Behavioral Health Treatment Agreement

• Addictions
• Aging & Caregiver Support
• Anxiety
• Bipolar
• Depression
• Grief & Loss
• LGBTQ+ Support
• Life Changes
• Obsessive Compulsive Disorder (OCD)
• Panic Disorders
• Parenting Support
• Phobias
• Relationship Issues
• Stress Management
• Trauma & PTSD
• And more…

• Emergency or crisis situations (suicidal or homicidal thinking, self-harm, or risk of harm to others)
• Active psychosis (hallucinations or delusions)
• Substance use in active medical detox
• Moderate to severe autism spectrum disorders
• Children under the age of 10
• Any condition or combination of mental health conditions that prohibit the ability to perform normal day-to-day activities

• DEA-controlled medications (including ADHD stimulant medications and anti-anxiety benzodiazepines)
• Detox medications (e.g., Suboxone, Methadone)
• Medications that require regular lab work and monitoring when lab work is not present for review during the appointments
• Medications that have the potential for abuse (e.g., pseudoephedrine, some muscle relaxants1)
• Sleep medications
• Medicinal marijuana

• 1Prescriptions are at the physician’s discretion and are only available for certain types of muscle relaxants for treatment of an acute condition for a maximum of 5 days with no refills.

Payment information is requested when scheduling most BH sessions. A cancellation is considered late when the appointment is cancelled less than 24 hours before the appointed time. A no-show is when a patient misses an appointment without cancelling. In either case, we will charge the patient a $50 missed appointment fee.

If a payment method is not requested at the time of registration or scheduling, I may be part of a group excluded based on affiliation, program type, or service being scheduled.

All Adult (18+) participants must have a registered account to participate in BH sessions, consent to treatment, and agree to MDLIVE terms of use and this treatment agreement.

Behavioral health therapy and psychiatry appointments are NOT recorded.

In order to be respectful of the provider’s time, as well as the time of other patients seeking care, I am responsible for coming to sessions on time, ensuring that my environment is private, quiet, and free from distractions. I will come prepared to actively engage in the therapeutic process with my provider by discussing symptoms I am experiencing and setting goals. I will make reasonable efforts to follow my provider’s clinical recommendations. I will try to arrive 5 minutes early to make sure I have logged into the portal and tested the sound and video on my computer if I have a video appointment. I will be prepared to answer the phone 5 minutes early if I have an audio appointment. I understand that if I am late, my session will still end at the scheduled time. If I am more than 12 minutes late for therapy or 5 minutes late for psychiatry, my session may be cancelled, and I will be expected to reschedule for a later date.

(Please review medications above that CANNOT be prescribed by MDLIVE providers)
I understand that my provider may only order medically necessary tests within the BH scope of practice, using their best clinical judgment and associated review of past medical history, current/past medications, presentation during the consult, and other data points available for medical decision making such as previous lab results.

I understand that I will be required to complete labs a minimum of 5 days before my medication management follow-up appointment. I acknowledge that if labs are not completed 5 days prior to my appointment, the appointment with my psychiatrist will be canceled, and I will be required to reschedule, following completion of lab work. I understand that failure to complete lab work may result in medication refills being withheld until lab work is complete. My provider may provide me with a one-time seventy-two-hour extension of my medication in order to ensure that I do not run out.

I also acknowledge that I may be charged additional costs for labs depending on my insurance coverage.

I understand that the therapeutic process relies on a good fit between provider and patient. As such, I understand I will have the opportunity to change providers (not to exceed 3 providers) if I don’t feel a therapeutic fit was achieved at intake. I will be required to identify one provider to see consistently for treatment. I acknowledge this opportunity is for my benefit as a patient as it allows for the establishment of a positive therapeutic relationship, the development of treatment goals, and appropriate continuity of care.

I understand that if I miss a session or cancel without giving at least 24 hours’ notice, I may be charged a no show/late cancellation fee of $50.00. This fee will not be covered by insurance.

I understand that if I have more than 2 or more no shows in a row or 3 or more no shows within a 3-month period with any of my MDLIVE providers, it may result in my termination and transition of my care outside of MDLIVE.

I understand that patients, providers, and staff are to communicate in a respectful and appropriate manner. Instances of hostile or inappropriate behavior by a patient may result in transition of services outside MDLIVE (if you have experienced communication by an MDLIVE provider or staff that you find violates this standard, please report as soon as you are able to MDLIVE Customer Service).

I understand that all communication with providers outside of clinical sessions must go through the MDLIVE message center, and never directly to a provider’s personal phone number, email, or device. The message center is used primarily for coordination of care and for communication about appointments or other recommendations. Clinical or therapeutic discussions that would warrant a scheduled visit are inappropriate for the messaging platform and are not allowed. In addition, overuse or misuse of the messaging feature may result in transition of care outside of MDLIVE. I acknowledge that providers generally check messages within 48 hours, on average. If I have an emergency, I will call 911, or go to my nearest emergency room. If I need non-emergency assistance, I will call MDLIVE Customer Service.

I understand that Behavioral Health visits are not recorded. I understand that what I share with my provider is confidential unless disclosure is required or otherwise allowed by law. I recognize the following exceptions to this confidentiality, in addition to those outlined in the MDLIVE Notice of Privacy Practices:

If my provider or MDLIVE staff have any concerns involving immediate safety, including if there is reason to believe that I will harm myself or someone else, I understand that MDLIVE providers and/or staff may call the police or local emergency services, initiate hospitalization, warn an identified potential victim, or contact any individual identified in my safety plan or patient record as a primary resource.

I also acknowledge that if an MDLIVE provider or staff has concerns about the abuse or neglect of a child, elderly person, or person with a disability, they have the legal obligation or the right to report this concern to state child and/or adult protection services.

I understand that MDLIVE providers require legal documentation that outlines guardianship/parental rights for medical decision-making and an emergency contact. I understand that as a parent/guardian of a minor seeking behavioral health services, I will be required to upload any documentation (i.e., parenting plan, divorce decree, foster/adoption paperwork) that would outline medical decision-making rights prior to scheduling an appointment/completing an intake session.

If a minor patient is experiencing an emergency, I will call 911, or go to my nearest emergency room.

I understand that MDLIVE behavioral health providers do not complete outside paperwork, give recommendations related to any legal matter or patient legal involvement or testify on behalf of or against a patient. I acknowledge that, if at any point during the course of my treatment, I become involved in a legal matter that might warrant the recommendations of my behavioral health provider, I will promptly notify my MDLIVE provider and transition my care outside of MDLIVE.

If it becomes reasonably clear to my provider that the telemedicine modality is not sufficient to meet my needs or is otherwise inappropriate, my MDLIVE provider will refer me to face-to-face and/or a higher level of care as indicated. I agree to follow through on these recommendations and will not return to MDLIVE outpatient care until: (1) I have followed through on all clinical recommendations, and (2) after reassessment it is considered appropriate for me to return to this level of care.

I specifically acknowledge that if I do not follow MDLIVE recommendations for care, I may be terminated from services and transitioned to care outside of MDLIVE. Other reasons for termination of services and transition to care outside of MDLIVE include, but are not limited to, threats, offensive or verbally abusive behavior, or other inappropriate conduct.

I understand my MDLIVE provider is not available 24/7 and that MDLIVE Behavioral Health is not a crisis management service. I understand that if I am in crisis, including at risk of harm to myself or someone else, or if I cannot wait to be scheduled to be seen, I will not use telemedicine. Instead, I will pursue emergency services via the nearest emergency room or by calling 911. I also recognize that the National Suicide Prevention Lifeline is available to me as a resource in any crisis situation at 988 or 1-800-273-8255.