Informed Consents

Telehealth Consent (NH & MA)

Informed Consent for ADHD Treatment (Adult Patients)

AI Scribe Consent


Telehealth Consent

(NH & MA)

Purpose: This section is an informed consent for receiving psychiatric treatment via telehealth. Telehealth (or telemedicine) means that you will receive care from our psychiatric nurse practitioner using electronic communications (such as live two-way video conferencing), rather than meeting in-person for all appointments. We provide telehealth services to patients located in New Hampshire and Massachusetts in accordance with applicable laws and professional standards. Before beginning telehealth services, it is important you understand the benefits, risks, and your rights regarding telehealth.

Nature of Telehealth: Telehealth involves the use of secure realtime video (and/or audio) communication to enable you and the clinician to see and speak with each other from different locations. At Six States ADHD, we use a HIPAA-compliant Zoom for Healthcare platform integrated through our EHR for all virtual visits. You will be able to attend appointments from a private location of your choice (e.g., your home or office) using a computer or smartphone with camera and microphone. The experience is similar to an in-person session in most ways, except that you and the provider will not be in the same room.

Telehealth Eligibility: You must physically be located in the state of New Hampshire or Massachusetts at the time of the telehealth session, because our provider is licensed only in those states. We will ask you to confirm your current location at the start of each session. If you are traveling or relocate outside of these states, please inform us as this may affect our ability to continue telehealth services or prescribe certain medications across state lines. In such cases, we will discuss alternatives (such as temporary arrangements or referrals).

Potential Benefits of Telehealth

  • Improved Access: Telehealth allows you to receive care without the need to travel to our office. This can be especially beneficial if you live far away, have transportation challenges, or have a busy schedule. It expands access to specialized ADHD care throughout NH and MA.

  • Convenience and Continuity: You can attend sessions from the comfort of your home. Follow-up appointments may be easier to fit into your day, which helps ensure you stay consistent with treatment. Telehealth can facilitate more frequent check-ins if needed, contributing to continuity of care.

  • Flexibility: In circumstances such as bad weather, minor illness, or pandemics, telehealth enables care to continue uninterrupted. It also can accommodate patients who might otherwise miss appointments due to work or family obligations.

  • Patient Comfort: Some individuals feel more at ease speaking about personal issues from their own familiar environment. This comfort can sometimes make it easier to engage in therapy or consultations.

  • Reduced Wait and Efficiency: Without commute times, often appointments can start promptly. You also avoid sitting in a waiting room. In some cases, it may be easier to loop in family members or other participants if needed (with your permission) via teleconference.

Potential Risks and Limitations of Telehealth

While we believe telehealth is a safe and effective way to provide psychiatric services, it does have some limitations and risks to consider:

  • Technology Problems: The quality of the video connection might be affected by internet bandwidth or technical issues. You might experience poor video/audio quality, delays, disconnects, or equipment failures. This could lead to misunderstandings or the need to reschedule or switch to a phone call. We will do our best to troubleshoot issues, but there is a chance a telehealth session could be disrupted or less effective due to technical difficulties.

  • Privacy Concerns: We use a secure platform to protect your privacy; however, privacy on your end depends on your environment. There is a small risk that someone could overhear or see your telehealth session if you are not in a private location. We recommend you choose a quiet, private place for your session and use your own secure internet connection (avoid public Wi-Fi). Additionally, while unlikely, any internet communication could theoretically be intercepted. Our platform’s encryption makes this risk very low, but not absolutely zero. We have taken steps to mitigate this risk in compliance with law.

  • Lack of Physical Presence: In a telehealth visit, the provider cannot perform certain types of exams (for example, checking your blood pressure, doing a physical neurological exam, etc.). We rely on your verbal information and observable cues on video. This limitation means there is a risk something could be missed that might be noted in person (such as subtle physical signs). We mitigate this by requesting you have regular in-person physical exams with a primary care provider, especially if you are on medications that require monitoring (e.g., blood pressure checks for stimulant medication). If during a telehealth session, it becomes apparent that an in-person evaluation or intervention is necessary, the provider will discuss this with you and may recommend an in-person visit or refer you appropriately.

  • Incomplete Data or Miscommunication: Without being in the same room, it might be slightly harder to read certain non-verbal cues or to ensure mutual understanding. There’s a potential for miscommunication or misunderstanding instructions. We will take extra care to speak clearly and confirm your understanding of important points. You are encouraged to ask questions if anything is unclear.

  • Emergency Situations: In the unlikely event that you have an urgent medical or psychiatric issue during a telehealth session (e.g., you faint, or you experience a severe psychological crisis), the provider cannot be there in person to assist. We will have an emergency plan (see below) to handle such situations, but response may be inherently less immediate than if you were on-site.

  • Variability in Effectiveness: Telehealth is effective for many psychiatric services, but it may not be appropriate for all situations or all patients. For example, certain complex assessments or severe psychiatric conditions might require in-person evaluation. If we determine telehealth is not the best option for your particular situation, we will discuss alternative arrangements (such as in-person visits or referral to a provider who can see you in person).

Patient Rights and Responsibilities in Telehealth

Your Rights: When receiving telehealth services from us, you maintain several important rights:

  • Right to Refuse Telehealth: You have the right to decline receiving services via telehealth at any time. Telehealth is voluntary. If you do not want to use telehealth, or if you want to stop telehealth and resume in-person care (or end treatment), you are free to do so. Your decision will not affect your right to future care, though we may need to discuss alternatives (for instance, if you cannot come to our office and do not want telehealth, we might refer you to a closer provider). Be aware that refusing telehealth might mean delaying or not receiving certain services if in-person is not available, but that choice remains yours.

  • Identification of Provider and Credentials: You have the right to know the identity and credentials of the healthcare provider on the video session. Our telehealth visits will be with a licensed Psychiatric Mental Health Nurse Practitioner (PMHNP) in either NH or MA. We will introduce ourselves and confirm our location (city and state) at the start of the session, so you know where we are practicing from. Typically, our provider will be in a private office or similar setting in one of those states.

  • Equality of Care: You have the right to receive care via telehealth that meets the same standard as in-person care. Telehealth services provided will conform to the standard of care for our profession just as if this were an in-person appointment. We will devote our full attention during the appointment and ensure you have time to ask questions, just like during an office visit.

  • Privacy and Confidentiality: Your rights to privacy extend to telehealth. Sessions are private and not observed by anyone on our side who isn’t disclosed to you. You have the right to be informed of all persons present at our end during the telehealth encounter (e.g., if a nurse or trainee were present, though in our case we generally do not have others present without asking you). We will also confirm that no one else is listening in on the call on our side. If you ever suspect an unwanted intrusion, please inform us immediately. You likewise have the right to privacy on your end; if you want a family member present or to sit in, that is your choice, and we ask you inform us who else is in the room on your side.

  • Language and Communication: If you have language preferences or hearing/vision needs, you have the right to request accommodations. We will provide culturally and linguistically appropriate services, including interpretation if you are not fluent in English (with advance notice, we can arrange a medical interpreter or accommodate ASL interpretation). Let us know if you require translation services or any aid to communicate comfortably.

  • Emergency Care: You have the right to be referred to in-person care (including emergency services) when needed. If during a telehealth session a situation arises that requires immediate in-person assessment (for example, a severe reaction or suicidal crisis), the provider will advise and assist in getting you appropriate emergency help (such as calling 911 or directing you to the nearest hospital). We will never simply disconnect if you are in crisis; we will engage emergency protocols as needed. (See Emergency Plan below.)

  • Option for In-Person Visits: Where feasible, you have the option to request an in-person appointment instead of telehealth. Our practice offers both in-person and telehealth services (subject to scheduling and location availability). If you prefer an office visit for any reason (or for certain types of appointments), please let us know and we will accommodate if possible. In some cases (such as exclusively virtual clinics or if distance is too great), in-person might not be practical, in which case we can discuss referral or other arrangements.

  • Right to Withdraw Consent: Even after consenting to telehealth, you retain the right to change your mind. You can withdraw your consent to telehealth either verbally during a session or by informing us in writing (e.g., email) at any time. There is no penalty for withdrawing consent. We will then discuss alternative plans for continuing your care, which may involve scheduling in-person visits if you are able to come to our office, or assisting you in finding local services if you are no longer within our reach in-person. (Do note that if you withdraw consent for telehealth and cannot do in-person, it might necessitate discontinuing services with us and referral to another provider.) Your health and preferences will guide our next steps.

Your Responsibilities: To ensure that telehealth sessions are effective and secure, patients have certain responsibilities as well:

  • Equipment and Environment: You are responsible for having the necessary equipment (smartphone, tablet, or computer with camera and microphone) and a reliable internet connection for sessions. Test your device before the appointment if possible. Try to be in a quiet, private location with minimal disruptions. Use a secure network and, if others are around, consider using headphones and sitting where your screen isn’t visible to others. This will help maintain your confidentiality.

  • Timeliness: Please log in to the telehealth session a few minutes before the scheduled time. If you encounter issues logging on, notify us as soon as possible. If you will be late or need to reschedule, treat it as you would an in-person appointment and inform us. Our standard policies on no-shows or late cancellations apply equally to telehealth visits.

  • Providing Accurate Information: During telehealth sessions, please communicate as clearly and thoroughly as you can about your symptoms, medication effects, or any changes in your health. Because we cannot measure things like blood pressure or weight in person, we might ask you to provide recent vital signs from another provider or self-report if you have home devices. We rely on you to report truthfully and accurately to the best of your ability.

  • Safety Planning: You must inform the provider of your current physical address at the start of each telehealth session. This is so that in the event of an emergency, we can dispatch help to the correct location. Also, please provide a phone number and an emergency contact person we can reach if needed (in case of technical failure or crisis). If your location changes mid-session (for example, you leave home), let us know. Keeping your contact and emergency information updated is your responsibility.

  • Follow-Up Care: Understand that telehealth is just one mode of care. You agree to follow our recommendations for follow-up, whether that means scheduling your next telehealth visit or obtaining lab tests or seeing your primary care doctor in person for complementary care. If we advise that you seek urgent or emergency in-person care (for example, go to an ER), you agree to take that advice seriously for your own safety.

  • Technology Familiarity: You don’t have to be a tech expert, but try to familiarize yourself with the basic use of the telehealth platform. We will send instructions for connecting to Zoom. If you need help, ask ahead of time. By starting the telehealth, you are acknowledging that you are comfortable proceeding in this format. If you struggle with the technology, we can explore alternatives (like a regular phone call, although purely telephone sessions have more limitations and may not be covered by insurance in some cases).

Confidentiality in Telehealth

We have explained in our Privacy Policy how we protect your information. Here we reiterate key privacy measures specifically for telehealth:

  • The session is conducted on Zoom for Healthcare which is encrypted and HIPAA-compliant. Only you and the provider (and any explicitly invited participants) are in the virtual meeting room.

  • We will not record the session without your permission, as stated. We also request that you do not record the session without informing us. If you wish to record for personal use, you must discuss this with the provider and obtain consent.

  • All rules of confidentiality that apply to in-person medical services apply to telehealth. We will document the session in your medical record just as we would an office visit. That record is protected by our usual privacy safeguards.

  • If you are using the patient portal or email to send any information before/after the session, use the secure portal whenever possible for PHI. Standard email or text messages are not fully secure. If you choose to communicate via standard email or text for convenience, we may ask you to acknowledge the privacy risk.

  • Be mindful of your own environment: having someone unexpectedly walk in or hearing what you say could compromise your confidentiality. You have the right to pause or request to reschedule if your privacy cannot be ensured at your location.

Emergency Plan for Telehealth

We take your safety seriously. Before beginning telehealth services, we will establish an emergency plan with you. This includes:

  • Your Location and Emergency Contact: As noted, at each telehealth session we will verify your physical address and have on file an emergency contact (someone we can reach, such as a family member or friend, in case an emergency arises). By proceeding with telehealth, you agree to provide this information and permit us to contact emergency services or that person if we deem it necessary for your safety.

  • If a Crisis Occurs During a Session: For example, if you experience a severe panic attack, express suicidal intent, or have a medical collapse during the call, the provider may attempt to keep you on the video while simultaneously contacting local emergency responders to send help to your location. If you disconnect and we are concerned for your safety, we will use the information we have to call 911 on your behalf and/or contact your emergency contact. We will do our best to notify you of this action and the reasons for it.

  • If Technology Fails: If the video call drops and we cannot reconnect, we will attempt to reach you via phone. Please ensure we have a correct phone number. If we cannot reach you and we have concern for your wellbeing (for instance, you were in the middle of discussing something critical), we may reach out to your emergency contact or call emergency services to do a wellness check. If there were no known safety concerns at that moment, we will simply wait for you to reconnect or contact you to reschedule.

  • After-Hours Emergencies: Telehealth is not designed for emergency care. If you are between sessions and experience a psychiatric emergency (for example, you have thoughts of harming yourself or others that you feel you might act on), do not wait for a telehealth appointment. Instead, call 911 or go to the nearest emergency room for immediate help. You can also call crisis hotlines such as 988 (the Suicide & Crisis Lifeline in the U.S.). Once you are safe, you or the hospital can notify us of what occurred. We will also provide guidance on who to contact (e.g., local crisis lines) as part of your safety planning.

  • Local Backup Plan: If you know that you live far from emergency services (e.g., rural area) or have particular medical conditions, we might ask if there’s someone near you who can be on standby during high-risk discussions or if we should schedule telehealth at times when another support person is present at your home (only if you’re comfortable) as an extra precaution.

By signing this Telehealth Consent (or otherwise agreeing to telehealth services), you acknowledge that you understand the above emergency plan and your role in it (providing accurate info, following emergency instructions, etc.).

Billing and Insurance for Telehealth

Telehealth services at our practice are billed similarly to in-person services. In both Massachusetts and New Hampshire, telehealth parity laws generally require insurance to cover telehealth for behavioral health as they would in-person visits. You are responsible for any copayments, coinsurance, or deductibles as determined by your insurer, just as with office visits. We recommend confirming with your insurance that tele-mental health sessions are covered. If you are private pay, our session fees for telehealth are the same as in-person.

If your insurance for some reason does not cover a telehealth session (for example, if you had a policy that opted out of telehealth coverage), you would be responsible for the session fee. We will help inform you of any coverage issues we are aware of. Additionally, if an in-person service (like a certain procedure) cannot be done via telehealth, we will let you know and possibly have you come in-person or schedule that service elsewhere.

There is no charge for the telehealth technology usage itself on your end (the Zoom link we provide is free for you to use; any cost is part of our practice overhead). However, you are responsible for any internet or data charges from your own provider for connecting.

Consent to Telehealth Services

By agreeing to engage in telehealth appointments with Six States ADHD, you confirm that:

  • You have been informed about how telehealth works, its potential benefits, and limitations. All your questions have been addressed to your satisfaction.

  • You understand that you have the right to refuse or discontinue telehealth services at any time without losing your right to future care or facing penalty.

  • You agree to the conditions and patient responsibilities outlined above (regarding technology, privacy, emergency planning, etc.).

  • You authorize the transmission of your information electronically for the purpose of your treatment, and consent to our documentation of telehealth sessions in your medical record.

  • You understand that no guarantees have been made about the results of treatment via telehealth; however, you understand the provider will follow standards of care.

  • If you have any concerns about telehealth, you will voice them with your provider to seek solutions or alternatives.

Typically, we will ask you to sign a separate Telehealth Informed Consent form (electronically or on paper) prior to your first telehealth appointment. This webpage copy serves as the detailed information about that consent. If you agree to these terms and proceed with scheduling a telehealth visit, it indicates your consent.

Please retain a copy of this Telehealth Consent information for your records. We are happy to provide you a printed or electronic copy on request.

Informed Consent for ADHD Treatment (Adult Patients)

Introduction: This section outlines the informed consent for psychiatric evaluation and treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in adults at Six States ADHD. The purpose is to ensure you understand the nature of the proposed treatment, including potential benefits, risks, and alternative options, so that you can make an informed decision about your care. ADHD can affect many aspects of life (attention, impulse control, organization, etc.), but effective treatments are available. Please read the following information carefully and ask any questions before agreeing to treatment.

Diagnosis and Assessment: Before initiating treatment, a thorough psychiatric evaluation will be conducted to confirm the diagnosis of Adult ADHD and assess your overall mental health. This typically includes a detailed personal and medical history, symptom questionnaires or rating scales, and possibly input from family or past records. It’s important to be open and accurate during this assessment. Sometimes ADHD symptoms overlap with or are influenced by other conditions (such as anxiety, depression, bipolar disorder, or substance use disorders). We will evaluate for these as well, since a correct diagnosis is crucial for effective treatment. If you are diagnosed with ADHD (with or without co-occurring conditions), we will discuss a tailored treatment plan for you.

Treatment Plan Overview: ADHD treatment often involves a combination of approaches. The main evidence-based options for adults include medication and behavioral therapies, often together for best results. We will work with you to develop a plan that may include:

  • Medication Therapy: For many adults, prescription medication significantly reduces ADHD symptoms. Stimulant medications are considered first-line treatment for ADHD and have a high success rate in improving focus, concentration, and impulse control. Non-stimulant medications are also available and can be effective for some patients, particularly those who do not tolerate or prefer not to use stimulants.

  • Psychotherapy or Coaching: This might include cognitive-behavioral therapy (CBT) targeted at ADHD, ADHD coaching, or other counseling to build skills in organization, time management, and coping strategies. Medication combined with therapy is often the most effective approach, as therapy can help you develop long-term strategies to manage ADHD and address any related emotional or behavioral issues.

  • Education and Lifestyle Adjustments: We will provide education about ADHD, and may recommend certain lifestyle changes or supports (for example: regular exercise, good sleep hygiene, dietary considerations, use of planners or apps to structure your day, etc.). If appropriate, involving family or partners in education can help them support you better. We might also refer you to resources like adult ADHD support groups or reading materials.

  • Treatment of Co-existing Conditions: If you have other mental health conditions (e.g., depression or anxiety often co-occur with adult ADHD), the treatment plan will also address those, either through therapy, additional medications, or referrals to specialists as needed. Treating these can be an important part of effectively managing ADHD.

We will discuss with you which approach(es) we recommend in your case, and the reasons why, as well as get your input on preferences (for example, whether you are open to medication, or which therapy goals you have). Your involvement in goal-setting is important. Together, we will periodically review your treatment plan and progress, and adjustments will be made based on effectiveness and any side effects or new issues.

Medication for ADHD

If medication is part of your ADHD treatment, please review the following important information about ADHD medications:

1. Stimulant Medications: Stimulants are a class of medications commonly used to treat ADHD. They include medications based on methylphenidate (e.g., Ritalin, Concerta) and amphetamine (e.g., Adderall, Vyvanse) compounds. These medications have been extensively studied and are considered first-line treatment for ADHD in adults due to their effectiveness at reducing core ADHD symptoms. Potential benefits of stimulants include improved attention span, increased focus and concentration, better impulse control, and often improved productivity and organizational ability. Many patients experience significant improvement in daily functioning on the right dose of stimulant medication.

However, stimulant medications also come with potential risks and side effects which you need to be aware of:

  • Common Side Effects: These can include insomnia or difficulty sleeping, decreased appetite or weight loss, dry mouth, headaches, or stomach upset. Some people experience jitteriness, mild increases in anxiety, or irritability, especially as the medication wears off. These side effects are often manageable by dose adjustments or timing of doses (for example, taking the medication earlier in the day to minimize sleep issues).

  • Cardiovascular Effects: Stimulants can cause increases in blood pressure and heart rate. For most healthy adults this is minor, but if you have underlying heart conditions, high blood pressure, or other risk factors, stimulant use could potentially pose a cardiovascular risk. Rarely, stimulants have been associated with more serious cardiac events in those with heart problems. We require that you inform us of any personal or family history of heart disease, arrhythmias, or fainting episodes. We may request you get a physical exam or EKG from your primary care provider before starting a stimulant if there are any cardiac risk factors. During treatment, we might periodically check your blood pressure and pulse. If you experience chest pain, shortness of breath, or fainting while on these medications, seek medical attention and notify us immediately.

  • Risk of Misuse and Dependence: Stimulant medications are classified as Schedule II controlled substances due to their potential for misuse and addiction. This means they are tightly regulated by law. There is a risk for psychological dependence and addiction if these medications are not used as prescribed. Some individuals without ADHD might abuse these medications for their energizing effects or other reasons. As an ADHD patient properly prescribed stimulants, studies indicate that you are less likely to develop a substance use disorder compared to untreated ADHD patients, provided you take the medication exactly as directed. Nonetheless, it is crucial to:

    • Take the medication only as prescribed. Do not change your dose or frequency without consulting us.

    • Do not share your medication with anyone else, never sell or give away your pills. Not only is that illegal, but it could harm someone for whom it was not prescribed.

    • Store your medication in a safe place, preferably locked or out of reach of others (especially children or anyone with a history of substance abuse). This is to prevent accidental or intentional misuse by others. If your medication is ever lost or stolen, we need to know. Note: Lost or stolen stimulant prescriptions may not be refilled early or replaced – you’d have to wait until the next scheduled refill due to strict controlled substance laws.

    • We may ask you to sign a separate stimulant medication contract acknowledging these rules, given the controlled nature of these drugs.

  • Potential for Tolerance: Some patients worry about “needing more medication over time.” While some tolerance (your body getting used to the medication) can occur, we mitigate this by using the lowest effective dose. If tolerance does develop, we may adjust your dose within safe limits or consider drug holidays (brief breaks from medication on non-critical days) as appropriate. However, do not stop or start “drug holidays” on your own; always discuss with the provider first. Sudden cessation can lead to withdrawal fatigue or mood changes in some cases.

  • Psychiatric Side Effects: Stimulants in some individuals might worsen anxiety, or occasionally trigger mood swings. Rarely, in predisposed individuals, they can contribute to symptoms like psychosis (hallucinations) or mania (if one has bipolar disorder that isn’t well controlled). These effects are not common at standard doses, but it’s important to report any unusual mental symptoms to us. We will screen for personal or family history of bipolar or psychosis to gauge this risk. If such symptoms occur, we would discontinue or adjust the medication immediately.

  • Other Possible Effects: You might notice minor growth in blood pressure or pulse as mentioned, or sometimes tics (involuntary movements or sounds) can emerge or worsen in susceptible individuals. Stimulants can also sometimes cause sexual side effects (like erectile issues) in some men, or slight anxiety or restlessness. Many side effects are dose-dependent and can be managed.

We will start at a low dose and titrate (adjust) the dose gradually to find the optimal balance of benefit and side effects. We will also monitor you, especially early in treatment and during dose changes. Regular follow-up appointments are required while you are on stimulants – typically more frequent (every 2-4 weeks) during initial titration, then at least every three months (and as mandated by law, you must have a visit at least once every few months for refills). Our policy is generally that you must be seen (virtually or in person) at least once every 3 months to continue receiving stimulant prescriptions, and more often if clinically indicated. We may also periodically check a state prescription monitoring program database for safety, to ensure no overlapping prescriptions from other providers (this is required by law in both NH and MA).

2. Non-Stimulant Medications: Non-stimulant options for ADHD include medications like Atomoxetine (Strattera), certain antidepressants (like bupropion), and alpha-2 agonists (like guanfacine or clonidine, often used off-label for adult ADHD). We might recommend a non-stimulant if stimulants are not effective for you, if you have undesirable side effects, have a history or risk of substance misuse, or simply prefer not to take stimulants. Non-stimulants can be very helpful for some patients, though they may take longer to work (several weeks to notice effect) and generally have a more modest effect size on symptoms compared to stimulants.

Non-stimulants have their own side effect profiles:

  • Atomoxetine can cause drowsiness, dry mouth, reduced appetite, or sometimes dizziness. It can also potentially affect blood pressure or mood in some cases. It carries a warning about suicidal thoughts in young people (mostly under 25) similar to antidepressants.

  • Bupropion (if used) can help both ADHD and depression, but may cause insomnia, jitteriness, or risk of seizures in those predisposed (we’d avoid it if you have seizure history).

  • Guanfacine/clonidine can cause sedation or low blood pressure; we often give those if there’s significant hyperactivity or impulse issues, or as an add-on, but less commonly as sole treatment in adults.

We will discuss the specific medication’s side effects with you if we go this route. Generally, non-stimulants are not controlled substances, so some of the restrictions on refills are less; however, they still require monitoring and follow-up.

3. Medication Management and Monitoring: When on any ADHD medication:

  • You agree to take the medication exactly as prescribed. Do not adjust the dose on your own. If you feel it’s not enough or too much, discuss it with us.

  • Do not abruptly stop certain medications without guidance (especially if on a high dose stimulant or certain antidepressants, which could cause withdrawal symptoms). We will guide any tapering process.

  • Inform us of all other medications or supplements you are taking (to avoid drug interactions). In particular, combining stimulants with some other stimulants or certain antidepressants can increase risk of side effects. Also avoid taking over-the-counter stimulants (like decongestant cold medicines or excessive caffeine) without checking, as those might compound effects.

  • Avoid illicit drugs and limit alcohol while on ADHD medication. Using stimulants with illicit stimulants (like cocaine or methamphetamine) or even high doses of caffeine or some workout supplements can be dangerous. Alcohol in moderation may be okay (discuss with provider), but excessive alcohol can worsen ADHD and is not advised, and combining with stimulants can strain your cardiovascular system. Especially, do not use sedatives or opioids in combination with stimulants without explicit guidance, as this can be risky.

  • If you are a woman of childbearing age, inform us if you plan to become pregnant or if you become pregnant. The safety of stimulant medication in pregnancy is not fully established; decisions will need to be made about continuing or adjusting treatment. Generally, we try to minimize any medication exposure in the first trimester if possible. We can discuss risks vs benefits in such an event.

  • Store medication securely (repeating because it’s very important). We recommend a lock box if you live with others or have children in the home.

  • Expect that we may request periodic urine drug screens or other monitoring, particularly if on controlled medications. This is a standard practice (“universal precautions”) to ensure medications are being taken as prescribed and not misused. It’s not about suspicion; we do this with many patients on controlled medications. By consenting to treatment, you agree to comply with toxicology screenings if asked. Typically, if requested, it might be once a year or randomly, and we would either have you do a urine test at a lab or during a visit.

  • We also check the Prescription Drug Monitoring Program (PDMP) in your state before prescribing and during treatment, to track controlled substance prescriptions. This is required by law and helps prevent duplicate controlled prescriptions. You consent to our review of your prescription history in this database as part of safely managing your care.

4. Expectations of Treatment and Compliance: We expect that:

  • You will attend follow-up appointments as recommended for medication monitoring. If you consistently miss appointments, we may not be able to continue prescribing for safety reasons. If you miss an appointment, we may not refill your medication until we see you next. This is to ensure proper monitoring.

  • You will communicate any side effects or concerns promptly. Don’t suffer in silence or stop the med on your own – call or message us so we can adjust.

  • You will also let us know if you feel the medication isn’t working well, or if your symptoms return/worsen, so we can tweak the plan.

  • If at any point you desire to stop medication, you agree to discuss it with us so we can do it safely and come up with an alternative plan (maybe focusing on therapy alone or other strategies). It’s absolutely your right to stop a treatment, but doing so collaboratively is safer.

Psychotherapy and Behavioral Interventions

As part of comprehensive ADHD care, we may recommend psychotherapy or ADHD coaching:

  • Cognitive Behavioral Therapy (CBT) for ADHD: This is a structured therapy that helps you develop skills to manage time, organize tasks, reduce procrastination, and challenge negative thoughts about your productivity or self-esteem. It can be very useful alongside medication. If we provide therapy in our practice or refer you to a therapist, you should know therapy is a collaborative process and progress can take time and effort from both parties (like homework assignments to practice skills between sessions).

  • Counseling for Co-morbid issues: If anxiety, depression, or other issues are present, therapy might focus on those as well.

  • ADHD Coaching: Different from therapy, coaching is more practical, focusing on day-to-day functioning (like creating schedules or systems for organization). We can refer to certified ADHD coaches if appropriate.

  • Group Therapy or Support: Sometimes group sessions or support groups for adults with ADHD can provide motivation, tips, and a sense of community. We can help connect you to these resources in the community or online if you’re interested.

Therapy and behavioral strategies have no medical side effects, but their "risks" might include feeling emotional when confronting challenges or investing time and effort for gradual improvement. The benefit is empowering you with skills that last a lifetime. You are free to participate or not in therapy recommendations, but we highly encourage engaging in some form of skills training or counseling, as research shows combined treatment is most effective.

Risks of Not Treating ADHD

It is also important to understand that choosing not to treat ADHD (either via medication or therapy) has potential risks. Untreated adult ADHD can contribute to difficulties in employment, higher likelihood of job changes or underachievement, struggles in academic pursuits, problems in relationships due to forgetfulness or impulsivity, and even an increased risk of accidents (for example, traffic accidents due to inattention). Many individuals with unaddressed ADHD may also be more prone to developing substance use problems, as they might self-medicate with drugs or alcohol. While treatment is a personal choice, being informed of these considerations is part of consent. We will respect whatever choice you make regarding treatment, and we can discuss strategies to manage ADHD symptoms even if you opt against medication or formal therapy (such as self-help strategies or workplace accommodations).

Alternative Treatment Options

Aside from the treatment modalities described (medication and therapy), you should be aware of alternative or adjunct approaches:

  • No medication (Therapy-Only or Coaching-Only): You may choose to try managing ADHD with behavioral strategies alone. This avoids any medication side effects. Many people can improve with structure, organizational tools, exercise, and therapy. The downside is it may not be as immediately effective on core symptoms for some individuals, and progress might be slower. This is a viable option, especially if your ADHD symptoms are mild or you strongly prefer to avoid medication.

  • Other Medical Treatments: There are some newer technologies (like neurofeedback or cognitive training programs, and in some cases brain stimulation techniques) touted for ADHD. Some patients explore neurofeedback, which attempts to train brainwave patterns. The evidence on these is still emerging; some find it helpful, others not as much. It’s generally safe if done by a reputable provider, but it can be time-consuming and costly and is not universally accepted as effective. We can discuss any specific alternative treatments you’re curious about. Supplements (like omega-3 fatty acids, certain vitamins) have been studied – they are generally low-risk but might have modest benefit at best.

  • Primary Care Management: Some patients may choose to have their primary care physician manage their ADHD meds instead of a psychiatrist/NP. Primary care can handle straightforward cases, though they might have less time for therapy or detailed management. If you ever prefer that route, let us know – we can collaborate with your primary provider or transition care.

  • Doing nothing: This is technically an alternative – choosing not to pursue formal treatment. We do not recommend simply doing nothing if ADHD is significantly impairing you, but that is your right. If you decline all treatment, we would document that you are aware of possible consequences and leave the door open for you to start treatment in the future if you wish.

Expected Benefits and Prognosis

With proper treatment, many adults with ADHD experience significant improvement in their ability to focus, organize, and regulate impulses. This can lead to better performance at work or school, improved self-esteem, and smoother relationships. Medications like stimulants have high response rates (a large percentage of patients see noticeable improvement). Behavioral strategies can further help you create lasting habits and structures to manage ADHD. Our goal is not just symptom reduction, but also helping you thrive with any coping skills needed.

It’s important to set realistic expectations: treatment helps manage ADHD, but it is not a “cure.” You should expect improvement, not perfection. ADHD is often a lifelong condition; however, with strategies and possibly medication, you can achieve success in your personal and professional life. We will also track other aspects like mood or anxiety, as improvement in ADHD symptoms can sometimes positively affect those as well (or vice versa).

Potential Risks and Side Effects of Treatment

We have covered medication side effects above. To summarize the key risks involved in ADHD treatment itself:

  • Medication side effects (some potentially serious, as discussed, but we will monitor closely).

  • The risk of stimulant misuse/dependence if not carefully managed (mitigated by our monitoring and your adherence).

  • Psychosocial risks: sometimes individuals feel labeled by a diagnosis of ADHD or struggle with self-esteem. We are here to support you through that and emphasize ADHD is a common, treatable condition – it does not reflect on your intelligence or character.

  • Therapy risks: occasionally discussing personal challenges can bring up emotional discomfort. This is usually temporary and part of the therapeutic process, but you should communicate with your therapist if something feels overwhelming.

  • Financial considerations: treatment may involve costs (copays for visits or meds, costs of therapy sessions if not fully covered by insurance, etc.). We can try to work within what’s feasible for you (for example, seeing you at medically appropriate intervals to minimize visits, prescribing generics when possible, etc.).

  • Inconvenience: managing ADHD might require regular appointments, structuring your day to remember meds or therapy homework, and other commitments of time.

We want you to be aware of these aspects, but none of these risks are unusual or unmanageable with proper care.

Patient Responsibilities & Agreements

To ensure the best outcomes, the patient (you) also has responsibilities in this treatment partnership:

  • Honest Communication: Be open about your symptoms, medication effects, and any difficulties adhering to the plan. If you feel something isn’t working, or if you’re experiencing bothersome side effects, tell us. Also, be truthful about things like substance use or if you haven’t been taking medication as prescribed – we need accurate information to help you safely.

  • Follow the Prescription and Plan: As emphasized, take medications only as directed. Attend your appointments. Implement behavioral recommendations as you are able (e.g., using a planner, trying out therapy exercises). The more you invest in the process, the better the likely outcome.

  • Safety Measures: Do not drive or operate heavy machinery if you feel impaired by medication (though stimulants usually improve attention, some people might feel jittery or have vision changes initially – gauge how you react first). Avoid any contraindicated substances. Keep your medication safe.

  • Medical Follow-ups: Keep your primary care provider in the loop that you are on ADHD medication, so they can also monitor general health parameters (like blood pressure at your annual physical). We may ask for collaboration with your PCP for things like baseline EKG or blood tests if needed.

  • No Diversion Contract: You agree not to divert (share/sell) medication and understand that doing so will result in termination of controlled prescriptions and potential reporting as required by law. We have a zero-tolerance policy for misuse of prescribed controlled substances.

  • Evaluation of Progress: Periodically, we will re-evaluate whether the treatment is meeting your goals. We might use rating scales or simply discuss how you’re doing in various life areas. Your responsibility is to engage in these evaluations honestly. If objectives are not being met, we may change the strategy.

  • Emergencies: If you experience severe side effects (e.g., chest pain, severe allergic reaction, suicidal thoughts that concern you), you will seek emergency help promptly. Also, if you ever feel urges to misuse medication or struggle with dependency, inform us so we can help – for example, if you find yourself wanting to take extra doses, that’s important to discuss.

Confidentiality and Release of Information

Your treatment is confidential as per HIPAA and privacy laws. We will not release information about your ADHD diagnosis or treatment to your employer, family, or anyone else without your written permission, except as required by law (e.g., court order or imminent safety risk situation). If you want us to coordinate with someone (like a therapist, or your primary care doctor, or a family member), you can sign a release allowing that communication. Some patients find it helpful for a spouse or parent to be involved in their care for support – that is entirely your choice and can be discussed.

One exception: If you are using insurance, insurance claims will have basic info such as diagnosis and services rendered, and they are subject to privacy protections on the insurer’s side.

Right to Withdraw Consent or to Refuse Treatment

Your participation in ADHD treatment is voluntary. You have the right to refuse any specific treatment or stop treatment entirely at any time. For example, you might decide you don’t want to take medication – that is your right. We might strongly recommend a certain treatment, but we cannot and will not force you. If you do refuse a key component (like medication), we will continue to support you with other available treatments if you wish, or refer you to another resource if appropriate.

If you decide to discontinue treatment with our practice altogether, we will respect your decision. Ideally, we ask that you discuss it with us so we can wrap up responsibly: for instance, if you have remaining medication, we might give you a plan to taper it safely, or provide you with referrals for follow-up should you need care later. If you move to another provider, with your authorization, we can share records to ensure continuity.

Please note: If at any point you withdraw consent for treatment but you are currently on a medication that could be unsafe to stop abruptly, we may ask to continue seeing you just long enough to safely discontinue the medication. Alternatively, if you refuse but do not attend a follow-up, you are at risk of withdrawal or untreated symptoms – that responsibility would fall to you if you cannot be reached. We will attempt to contact you in such scenarios, but ultimately it is your right to disengage.

Our practice also reserves the right to terminate treatment if certain boundaries are violated (for example, if you repeatedly do not follow safety agreements, if there is diversion of meds, if appointments are continually not followed, or if you behave inappropriately toward staff). We would generally give you notice and referrals if that were to happen, per our termination policy.

Questions and Consent

You have the opportunity to ask any questions about ADHD, its treatment, and this consent form. We want to ensure you feel fully informed. Some common questions include:

  • How long will I need to be on medication? (Answer: it varies; some use it long-term, others for a few years. We will periodically reassess the need. Some patients take “breaks” in certain life periods; it’s individualized.)

  • What if I decide to stop medication and then my symptoms worsen? (You can always resume treatment; we would work with you on that. Stopping is not permanent if you change your mind.)

  • Can I try medication for a while without therapy, or vice versa? (Yes, we can tailor to what you’re open to, though we’ll advise what we think is ideal.)

  • Will this go on my permanent record or affect anything like my job or driving license? (Your medical record is private. ADHD treatment itself typically does not affect your driver’s license unless you had severe uncontrolled symptoms causing accidents, which is rare. Some licensing applications or job roles might ask if you have any condition that affects performance – if you’re concerned, we can discuss how to navigate that, but generally if treated, ADHD shouldn’t impede most jobs.)

After discussing and having all questions answered, you will be asked to give your consent to proceed with the treatment plan. By giving consent, you acknowledge that you understand the information provided to you, and that you agree to actively participate in your ADHD treatment under these terms.

Consent: I have read and understood the above information about the evaluation and treatment of Adult ADHD, including the potential benefits, risks, side effects, and my own responsibilities. All my questions have been addressed. I willingly give my consent to receive psychiatric treatment for ADHD with Six States ADHD (Six States Wellness PLLC). I understand I can withdraw consent at any time.

AI Scribe Consent (Use of JotPsych by SmartScribe)

Purpose: Six States ADHD aims to provide you with attentive and personalized care. In order to help our clinician focus on you during sessions (instead of busy note-taking), we utilize an AI-powered scribe technology called JotPsych (developed by SmartScribe Corp.) to assist in creating clinical documentation. This section explains what JotPsych is, how it will be used in your care, what data it handles, and to obtain your consent for its use during your sessions. Your participation is voluntary, and you may opt out if you have concerns.

What is JotPsych?

JotPsych by SmartScribe is a secure technology tool that listens to the conversation during medical appointments and generates draft clinical notes from that dialogue. Think of it as a highly advanced note-taking assistant. It uses speech-to-text and artificial intelligence to summarize the important details of our conversation (such as symptoms you describe, medications discussed, treatment plans, etc.). The primary goal of JotPsych is to allow the provider to give you full attention without constantly typing, while still producing accurate and timely documentation of the visit. This can improve the quality of our interaction, as the provider can maintain better eye contact and listen more actively, knowing that note details are being captured in the background.

JotPsych runs on a secure device/application that will be present (typically a smartphone or computer in the office) which picks up the “ambient conversation” in the room (or over telehealth) and transcribes it in real time. The provider will later review the AI-generated note for accuracy, edit it as needed, and then save it to your official medical record. JotPsych may also assist by highlighting key points or suggesting sections for the note, which the clinician verifies.

How Your Data Will Be Used with JotPsych

If you consent to the use of JotPsych during your sessions, here is how the information is handled and used:

  • Documentation of the Visit: The audio of our conversation is processed by the JotPsych system to create a text draft of the clinical note. Important details like your symptoms, concerns, diagnosis, and treatment plan are transcribed. This draft is then used by the provider to complete the official visit documentation. The resulting note (after the provider’s review) becomes part of your medical record, just as a typed note would. The AI’s role is supportive; the provider remains responsible for the content and accuracy of your chart. No final documentation goes into your record without clinician approval.

  • Quality Improvement and Training: The data captured may be utilized by SmartScribe Corp (the company behind JotPsych) to improve their service. This could include quality assurance processes such as algorithm training or accuracy checks. Importantly, any use of data for these purposes is done in compliance with privacy laws – typically data is aggregated or de-identified when used to improve the AI, meaning they are not focusing on your individual identity, but rather patterns across many conversations to refine the technology. Our clinic may also review how the AI is performing as part of quality improvement for our documentation workflow, but again your privacy is maintained.

  • Compliance with Privacy Laws: SmartScribe Corp. and our practice will comply with all applicable federal, state, and local laws regarding the privacy and security of your information, including HIPAA. This means the audio and transcripts are protected with encryption and treated as Protected Health Information. SmartScribe acts as a Business Associate to our practice, bound by a contract to protect your data. The information from the AI is not made public or shared outside of the purposes stated (documentation and quality improvement) unless required by law or you authorize it.

  • Storage of Audio/Text: You might wonder, does the system keep a recording of our session? According to SmartScribe, they handle data with utmost care. Typically, the audio is processed in real-time to text. The text draft is saved for the provider to review. SmartScribe’s policies (see below) indicate that data is stored securely. We will treat the transcript as part of your medical record under HIPAA. We do not separately keep audio recordings of sessions beyond what the AI uses in the moment (unless a recording is specifically made for some reason, which is not our standard practice). Any data stored by SmartScribe is safeguarded and only accessible to authorized persons (like your provider or the SmartScribe system for processing).

What JotPsych/SmartScribe Will NOT Do

  • No Guarantee of Outcomes: While JotPsych aims to improve documentation efficiency, SmartScribe Corp. does not guarantee that using this technology will improve medical outcomes or lead to faster diagnosis or any specific benefit to you. In other words, it’s a tool for note-taking convenience; your care quality will continue to depend on the clinician’s expertise and your collaboration. You should not expect, for example, that the AI will catch something the provider might miss or that it adds any diagnostic capability. It is not a decision-making AI, it’s a documentation aid.

  • No Decision Making or Advice: JotPsych will not be giving medical advice, making decisions, or speaking to you. You might not even notice it during sessions beyond perhaps seeing a device that’s enabled for it. All treatment decisions will still be made by your human provider. The AI does not replace any part of the therapeutic interaction; it operates in the background.

  • No External Use of Raw Data: SmartScribe will not sell your personal data or use it for advertising. They will not contact you directly. The content of your sessions is not used outside of the context of providing this service, except potentially in an anonymized way for improving the algorithm as mentioned. Also, our clinic will not use the AI transcripts for anything other than your care documentation and internal quality checks. For example, we won’t be publishing your conversations or using them in case studies without your explicit consent and de-identification.

Data Privacy and Security with JotPsych

SmartScribe Corp. states that it takes privacy and security of your information very seriously. Here are key privacy points:

  • HIPAA Compliance: JotPsych and SmartScribe are designed to be HIPAA-compliant. This means they implement administrative, physical, and technical safeguards required by law to protect health information. Data transfer between our devices and SmartScribe’s servers is encrypted. Access to their system is restricted to authorized users. They also likely have audit controls and monitoring to prevent and detect any unauthorized access.

  • Independent Verification: SmartScribe works with independent third parties to verify their compliance and security (according to their statements). This should give additional assurance that an outside entity has evaluated their system’s security measures.

  • Your Ability to Review Policies: SmartScribe has their own Terms of Service and Privacy Policy which you have the right to review. They are available online at:

  • These documents provide detailed information on how SmartScribe uses data, legal rights, and protections. We encourage you to read them if you have concerns. If you have trouble accessing them, we can provide a copy.

  • No Unauthorized Access: The raw audio or interim transcript is not accessible to anyone except through the secure SmartScribe system. Within our practice, only the clinician (and perhaps designated technical staff for support) would have access to the transcripts. We treat the transcripts with the same confidentiality as therapy notes. SmartScribe’s staff (engineers or data scientists) might see snippets if debugging or improving the AI, but they are bound by confidentiality agreements and the data would typically be de-identified.

  • Data Retention: The final notes become part of your chart indefinitely (per medical record retention laws). As for the audio or draft data on SmartScribe’s side, they may retain transcripts for a certain period for quality purposes. If you ever revoke consent (see below), we will ensure no further data from future sessions is sent to SmartScribe. Data already processed would still likely reside in past records.

Your Choice and Rights

Using the AI scribe is completely optional. We believe it enhances our note-taking process, but your comfort is our priority. Here are your rights regarding JotPsych:

  • Right to Refuse or Opt-Out: You do not have to consent to the use of JotPsych. If you decline, we will simply take notes manually as we traditionally would. This might mean the clinician types more during sessions or scribbles notes on paper. You may notice slightly more pauses as we document, but we will ensure your care is not compromised. There is no penalty or loss of benefits if you refuse the AI scribe; you will receive the same quality of care. If you initially consent and later change your mind, you can withdraw consent at any time. Just inform us (preferably in writing, so we have a record). We will then stop using the AI for your sessions moving forward, with no questions asked.

  • Right to Ask Questions: Feel free to inquire how the system works or request that we show you the device set-up. We can explain how we activate it and how the data flows. Transparency is important; you have the right to know what’s happening with your information.

  • Right to Access Documentation: You always have the right to see the notes in your medical record (as described in the Privacy Policy section). The presence of AI doesn’t change that. If you want to know what note was generated or how it looks, you can request a copy of your visit note through the patient portal or medical records request. You’ll see the finalized note (which is based on the AI draft, edited by the provider). If you have concerns about accuracy, bring them up.

  • No Recording Beyond Note: We reiterate that no one is creating a saved audio or video recording of your session for other purposes when using JotPsych. It’s distinct from, say, recording a Zoom meeting. The AI might temporarily buffer audio to process it, but it’s not keeping an accessible recording that could be replayed. If you still feel uneasy or if you have a very sensitive discussion and want the AI off for that portion, you can say so. For instance, you might consent but say “please pause it while I discuss this one thing.” The provider can mute or deactivate the capture if needed. We want you to be comfortable being candid.

  • Quality Control: By consenting, you understand that SmartScribe’s team might review de-identified snippets for quality control. If you had any objection to even de-identified use, you should probably opt out of the service, as that is part of how the technology improves. We trust that they handle it professionally.

Withdrawal of Consent

As noted, you can withdraw consent to JotPsych at any time. To do so, simply inform your provider that you no longer want your sessions to utilize the AI scribe. It is best to also put this in writing (such as sending an email or signed note stating “I withdraw my consent for use of the JotPsych AI scribe in my sessions”). This creates a clear record.

Once consent is withdrawn, we will immediately stop enabling the SmartScribe system during your visits. This will have no effect on your ability to continue treatment with us; it just means the provider will revert to conventional note-taking. There is no penalty, and you will not be charged any fee related to discontinuing its use (note: we do not charge patients for using the AI either; it’s a tool on our side).

We will inform SmartScribe that your data should no longer be collected. Any data already collected cannot be retroactively deleted from our records (those are legal medical records) or from any backups SmartScribe had, but it will no longer be actively used except as part of past record. Typically, withdrawal just means going forward, nothing is sent to them.

Acknowledgement and Consent

We use JotPsych in your care, so by using our website, you are confirming the following:

  • I have been informed about the use of JotPsych by SmartScribe Corp as an AI scribe tool during my medical sessions. I understand how it works and what it does with my protected health information.

  • I understand the purpose is to aid in creating accurate medical notes and that it may improve the provider’s ability to focus on me. The potential benefits and any minimal risks to my privacy have been explained.

  • I have had the opportunity to ask questions about JotPsych and all my questions have been answered to my satisfaction.

  • I understand that my information will be handled according to HIPAA and applicable laws while using this service, and that I can review SmartScribe’s Terms of Use and Privacy Policy if I want more details.

  • I understand that I can decline or withdraw from using the AI scribe at any time without any impact on the rest of my treatment.

  • By giving this consent, I do not waive any of my rights under privacy laws, and I know this is a permission I am granting which I can also revoke.

  • I hereby consent to the use of JotPsych by SmartScribe Corp during my psychiatric consultations and appointments with Six States ADHD by booking through this website and scheduling appointments and services.

Final Note: The above policies and consents are meant to protect your rights and inform you of our practices. We strive to provide high-quality care in a transparent and patient-centered way. If you have any questions or concerns about any policy or consent form, please do not hesitate to discuss them with us. Your comfort and trust are extremely important. Thank you for taking the time to review these documents. We look forward to working with you towards your health and wellness goals.