you may make an informed decision on whether or not to use telehealth services.

You understand that, in connection with telehealth services, your provider will be located at a remote location and will not be physically present with you. Your provider will communicate with you during scheduled telehealth appointments. Blossom BH Opco, Inc. has a secure platform that your provider can use to communicate with you via video, audio, or messaging communications. However, there always is a possibility that the transmission of your information could be disrupted or distorted by technical failures, or could be interrupted by unauthorized persons. To increase security, Blossom BH Opco, Inc. recommends that you avoid using public access computers or shared networks.

Telehealth has the same purpose or intention as psychotherapy, psychological treatment, and other mental health or counseling treatment that are conducted in person. However, due to the nature of the technology used, you may experience telehealth somewhat differently than face-to-face treatment appointments. Therefore, your provider will continuously assess whether telehealth is appropriate for your specific treatment needs.

It is important that you establish a plan with your provider in case you experience technological difficulties and get disconnected, or you experience a mental health crisis requiring in-person treatment.

If you get disconnected due to technological difficulties, your Blossom BH Opco Professional will contact you using your information on file with Blossom BH Opco, Inc. If you get disconnected during a mental health crisis, your Blossom BH Opco Professional will contact you, or if they are unable to reach you, your emergency contact. It is imperative that you ensure your, or your emergency contact’s, information is always up-to-date.
If you are experiencing an emergency situation, you must call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call or text the National Crisis & Suicide Lifeline at 988 for free 24-hour hotline support.

C. Medication Management

If indicated, your provider may recommend certain medication(s) that may be used in conjunction with therapy. Your provider may only prescribe medications if they are licensed to do so in the state where they are licensed to provide services and if, in their professional judgment, the use of medication is medically indicated. As with therapy, there are potential benefits and risks associated with each medication. Your provider will discuss with you your options for mental health-related medications, the reasons for recommending medication, the proper usage of the medication, the potential side effects, and what to do if you experience any side effects. You have the right to refuse medication without any impact on your treatment relationship with your provider. If you choose to proceed with your Blossom BH Opco Professional’s recommendation for medication, they will provide you with a written prescription or will electronically transmit the prescription to a pharmacy of your choosing. Neither your Blossom BH Opco Professional nor Blossom BH Opco, Inc. will dispense medication to you directly. As with any medication, compliance with the medication’s prescribed usage is important for its effectiveness and to avoid negative side effects. As such, it is important that you understand and agree to the following:

Take any medications as prescribed.
Alert your provider to all medications, vitamins and/or supplements you are currently taking and alert them if you start or stop any medications, vitamins or supplements prescribed by another provider or of your own volition.
Discuss with your provider any side effects you may experience while taking the medication.
Do not stop taking medications without consulting with your provider, as doing so may result in negative side effects.
Do not share, sell, give away, dispense, or improperly dispose of your medication. If you do so, your provider and/or Blossom BH Opco, Inc. reserve the right to terminate your treatment relationship.

Certain laws or regulations may require you and your provider to have an in-person, face-to-face meeting at some point prior to or during your use of medication. Your provider will alert you if any such laws apply and will require you to comply with any in-person requirements before issuing a prescription or refill request.

If your provider is not authorized to prescribe medication, they may refer you to another provider who can assess the appropriateness of medication in your treatment and prescribe medication based on their professional judgment.

D. Confidentiality

Interactions with your provider will be confidential. There may be situations, however, where a provider is required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. For example, your provider may be required by law to report abuse or neglect. Additionally, in the event that you are a danger to yourself or others, your provider may be required by law to take action that discloses certain information about you. Providers may also have a duty to warn anyone who may be in imminent danger as a result of your threats or frame of mind. Please ask your provider or Blossom BH Opco, Inc. if you have any questions about mandatory reporting situations.

E. Records

Your records will be stored securely for a minimum of ten years. Should you ever need access to your records, please contact Blossom BH Opco, Inc. You acknowledge that you have received the Blossom BH Opco, Inc. Notice of Privacy Practices, which outlines our record-keeping and Protected Health Information confidentiality procedures. All applicable confidentiality protections and ethical rules will apply to telehealth services in the same way as with in-person therapy.

F. Financial Information

You have received information on the fees that you will incur for services. You understand that you are financially responsible for charges that are not covered or paid by your insurance. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Blossom BH Opco, Inc. to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Blossom BH Opco, Inc. for the charges for which Blossom BH Opco, Inc. is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.

If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgment of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:

You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth, and, after considering such matters, you consent to receiving telehealth services if such modality is appropriate and desired.
No promises or guarantees have been made to you regarding the therapy or medication management services that you will receive.
You have provided, or will provide before treatment, Blossom BH Opco, Inc. with accurate and up-to-date personal, medical, and financial information necessary for your care and treatment.
You understand that you may revoke this consent in writing at any time, except to the extent that your provider has already taken action in reliance on it.

It is our obligation to provide you with the information you need in order to decide whether to consent to the treatment that you will be receiving. The purpose of this form is to verify that you have received this information and give consent to treatment. Please read this form carefully before acknowledging.

A. Treatment Information

Blossom BH Opco, Inc. provides therapy and medication management services for adults. Therapy is a process where mental health concerns and disorders are assessed, evaluated, and treated. There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During appointments, you will discuss the nature of your mental health concerns, the goals of treatment, and any treatments your provider recommends. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment, including potential medication that may be used in conjunction with therapy.

Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include a significant reduction in feelings of distress, better relationships, improved problem-solving and coping skills, and resolution of specific problems. Given the nature of therapy, it is difficult to predict what exactly will happen, but your provider will use their best efforts to address the risks and benefits. The provider will discuss the likelihood of achieving your treatment goals and reasonable alternatives, and you will be actively involved in your mental health journey. You fully acknowledge that any benefit from therapy is directly dependent upon your participation and progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment or revoke your consent to the treatment altogether.

Your relationship with your provider is, and will always remain, professional. All parties will treat each other with respect at all times. You acknowledge that you have received information about your provider, including their qualifications and credentials (listed on the provider profile), and that you may ask about a provider’s qualifications and credentials either during appointments or by contacting Blossom BH Opco, Inc. If, at any time, you have concerns or complaints about your treatment, you may direct them to your provider or Blossom BH Opco, Inc.

B. Telehealth

Mental health services can be furnished using a number of different modalities, including telehealth, which allows you to seek care services using a secure audio or visual technology platform, rather than requiring you to come into an office for face-to-face appointments. Telehealth services are provided synchronously, meaning you and your provider will communicate in real time during a scheduled appointment over an audio/visual technology platform. There are many benefits to telehealth services, such as easier and more convenient access to services and receiving services from the comfort and safety of your home or workplace. However, there are also risks associated with telehealth services, including, but not limited to, technological failures, delays in response, and the limitations of therapy via electronic means. This section is intended to inform you of these risks, as well as the benefits, so that you may make an informed decision on whether or not to use telehealth services.

You understand that, in connection with telehealth services, your provider will be located at a remote location and will not be physically present with you. Your provider will communicate with you during scheduled telehealth appointments. Blossom BH Opco, Inc. has a secure platform that your provider can use to communicate with you via video, audio, or messaging communications. However, there always is a possibility that the transmission of your information could be disrupted or distorted by technical failures, or could be interrupted by unauthorized persons. To increase security, Blossom BH Opco, Inc. recommends that you avoid using public access computers or shared networks.

Telehealth has the same purpose or intention as psychotherapy, psychological treatment, and other mental health or counseling treatment that are conducted in person. However, due to the nature of the technology used, you may experience telehealth somewhat differently than face-to-face treatment appointments. Therefore, your provider will continuously assess whether telehealth is appropriate for your specific treatment needs.

It is important that you establish a plan with your provider in case you experience technological difficulties and get disconnected, or you experience a mental health crisis requiring in-person treatment.

If you get disconnected due to technological difficulties, your Blossom BH Opco Professional will contact you using your information on file with Blossom BH Opco, Inc. If you get disconnected during a mental health crisis, your Blossom BH Opco Professional will contact you, or if they are unable to reach you, your emergency contact. It is imperative that you ensure your, or your emergency contact’s, information is always up-to-date.
If you are experiencing an emergency situation, you must call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call or text the National Crisis & Suicide Lifeline at 988 for free 24-hour hotline support.

C. Medication Management

If indicated, your provider may recommend certain medication(s) that may be used in conjunction with therapy. Your provider may only prescribe medications if they are licensed to do so in the state where they are licensed to provide services and if, in their professional judgment, the use of medication is medically indicated. As with therapy, there are potential benefits and risks associated with each medication. Your provider will discuss with you your options for mental health-related medications, the reasons for recommending medication, the proper usage of the medication, the potential side effects, and what to do if you experience any side effects. You have the right to refuse medication without any impact on your treatment relationship with your provider. If you choose to proceed with your Blossom BH Opco Professional’s recommendation for medication, they will provide you with a written prescription or will electronically transmit the prescription to a pharmacy of your choosing. Neither your Blossom BH Opco Professional nor Blossom BH Opco, Inc. will dispense medication to you directly. As with any medication, compliance with the medication’s prescribed usage is important for its effectiveness and to avoid negative side effects. As such, it is important that you understand and agree to the following:

Take any medications as prescribed.
Alert your provider to all medications, vitamins and/or supplements you are currently taking and alert them if you start or stop any medications, vitamins or supplements prescribed by another provider or of your own volition.
Discuss with your provider any side effects you may experience while taking the medication.
Do not stop taking medications without consulting with your provider, as doing so may result in negative side effects.
Do not share, sell, give away, dispense, or improperly dispose of your medication. If you do so, your provider and/or Blossom BH Opco, Inc. reserve the right to terminate your treatment relationship.

Certain laws or regulations may require you and your provider to have an in-person, face-to-face meeting at some point prior to or during your use of medication. Your provider will alert you if any such laws apply and will require you to comply with any in-person requirements before issuing a prescription or refill request.

If your provider is not authorized to prescribe medication, they may refer you to another provider who can assess the appropriateness of medication in your treatment and prescribe medication based on their professional judgment.

D. Confidentiality

Interactions with your provider will be confidential. There may be situations, however, where a provider is required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. For example, your provider may be required by law to report abuse or neglect. Additionally, in the event that you are a danger to yourself or others, your provider may be required by law to take action that discloses certain information about you. Providers may also have a duty to warn anyone who may be in imminent danger as a result of your threats or frame of mind. Please ask your provider or Blossom BH Opco, Inc. if you have any questions about mandatory reporting situations.

E. Records

Your records will be stored securely for a minimum of ten years. Should you ever need access to your records, please contact Blossom BH Opco, Inc. You acknowledge that you have received the Blossom BH Opco, Inc. Notice of Privacy Practices, which outlines our record-keeping and Protected Health Information confidentiality procedures. All applicable confidentiality protections and ethical rules will apply to telehealth services in the same way as with in-person therapy.

F. Financial Information

You have received information on the fees that you will incur for services. You understand that you are financially responsible for charges that are not covered or paid by your insurance. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Blossom BH Opco, Inc. to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Blossom BH Opco, Inc. for the charges for which Blossom BH Opco, Inc. is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.

If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgment of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:

You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth, and, after considering such matters, you consent to receiving telehealth services if such modality is appropriate and desired.
No promises or guarantees have been made to you regarding the therapy or medication management services that you will receive.
You have provided, or will provide before treatment, Blossom BH Opco, Inc. with accurate and up-to-date personal, medical, and financial information necessary for your care and treatment.
You understand that you may revoke this consent in writing at any time, except to the extent that your provider has already taken action in reliance on it.