NEW Patients: You must complete all onboarding documents under the Documents tab in your portal account at least 72 hours before your first appointment to confirm your appointment. If you schedule within 72 hours, you must complete all onboarding documents at least 24 hours prior to your appointment. Unconfirmed appointments will be canceled to make room on the schedule for other patients, and you will be asked to complete your documents and reschedule.

Patients who want to confirm our current Self-Pay Rates should click here.

If you have an emergency, call 911, 988, or report to your closest emergency room immediately.

Welcome to Stasis Behavioral Health ("Practice"). This document outlines essential information regarding our services, policies, your rights as a patient, and your significant responsibilities. It is crucial that you read this entire document carefully before signing. Your signature below indicates that you have read, fully understood, and voluntarily agree to be legally bound by all terms and conditions contained herein. If you do not understand any part of this document, it is your responsibility to ask for clarification before signing.

I. Welcome to Stasis Behavioral Health

This section introduces you to our practice, our philosophy of care, and the services we provide. A clear understanding and acceptance of these aspects are fundamental to establishing a therapeutic relationship.

• A. Our Mission and Approach to Your Care at Stasis Behavioral Health Stasis Behavioral Health's mission is to provide compassionate, evidence-based psychiatric care, meticulously tailored to meet your individual needs. We aim to foster a collaborative partnership between you, the patient, and your provider, grounded in mutual respect and open communication. Our approach is patient-centered, emphasizing a comprehensive understanding of your concerns to develop constructive pathways toward improved mental health. We utilize proven therapeutic strategies, including specialized medication management and psychotherapy, to support your journey to wellness. Success in treatment requires your active participation, honesty, and adherence to the agreed-upon treatment plan and all Practice policies.  

• Our self-pay model is designed to support a direct therapeutic alliance, focusing entirely on your clinical needs and preferences without the constraints often imposed by external insurance companies. This model allows for a more personalized and responsive approach to your care, ensuring that treatment decisions are made solely between you and your provider, prioritizing your well-being. This commitment to a direct partnership is particularly vital, as your active investment—both personal and financial—in your treatment is a key component of achieving positive outcomes. You acknowledge that payment for services does not guarantee specific results.

• B. Services We Offer at Stasis Behavioral Health Stasis Behavioral Health specializes in providing comprehensive outpatient psychiatric services focused on medication management and psychotherapy. Our services are designed to address the biological, psychological, and social aspects of mental health conditions. These include:  

  • Comprehensive Psychiatric Evaluations: Assessments to understand your concerns and formulate an initial diagnostic impression. Diagnosis is based on information provided by you and clinical observation; accuracy depends on your full and truthful disclosure.

  • Medication Management: This involves discussions about medication options, ongoing monitoring, follow-up appointments, and education regarding prescribed medications. Providers exercise clinical judgment in prescribing; there is no obligation to prescribe any specific medication requested by the patient.  

  • Psychotherapy: We offer psychotherapeutic services, which may be provided in conjunction with medication management or as a standalone treatment. The nature and goals of psychotherapy will be discussed, and separate informed consent obtained as detailed in Section III.

  • Treatment for a Range of Psychiatric Conditions: Including but not limited to mood disorders, anxiety disorders, trauma-related disorders, and attentional disorders. The scope of conditions treated is determined by provider expertise and the limitations of an outpatient setting.

• Philosophy on Controlled Substances and ADHD Treatment: Stasis Behavioral Health advocates for the safe, responsible, and judicious use of all medications. We exercise extreme caution and adhere to strict clinical guidelines regarding the prescription of controlled substances (e.g., stimulants, benzodiazepines). We prioritize exploring all appropriate treatment options, including non-controlled medications and therapies, to minimize or eliminate reliance on controlled substances whenever clinically indicated and safe. Prescriptions for controlled substances, if deemed appropriate by the provider in their sole clinical judgment, are provided in limited quantities, require frequent monitoring appointments (at your expense), and are subject to all federal and state regulations, including those pertaining to telehealth. We reserve the right to require urine drug screens, pill counts, or other monitoring measures at any time, at your expense. We are committed to safe prescribing and reserve the absolute right to decline initiating, decline refilling, or to taper and discontinue controlled substances if deemed clinically appropriate, if policies are violated, or if concerns about misuse, diversion, aberrant behavior, or safety arise. If you are prescribed a Schedule IV controlled substance (such as alprazolam or Lorazepam), you must follow-up at least every 90 days for refills. If you are prescribed a Schedule II controlled substance (such as Lisdexamfetamine or Amphetamine-Dextroamphetamine), you must follow-up every 30 days for retail pharmacies and every 90 days for mail order pharmacies. Non-adherence to controlled substance policies will result in termination of care.
  
  For Attention-Deficit/Hyperactivity Disorder (ADHD), our approach includes a thorough evaluation and consideration of non-stimulant medications and behavioral therapies alongside or as alternatives to stimulant medications. This careful prescribing philosophy manages expectations and underscores our commitment to long-term wellness and responsible medical practice, protecting both the patient and the Practice.  

• C. Our Commitment to Partnership in Your Mental Wellness at Stasis Behavioral Health The therapeutic relationship is a partnership requiring mutual commitment. Your active participation, complete honesty, timely communication, and adherence to the agreed-upon treatment plan and Practice policies are essential for the potential success of treatment. We commit to providing care consistent with professional standards, and in turn, we rely on your commitment to engage actively and responsibly in your treatment, including fulfilling your financial obligations. Failure to uphold your responsibilities may hinder treatment progress and could lead to termination of the therapeutic relationship.  

II. Understanding Your Rights and Our Privacy Practices (Notice of Privacy Practices - NPP) for Stasis Behavioral Health

Stasis Behavioral Health is dedicated to maintaining the privacy of your protected health information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI, your rights concerning your PHI, and our legal obligations under HIPAA. Your signature acknowledges receipt of this Notice.  

• A. Our Pledge Regarding Your Medical Information Stasis Behavioral Health is committed to protecting the privacy of your health information (PHI) as required by federal law. We create a record of the care and services you receive, and we are committed to keeping this information confidential according to applicable laws.  

• B. How We May Use and Disclose Your Protected Health Information (PHI) We may use and disclose your PHI without your specific written authorization for purposes of Treatment, Payment, and Healthcare Operations, as well as for appointment reminders, discussing treatment alternatives, informing you of health-related benefits/services, and engaging Business Associates who perform functions on our behalf (subject to confidentiality agreements).  

• C. Disclosures Required or Permitted by Law (Without Your Specific Authorization) We may use or disclose your PHI without your specific authorization when required or permitted by law, including for public health activities, health oversight, law enforcement purposes, judicial proceedings, averting serious threats to health or safety, reporting abuse/neglect, workers’ compensation, national security, coroners/medical examiners, organ donation, research (with safeguards), military/veterans purposes, inmates, and collections.  

• D. Your Rights Regarding Your Protected Health Information You have rights regarding your PHI, including the right to inspect/copy, request amendment, request an accounting of disclosures, request restrictions (we are not required to agree, except in limited circumstances related to self-paid services), request confidential communications, obtain a paper copy of this Notice, and be notified of a breach of unsecured PHI.  

• E. Special Considerations for Minors Consent for treatment and access to PHI for minors (under 18) are governed by applicable state law where the minor is located at the time of service. Stasis Behavioral Health adheres to these laws regarding parental/guardian consent and minor confidentiality.  

• F. Changes to This Notice Stasis Behavioral Health reserves the right to change this Notice and our privacy policies at any time, effective for all PHI we maintain. The current notice will be available in our office and on our website.  

• G. Complaints and Contact Information If you believe your privacy rights have been violated, you may file a complaint with Stasis Behavioral Health's Privacy Officer or the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. Contact information for our Privacy Officer is:  support@stasisbehavioralhealth.com.

III. Informed Consent for Your Treatment at Stasis Behavioral Health

This section confirms your informed consent to receive psychiatric evaluation and treatment (including medication management and/or psychotherapy) from providers at Stasis Behavioral Health. Informed consent is an ongoing process. By signing this document, you acknowledge that you have been provided with sufficient information regarding the nature of the proposed treatments, the potential benefits, the significant potential risks and side effects, and alternative options. You confirm that you understand this information, have had the opportunity to ask questions, and voluntarily consent to proceed with evaluation and treatment. You understand you have the right to withdraw consent at any time in writing, but that withdrawal does not absolve you of financial responsibility for services already rendered.  

• A. Consent to Psychiatric Treatment and Medication Management You understand, acknowledge, and agree to the following regarding psychiatric treatment and medication management:

  • Evaluation and Diagnosis: You consent to undergo psychiatric evaluation. You understand diagnosis is based on the information you provide and clinical assessment. You agree to provide a complete, truthful, and accurate history of your medical and psychiatric conditions, treatments, hospitalizations, medications (prescribed, over-the-counter, supplements), allergies, and all substance use (including alcohol, illicit drugs, cannabis). Withholding or providing inaccurate information can significantly compromise your care, lead to incorrect diagnoses or treatments, cause adverse effects (including serious harm or death), and may result in termination of care. Stasis Behavioral Health and its providers are not liable for adverse outcomes resulting from your failure to provide complete and accurate information. You must acknowledge the possibility that you have a mental health condition requiring treatment, even if you disagree with a specific diagnosis, for treatment to proceed.  

  • Nature and Purpose of Treatment: You consent to medication management as deemed clinically appropriate by your provider.  

  • Potential Benefits: You understand potential benefits may include symptom reduction and improved functioning, but there are no guarantees of specific results or cure.  

  • Potential Risks, Side Effects, and Discomforts of Psychotropic Medications: You acknowledge that ALL medications, including psychotropic medications, carry risks and potential side effects. These can range from common and mild to serious, permanent, or life-threatening. You understand that it is impossible to list every potential risk or side effect, but you acknowledge awareness of the general categories and specific examples provided below, and that you have the opportunity to discuss specific risks of any prescribed medication with your provider. Potential risks and side effects include, but are absolutely not limited to :  

    • Common Effects: Drowsiness, dizziness, fatigue, insomnia, headache, dry mouth, nausea, vomiting, diarrhea, constipation, appetite changes, weight gain/loss, sweating, blurred vision, sexual dysfunction, tremors, agitation, anxiety, etc.

    • Serious/Less Common Effects: Significant mood/behavior changes (worsening depression, mania, psychosis, hallucinations, aggression, impulsivity), suicidal thoughts/behaviors, confusion, memory loss, speech/coordination problems, fainting, seizures, heart problems (arrhythmias, blood pressure changes, chest pain), movement disorders (tics, tardive dyskinesia), urinary problems, swelling, severe skin reactions (Stevens-Johnson Syndrome), sun sensitivity, vision/hearing changes, liver/kidney problems, blood disorders (agranulocytosis), electrolyte imbalances, neuroleptic malignant syndrome, serotonin syndrome, stroke, heart attack, allergic reactions, dependence, withdrawal syndromes, etc.

    • Specific Risks: Different medication classes (antidepressants, antipsychotics, mood stabilizers, anxiolytics, stimulants) have unique risk profiles. Risks associated with polypharmacy (multiple medications) exist. Risks during pregnancy/breastfeeding are significant and must be discussed if applicable. Risks of drug interactions with other medications, supplements, or substances (including alcohol) are significant. Risks associated with abrupt discontinuation exist. Cognitive/motor impairment risks exist. Dependency/withdrawal risks exist, especially with controlled substances.

  • Your Responsibility Regarding Medications: You agree to take medications exactly as prescribed. You agree to report any side effects, adverse reactions, worsening symptoms, or thoughts of self-harm or harm to others to your provider immediately. You agree to inform your provider of any new medications, supplements, or substances you start taking. You agree not to share, sell, or divert prescribed medications.

  • "Trial-and-Error" Process: You understand that finding an effective medication regimen often requires adjustments and may take time. This process requires your patience and adherence.  

  • Off-Label Use: You consent to the possibility of being prescribed medications "off-label" if your provider deems it clinically appropriate, and understand the rationale will be explained.  

  • Controlled Substances: You specifically acknowledge and agree to the strict policies regarding controlled substances outlined in Section I.B, including monitoring requirements and the provider's absolute discretion in prescribing or discontinuing these medications.  

  • Alternative Treatment Options: You acknowledge awareness of alternatives to medication, including psychotherapy, lifestyle changes, or no treatment, and their potential risks and benefits.  

  • Provider Judgment: You understand that treatment recommendations are based on your provider's clinical judgment. Your provider reserves the right to refuse or discontinue any treatment they deem clinically inappropriate, unsafe, or not in your best interest.  

  • NO GUARANTEES: You explicitly acknowledge and agree that Stasis Behavioral Health and its providers make NO GUARANTEES or promises regarding the outcome or effectiveness of any treatment. Results vary significantly between individuals.

• B. Consent for Psychotherapy If psychotherapy is undertaken, you understand, acknowledge, and agree to the following:

  • Approach and Goals: You consent to the therapeutic approach proposed and understand the goals.  

  • Potential Risks and Discomforts: You acknowledge that psychotherapy involves potential risks and discomforts, including but not limited to : experiencing painful emotions or memories; temporary worsening of symptoms; potential life changes that may be stressful; potential impact on existing relationships; development of strong or uncomfortable feelings towards the therapist (transference); and the possibility of limited progress or, rarely, negative outcomes or triggering of serious issues like self-harm thoughts (which must be reported immediately).  

  • Potential Benefits: You understand potential benefits include improved coping, insight, and well-being.  

  • Alternatives: You acknowledge awareness of alternatives.  

  • Boundaries: You understand the therapeutic relationship is professional, not social, and boundaries are necessary.  

  • NO GUARANTEES: You explicitly acknowledge and agree that Stasis Behavioral Health and its providers make NO GUARANTEES or promises regarding the outcome or effectiveness of psychotherapy.

• C. Your Right and Responsibility in Decision-Making You have the right to make decisions about your care, including accepting or refusing treatment, asking questions, and withdrawing consent (verbally or in writing). You also have the responsibility to actively participate, provide accurate information, report concerns promptly, and adhere to the treatment plan and policies. Failure to do so may compromise your care and is grounds for termination.  

• D. Consent for Minors For patients under 18, consent is provided by a parent/legal guardian per applicable state law.  

IV. Our Financial Policy and Your Responsibilities

• Stasis Behavioral Health operates exclusively on a self-pay basis. Understanding and agreeing to this financial policy is required to receive services.

• A. Credit/Debit/HSA Cards. You authorize charges to your credit card through SimplePractice for services rendered. These charges will appear on your bank/credit card statement as [STASIS BH]. You have the right to request a paper copy of this document. You authorize STASIS BEHAVIORAL HEALTH to charge your credit card. You also agree that my credit card can be charged for any session that is not cancelled at least 24 hours prior to the scheduled session. You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify STASIS BEHAVIORAL HEALTH in writing of any changes in your account information or the termination of this authorization. You certify that you are an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. You acknowledge that credit card transactions could be linked to Protected Health Information.

• B. Fees for Services and Payment Expectations Payment in full is due at the time of service unless other specific written arrangements are made in advance. Accepted payment methods are. A current Self-Pay Fee Schedule is available upon request and/or via this website. You are responsible for knowing the fees associated with your scheduled services.  You agree that you will not be permitted to schedule if you have an unresolved balance and no agreed payment plan. We reserve the right to require a deposit of $150 before you can schedule future visits if you fail to pay your balance at the time of service.

• C. Our Policy Regarding Insurance Stasis Behavioral Health does NOT participate in any insurance plans (commercial, Medicare, Medicaid, etc.). We do NOT bill insurance. We are considered "out-of-network" providers for all plans. You are personally and fully responsible for payment at the time of service.

• Superbills: Upon request, we can provide a superbill (detailed receipt) for paid services. You may be able to submit this to your insurer for potential out-of-network reimbursement. However, Stasis Behavioral Health makes absolutely NO guarantees regarding insurance reimbursement. Verifying your out-of-network benefits, coverage, deductibles, and claim procedures is solely your responsibility. We do not assist with insurance claims or disputes.

• D. Medicaid and Other Third-Party Payers Stasis Behavioral Health does not participate in Medicaid. Medicaid beneficiaries choosing our services do so as self-pay patients, are fully responsible for our standard fees, including missed appointment and late cancelation fees, and acknowledge Stasis Behavioral Health cannot submit claims to Medicaid for our services.

• E. Information for Self-Pay Patients and Good Faith Estimates (No Surprises Act) As a self-pay patient, you have the right to receive a Good Faith Estimate (GFE) of expected charges for scheduled services. We will provide a GFE upon request or automatically under conditions specified by the No Surprises Act. The GFE is an estimate; actual costs may vary if complications arise or your treatment plan changes. For questions, visit www.cms.gov/nosurprises.

• F. Policy on Missed Appointments and Cancellations. Your appointment time is reserved exclusively for you. Appointments must be canceled or rescheduled within the patient portal a minimum of twenty-four (24) business hours' prior to the appointment's scheduled date and time. A fee equal to the FULL current self-pay rate for the scheduled service will be charged directly to you for missed appointments ("No-Show") or appointments cancelled/rescheduled with less than twenty-four (24) business hours' notice ("Late Cancellation"). There are absolutely NO exceptions to this policy. This fee is your personal responsibility, is not billable to any third party, and cannot be submitted on a superbill. Repeated late cancellations or no-shows may result in termination of care.

• G. Understanding Our Collections Process Timely payment is required. Overdue accounts will receive reminders. Accounts remaining unpaid may be turned over to an external collections agency or pursued via legal means. You agree to be responsible for all costs associated with collecting the debt, including agency fees, attorney fees, and court costs. You agree that non-payment is grounds for termination of services.

V. Consent for Use of Technology: Telehealth, Digital Communication, and AI at Stasis Behavioral Health

Stasis Behavioral Health utilizes technology to facilitate care. Your consent to these uses is required.

• A. Telehealth Services at Stasis Behavioral Health Telehealth involves providing care remotely via secure video conferencing.

  • Consent & Appropriateness: You consent to the use of telehealth if offered and deemed clinically appropriate by your provider. Telehealth has benefits (convenience) and limitations (not suitable for all situations, potential technical issues).  

  • Your Responsibilities: You are responsible for having a suitable device, reliable internet, and a private, secure, quiet location for all telehealth sessions to protect confidentiality. You MUST be physically located within a state where your provider is licensed at the time of service and confirm your location at the start of each session. Failure to ensure privacy on your end is your responsibility.  

  • Privacy and Security: We use HIPAA-compliant platforms, but no technology is entirely risk-free. You accept the inherent risks of electronic transmission.  

  • Emergency Procedures: Telehealth is NOT for emergencies. In an emergency, call 911 or go to the nearest ER. You must provide your accurate physical location for safety planning.  

  • Limitations: You understand certain assessments or treatments may not be possible via telehealth. Technical failures may interrupt sessions.

• B. Communicating Electronically with Us (Email, Secure Messaging, Text)

  • Standard Email: Unencrypted email is NOT secure for PHI. Stasis Behavioral Health uses secure, HIPAA-compliant services for email and text. If you choose to use standard email, you accept all risks of interception or misdirection. We discourage sending sensitive clinical details via standard email. Stasis Behavioral Health is not liable for breaches resulting from your use of unsecure email.  

  • Text Messaging: May be used for limited purposes (e.g., reminders) with prior consent. Not for urgent matters or detailed clinical discussion.  

  • Response Times: Electronic communications are typically monitored during business hours only. Allow [e.g., 1-2] business days for non-urgent responses. Do NOT use electronic communication for emergencies.

• C. Our Use of Artificial Intelligence (AI) in Your Care We may use AI tools for administrative support or to assist providers (e.g., AI scribes).

  • Oversight: All clinical decisions are made by your human provider, who reviews AI-assisted information.  

  • Transparency & Privacy: We aim for transparency and ensure AI tools comply with privacy standards. You may have opt-out rights for certain applications where feasible.  

  • Consent: Your signature constitutes consent to the use of AI as described.

• D. Consent for Audio/Video Recording Stasis Behavioral Health does NOT record audio or video of patient appointments (in-person or telehealth) unless explicit, prior, written, mutual consent is obtained for a specific purpose (e.g., supervision). Unauthorized recording by patients is strictly prohibited and grounds for termination.  

VI. All Rules: General Practice Policies and Patient Responsibilities at Stasis Behavioral Health

Adherence to these policies is mandatory for all patients. Failure to comply may result in termination of care.

• A. Appointments: Scheduling, Punctuality, and Changes

  • Scheduling: Use the patient portal or call during business hours.  

  • Punctuality: Arrive on time. Late arrivals may result in shortened sessions charged at the full rate. Chronic lateness may lead to termination.  

  • Changes/Cancellations: Adhere strictly to the 24-business-hour notice policy (Section IV.E).

• B. Communicating with Our Practice

  • Use the secure portal or phone during business hours for non-emergencies. Allow appropriate response times (see V.B).  

  • Business Hours:.

  • After-Hours: Phone and portal are not monitored outside business hours, weekends, or holidays. NO emergency coverage is provided. You should call 911, 988, or visit the closest emergency room if you have an urgent issue.

• C. Medication and Prescription Refill Policies

  • Refill Requests: Use the secure email at support@stasisbehavioralhealth.com. Allow at least one to three (1 to 3) business days for processing. It is YOUR responsibility to monitor your medication supply and request refills well in advance to avoid running out. Urgent refill requests due to lack of planning may not be accommodated and may incur fees if addressed outside standard procedures.  

  • Clinical Assessment Required: Refills require ongoing clinical assessment and adherence to follow-up appointments. Prescriptions will not be refilled if you are overdue for appointments.  

  • Controlled Substances: Strict adherence to policies in Sections I.B and III.A is required. Early refills are not permitted. Lost/stolen controlled substance prescriptions will generally NOT be replaced. Non-compliance leads to termination.

  • Telehealth Prescribing: Adheres strictly to all DEA and state regulations.  

  • No Obligation to Prescribe: Providers have no obligation to prescribe any medication deemed inappropriate or unsafe.  

• D. IMPORTANT: WE DO NOT PROVIDE EMERGENCY OR CRISIS SERVICES STASIS BEHAVIORAL HEALTH IS AN OUTPATIENT PRACTICE AND IS NOT EQUIPPED FOR, AND DOES NOT PROVIDE, EMERGENCY, CRISIS, OR URGENT CARE SERVICES. IF YOU ARE EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, A CRISIS, FEEL UNSAFE, OR HAVE THOUGHTS OF HARMING YOURSELF OR OTHERS, YOU MUST IMMEDIATELY CALL 911, OR CALL OR TEXT THE 988 SUICIDE & CRISIS LIFELINE, OR GO TO YOUR NEAREST HOSPITAL EMERGENCY ROOM. DO NOT USE THE PATIENT PORTAL, EMAIL, OR OFFICE PHONE FOR EMERGENCIES. Relying on these non-emergency channels could dangerously delay necessary care.  

• E. Maintaining a Respectful and Safe Environment & Grounds for Termination A respectful and safe environment is required. The following behaviors are grounds for immediate termination of care from Stasis Behavioral Health: harassment, threats, violence (verbal or physical), intimidation, discrimination, disruptive behavior, bringing weapons onto premises, being inappropriately under the influence of non-prescribed substances, failure to pay for services at the time of service, chargebacks for valid charges, non-compliance with treatment recommendations or Practice policies (including financial and controlled substance policies), providing false or misleading information, misuse of communication channels, unauthorized recording, or any behavior that compromises the safety or therapeutic environment for staff or other patients. Law enforcement may be contacted if appropriate.  

• F. Your Role and Responsibility in Your Treatment Success Your active involvement and responsibility are crucial. This includes, but is not limited to :  

  • Attending appointments punctually.

  • Providing complete and accurate information (medical, psychiatric, substance use history).

  • Taking medications exactly as prescribed.

  • Reporting side effects, concerns, or changes promptly.

  • Communicating openly and honestly.

  • Actively participating in treatment planning and follow-through.

  • Adhering to all financial and practice policies.

  • Arranging timely refills.

  • Failure to fulfill these responsibilities can negatively impact treatment outcomes, compromise safety, and may lead to termination of care.

• G. Compliance with All Practice Policies By becoming a patient, you agree to comply with all policies of Stasis Behavioral Health, as outlined in this document and any other communications. We reserve the right to update policies, and continued treatment implies acceptance of current policies.  

VII. Legally Binding Electronic Signature Agreement for Stasis Behavioral Health Services

Your electronic signature creates a legally binding agreement between you ("Patient") and Stasis Behavioral Health ("Practice").

• A. Acknowledgement of Receipt, Understanding, and Agreement By electronically signing, you acknowledge: (1) You have received, read, and fully understood this entire "Patient Terms and Conditions of Service" document. (2) You have had ample opportunity to ask questions about any part of this document and received satisfactory answers. (3) You voluntarily agree to all terms, conditions, policies, acknowledgements, and consents contained herein without reservation.  

• B. Consent to All Terms, Conditions, Policies, and Consents Herein Your signature specifically signifies your informed consent and agreement to all sections, including but not limited to: Consent to Treatment (Section III, acknowledging all risks and no guarantees); Financial Policy and Payment Responsibility (Section IV, including cancellation/no-show fees); Notice of Privacy Practices (Section II); Consent for Use of Technology (Section V); and Agreement to all General Policies and Patient Responsibilities (Section VI), including grounds for termination.  

• C. Validity of Electronic Signature (ESIGN Act Compliance) You agree your electronic signature is the legal equivalent of a manual/handwritten signature and constitutes your acceptance of this Agreement, pursuant to the ESIGN Act and applicable state laws. You consent to be legally bound by all terms.  

• D. Limitation of Liability and Hold Harmless You acknowledge the inherent risks associated with psychiatric treatment (medication and psychotherapy) and the limitations of care described herein. You understand there are no guarantees of outcome. To the maximum extent permitted by law, you agree to release and hold harmless Stasis Behavioral Health, its owners, employees, contractors, and providers from any and all claims or liabilities arising from your treatment, except for claims arising directly from gross negligence or willful misconduct by the Practice or its providers. You acknowledge that treatment success depends significantly on your own actions, accuracy of information provided, and adherence to the plan. This does not waive any rights you may have that cannot be waived under applicable law.

• E. Your Right to Request a Paper Copy / Record Retention You may request a paper copy of this signed document. Stasis Behavioral Health will retain an electronic record.  

• F. Voluntary Agreement You affirm that you are signing this agreement voluntarily, free from any duress or undue influence, and that you are competent to understand and agree to its terms.  

By electronically signing, you affirm your understanding, acceptance, and agreement to be legally bound by all terms and conditions set forth in this comprehensive document.

     We hope you have a great experience with Stasis Behavioral Health and we will work with you until we help you find your individual solution. Have an amazing day!

Respectfully,

The Stasis Team