Psychiatric Informed Consent

Sol Care Clinic — Psychiatric Mental Health Service Line

2802 Grand Fountains Drive, Houston, TX 77054 · NPI #1629797782 (PMHNP-BC) · Texas APRN License #1095300

1. Nature of Psychiatric Services

I voluntarily consent to psychiatric evaluation, diagnosis, treatment planning, medication management, and follow-up care provided by a board-certified Psychiatric Mental Health Nurse Practitioner (PMHNP-BC). Treatment may include prescription medication, supportive counseling, lifestyle and nutritional guidance, and integrated specimen collection for medication-level monitoring.

2. Prescriptive Authority & Controlled Substances

The PMHNP practices under a signed Texas Prescriptive Authority Agreement (PAA) with a delegating physician (Texas Occupations Code Ch. 157) and holds an active DEA registration for controlled-substance prescribing under 21 USC § 829. Controlled medications (such as stimulants for ADHD or scheduled hypnotics) are prescribed only when clinically appropriate, in compliance with the Texas Prescription Monitoring Program (PMP).

3. Risks & Benefits

Psychiatric medications may carry side effects including but not limited to: weight changes, sleep changes, gastrointestinal effects, sexual side effects, mood changes, and in rare cases serotonin syndrome, suicidal ideation (especially in patients under 25), or cardiac/metabolic effects. Benefits commonly include reduction of symptoms, improved functioning, and improved quality of life. The PMHNP will discuss risks specific to any prescribed medication before initiation.

4. Limits of Service — No Emergency Care

ADEYSONS HEALTH does not provide emergency or crisis psychiatric services, 24/7 on-call coverage, inpatient admission, or involuntary commitment evaluations. If you are experiencing thoughts of self-harm, harm to others, or a psychiatric emergency, dial 911, call or text 988 (Suicide & Crisis Lifeline), or proceed to the nearest emergency department.

5. Telehealth Limitations

If your visit is conducted via telehealth, you must be physically located in the State of Texas at the time of the visit (per Texas Occupations Code Ch. 111 and the Texas Medical Board telemedicine rules). Telehealth is not a substitute for emergency care and the provider may require an in-person visit at any point in your care.

6. Integrated Lab Collection

Where clinically indicated (e.g., lithium levels, metabolic panels, thyroid panels, drug levels), blood may be drawn during the same visit by a certified phlebotomist. ADEYSONS HEALTH does not perform diagnostic testing in-house. Specimens are transported under HIPAA chain-of-custody to your physician-designated reference laboratory (Quest Diagnostics, LabCorp, or other).

7. HIPAA & Psychotherapy Notes

I acknowledge receipt of the ADEYSONS HEALTH Notice of Privacy Practices (HIPAA, 45 CFR § 164.520), available at adeysonshealth.com/privacy. I understand that psychotherapy notes receive heightened protection under 45 CFR § 164.508(a)(2) and are not released to insurers, employers, or family members without my separate written authorization.

8. Confidentiality & Mandatory Reporting

Confidentiality is foundational to psychiatric care. However, the PMHNP is required by Texas law to break confidentiality in narrow circumstances: imminent danger to self or others, suspected abuse or neglect of a child or vulnerable adult (Texas Family Code Ch. 261 and Texas Human Resources Code Ch. 48), or in response to a valid court order.

9. Financial Responsibility & Assignment of Benefits

I accept financial responsibility for any service not covered by my insurance carrier and assign benefits payable to ADEYSONS HEALTH LLC. I understand that mental-health benefits may differ from medical benefits and that some plans require pre-authorization.

10. Right to Revoke

I may revoke this consent in writing at any time. Revocation will be effective on receipt and will not affect care already provided. To revoke, email info@adeysonshealth.com.