Psychiatric treatment via telehealth for adults who want to stop feeling exhausted, overwhelmed, and unworthy and start feeling calm, confident, and capable.

Dr. Rafferty knows that connecting with a mental health provider can be a challenging endeavor. It is important that you feel there is a good fit between you and your provider. Dr. Rafferty is truly interested in getting to know you and will spend the right amount of time with you so you are heard.

An initial evaluation typically takes 60 minutes to complete, depending on your personal needs. The goal of this first evaluation is to offer the highest level of care possible and a full hour allows time for all of your mental health needs to be addressed and questions to be answered. Please be sure to schedule yourself enough time, including time to check your internet connection and get logged in to the telehealth waiting room. 

Before the end of your first visit, Dr. Rafferty will determine whether you will benefit from further evaluation or begin treatment. In some cases, an additional visit may be necessary to complete the initial evaluation (such as for someone with an extensive psychiatric history or complicated presentation) as extra time may be needed to gather information from you, speak to your family or loved ones, review past medical records, or order any necessary lab work. If this is the case Dr. Rafferty will help you schedule time at a future date to complete the evaluation.

The initial evaluation is an opportunity for you to decide whether working with Dr. Rafferty will be a good fit for you. Dr. Rafferty does not prescribe medications until the initial evaluation is completed so please be sure that you have enough medication from your previous provider. If it turns out that you may benefit from treatment elsewhere you will be referred to an appropriate treatment center.

During the evaluation you will be asked questions about your current symptoms, your past psychiatric history, your medical history, and other relevant information. These questions may be personal and uncomfortable to talk about. Dr. Rafferty will make efforts to balance moving at your pace with obtaining all the necessary information to provide appropriate treatment.

If you have past medical or psychiatric records it may be helpful to send copies of laboratory or other test results. Please have contact information for previous psychiatrists or physicians and complete releases for collateral information with them so that Dr. Rafferty can contact them if needed.

Please bring a list of all current prescriptions with you to the first appointment so that Dr. Rafferty can be aware of all medications you are taking.

Dr. Rafferty accepts several insurances. Please contact your insurance company to be sure your services will be covered. 

Dr. Rafferty is not a Medicare provider and her services are not eligible for reimbursement by Medicare.

Dr. Rafferty does not do evaluations or complete paperwork for Workers’ Compensation or Disability Benefits.

Payments are due at the time of scheduling via credit card or at the time of appointment via cash or check. A block of time is reserved for your appointment so if you need to cancel please provide 24 business hours of advance notice. If you do not cancel in less than 24 business hours or fail to appear for an appointment you will be charged a fee for the visit. Your insurance company is unlikely to reimburse for missed sessions. Consistent attendance at follow up appointments is important for safe medical care. Prescriptions are sent electronically to your preferred pharmacy during appointments. Medications are not ordinarily refilled over the telephone except in the case of an emergency. You will then receive a prescription valid for enough medication until your next appointment. You are encouraged to contact Dr. Rafferty (or the emergency department in case of emergency) if you are having any problems with medications. It is your responsibility to ensure you have an appointment scheduled before your medications run out.  Dr. Rafferty does not accept automatic refill requests from pharmacies. This is to ensure your health and safety by always checking that the medication you are taking is the right one for you.

Each person is given a block of time. Dr. Rafferty does her best to be on time, but due to the personalized level of care given, at times may be up to 10 minutes late. Please be available for the full amount of time scheduled so that you are able to be seen in the rare times Dr. Rafferty is running late. 

I [print client’s name] ________________________________ hereby consent to engaging in telemedicine via Doxy.me, or other electronic means with Dr. Sonya E. Rafferty, NPP, LMHC (provider) as part of my treatment. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my personal medical/mental health information, both orally and visually, through electronic means, to health care practitioners located in New York State or outside of New York State. 

I understand that I have the following rights with respect to telemedicine: 

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. Should I do so, I will not risk the loss or withdrawal of treatment benefits to which I would otherwise be entitled. 

(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to any other entities shall not occur without my written consent. 

(3) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. 

(4) I understand that I have a right to access my mental health information and copies of my mental health records in accordance with New York State law. 

(5) I also understand that there are inherent risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information or treatment could be interrupted or accessed by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. 

(6) I understand that telemedicine based services and care may not be as complete as in-office services in some instances. I understand that if my provider believes I would be better served by another form of mental health services (e.g. in-office services), I will be referred to in-office services when or as needed. 

(7) I agree that if I am feeling suicidal, homicidal, or otherwise experiencing a mental health crisis I will call 911, present to the nearest hospital emergency department, or contact the suicide hotline (1-800-273-8255).

(8) I understand that I am responsible to check with my state and with my insurance provider before engaging in telehealth services to be certain that services provided by Sonya Rafferty, NYS license #401492 will be approved and covered. I agree that I am responsible for all fees associated with these telehealth services. 

(9) I understand that there are potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and the efforts of my provider, my condition may not immediately improve, and in some cases may even decline. I have read and understand the information provided above. I have discussed any and all of my current questions with my provider and they have been answered to my satisfaction. 

(10) Finally, I understand that these visits are professional appointments and I am to present to these appointments as I would in person, including but not limited to, arriving on time fully dressed and ready to participate, not partaking in alcohol, nicotine, or substance use during the session, and joining from a stable and safe location (not while driving, in bed, or in a public location). 

__________________________________________           ______________ 

Signature of client/parent/guardian/conservator                    Date 

__________________________________________           ______________ 

If signed by other than client indicate relationship                 Date