New Patient Pre-Screener

Pre-Screener Universal Consent

Please review and acknowledge the statements below. This consent covers our initial prescreening only and does not establish an ongoing provider–patient relationship until you complete full intake and we confirm acceptance.

1) Consent for Treatment — Prescreen Only

• I consent for SHIELD Psychiatry PLLC to review information I provide and to conduct a brief prescreen to determine service eligibility and safety.
• I understand this prescreen may include the collection of health information and follow-up questions.
• I understand this consent is limited to the prescreener; full evaluation and treatment require additional consents and acceptance into care.

2) Telehealth Consent (Florida)

• I understand prescreening/evaluation may occur via secure audio/video technology.
• I confirm I (or my child/ward) am physically located in Florida during any telehealth encounter, per Florida law (F.S. 456.47).
• I understand telehealth has benefits and limitations (e.g., rare technical failures), and I may request in-person referral if appropriate.
• In an emergency, I will call 911 or go to the nearest emergency department.

3) HIPAA Notice of Privacy Practices (Acknowledgement)

I acknowledge receipt and availability of SHIELD Psychiatry’s Notice of Privacy Practices (NPP), which explains how my Protected Health Information (PHI) may be used and disclosed, and my rights under HIPAA.

4) Consent to Receive Text/Email

I consent to receive text messages and/or emails related to scheduling, registration, reminders, and prescreen follow-up. Message/data rates may apply. I can opt out at any time.

5) Practice Policies (Summary)

• Non-emergency practice: We do not provide emergency services. In emergencies, call 911 or go to the nearest ED.
• Telepsychiatry, ages 5–25: Services are delivered virtually to eligible patients located in Florida.
• Financial model: Concierge/cash-pay practice; patients are responsible for payment and may request superbills.
• Communication: Secure messaging occurs via Spruce/IntakeQ per HIPAA; avoid urgent messages via portal.

Preferred Contact for Prescreen Follow-up

Attestation

By signing, I affirm that the information I provide in the prescreener is true and accurate to the best of my knowledge and that I am authorized to consent (as the patient or legal guardian).