Consent for Treatment Advanced Behavioral Counseling of Northern New Jersey, LLC www.abcnnj.com 55 Newton-Sparta Rd. Suite 103/104, Newton, NJ 07860 (973) 579-9394 NPI 1184878449I. Informed Consent for TreatmentClient Name* Date Of Birth* MM slash DD slash YYYY By typing my name in the above input box, I certify that I am at least 18 years of age, and I consent to the rendering of such evaluation and treatment by: ABCNNJ, LLC located at the above address or virtually via a HIPPA compliant platform (ZOOM or Doxy.me) 1. I understand the office of Advanced Behavioral Counseling, LLC offers both in person and telehealth sessions secondary to the health crisis surrounding COVID 19. 2. I am aware that clinical practice is not an exact science, and I acknowledge that no representations, guarantees or warranties have been made to me as to the result of any evaluation or treatment procedure that I may receive. 3. I understand that ABC, LLC staff consist of licensed psychiatric nurse practitioners and therapists, who work as a treatment team. For comprehensive care, they may at times discuss confidential information with each other and their collaborating psychiatrist, Dr. Sandra Squires, MD. 4. I understand that there may be potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that ABC or I may discontinue the telehealth session if we determine that the videoconferencing connections are not adequate for the situation. 5. I understand that my healthcare information may be shared with other third parties for scheduling and billing purposes, as is the case for in-person sessions. 6. I understand and agree that to preserve confidentiality, I will be in a private room with a closed door without any other individuals present in person or online, unless agreed upon prior to beginning the session. Only my mental health clinician and I will be participating in the session unless we have agreed to have other support persons present. I also understand that the clinician will need to know my location (in the event of an emergency). 7. I understand that if I am using a third-party payor such as health insurance, the plan will be billed and I will be responsible for the contracted rate towards the deductible, co-insurance, and/or co-pay. If I am not able to physically report to the office to present payment, I authorize ABC to charge the credit card on file, and that I can request an invoice for such payment. If I am not utilizing a third-party payor, I agree to pay the fee agreed upon with my clinician. II. Medication Consent Form 8. I agree to be educated regarding the possible side effects of medication and any possible drug and/or food interactions that may occur. (Please check one of the following): _______ I or _______ a person for whom I am the legal guardian and I, consent to the prescribing/administration of this medication. If the person taking this medication becomes pregnant or is breast-feeding, or if my medical condition changes and there are any changes in my medication, I agree to discuss this prior/during treatment. By signing this form, I certify: • That I have read or had this form read and/or explained to me and fully understand its contents. • That I have been given ample opportunity to ask questions and that the questions have been answered to my satisfaction. Client/Parent/Guardian Signature*Date* MM slash DD slash YYYY WitnessDate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.