New Patient Intake & Consent Packet

Emergency Contact

Other Care Providers

Insurance / Billing

You may leave sensitive narrative items blank and discuss them directly with your provider.

What brings you to care now?

Psychiatric history

Current medications and supplements

Medical history

Substance use (clinical information)

I voluntarily consent to psychiatric services from I Once Was Lost, But Now I'm Found, PLLC. Services may include psychiatric evaluation, diagnosis, medication management, screening tools, patient education, safety assessment and planning, brief/supportive psychotherapeutic interventions when clinically appropriate, referrals, and coordination of care.

I understand that treatment is collaborative. I may ask questions about recommended treatment, including expected benefits, material risks and side effects, reasonable alternatives, and the potential consequences of declining treatment. No specific treatment outcome can be guaranteed.

I understand that I may decline or withdraw consent for treatment to the extent permitted by law. Doing so may affect the provider's ability to safely continue a particular medication or treatment plan.

I understand that this consent does not replace specific informed-consent discussions that may be appropriate for particular medications, procedures, or services.

Telehealth uses electronic audio/video technology to provide care when the patient and provider are in different locations. I understand potential benefits include improved access and convenience, while limitations may include technology failure, privacy risks, and reduced ability to perform certain physical assessments.

I understand that psychiatric medications may be recommended as part of treatment. I will have an opportunity to discuss the reason for treatment, expected benefits, significant risks and side effects, reasonable alternatives, and questions I may have.

I agree to provide accurate information about prescription and nonprescription medications, supplements, alcohol, cannabis or other substances when clinically relevant; medication allergies; significant medical changes; and medications prescribed by other clinicians.

When relevant to medication safety, I agree to discuss pregnancy, suspected pregnancy, breastfeeding, or plans for pregnancy with my provider.

I understand that I should not change a prescribed dose or abruptly stop medication without discussing it with my provider when reasonably possible. Some medications may cause withdrawal symptoms or other adverse effects when stopped suddenly. Medication response varies, and no specific result is guaranteed.

If I am prescribed a controlled medication, including a stimulant or benzodiazepine, I agree to use it only as prescribed.

This agreement does not guarantee that a controlled medication will be prescribed. Prescribing decisions are based on clinical assessment, applicable law, safety considerations, and ongoing evaluation.

The practice may need to contact me about appointments, billing/insurance, prescriptions, laboratory results, treatment follow-up, and other matters related to my care. I understand that standard email and SMS/text may carry privacy and security risks.

I understand I may request reasonable confidential communications or update these preferences by contacting the practice.

Routine refill requests should be submitted before medication is exhausted. Please allow 2 business days for routine refill processing.

I understand that insurance verification or authorization is not a guarantee of payment. I am responsible for applicable copayments, coinsurance, deductibles, noncovered services, and other patient-responsibility amounts consistent with applicable law and my insurance plan.

Cancellation notice: Please provide at least 24 hours' notice when cancelling or rescheduling.

Late cancellation / no-show fee: $50, when permitted by applicable law and payer contract.

The practice will follow applicable payer contracts and law when assessing patient charges.

I Once Was Lost, But Now I'm Found, PLLC does not provide 24-hour emergency or crisis response.

If I am in immediate danger, believe I may harm myself or someone else, experience a medical emergency, or cannot safely wait for a response, I will call 911, go to the nearest emergency department, or call/text 988.

Routine voicemail, email, text, and patient-portal messages are not continuously monitored and should not be used for emergencies.

For urgent but non-emergency clinical concerns during business hours, contact the practice using the designated clinical communication method.

Practice phone: 253-509-1612

Use this form when you want the practice to obtain, release, or exchange information with another person or organization. This authorization is separate from routine treatment consent.

I understand that I may revoke this authorization in writing except to the extent action has already been taken in reliance on it. I understand treatment generally will not be conditioned on signing an authorization except where permitted by law. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA, except where other law continues to protect it. Additional protections may apply to certain records, including psychotherapy notes and substance use disorder records.

Effective Date: September 28, 2026

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed, how you can obtain access to that information, and the privacy responsibilities of I Once Was Lost, But Now I'm Found, PLLC.

Your Rights

• Request access to or a copy of your paper or electronic health record, subject to applicable law.
• Ask us to correct or amend information in your record.
• Request confidential communications.
• Ask us to limit certain uses or disclosures. Some requested restrictions are not required to be accepted, except where law requires otherwise.
• Request an accounting of certain disclosures.
• Receive a paper copy of this Notice.
• Choose an authorized personal representative to act for you.
• File a privacy complaint without retaliation.

Your Choices

In circumstances where your permission is required, we will obtain it before using or disclosing your information. You may have choices regarding communication with family or others involved in your care and certain other disclosures.

Our Uses and Disclosures

We may use or disclose health information as permitted or required by law, including for treatment, payment, health care operations, public health and safety activities, legal requirements, and other purposes authorized by law. Washington law may provide additional protections for mental health information. Psychotherapy notes, when maintained separately as defined by law, receive additional protection.

Substance Use Disorder Records

Federal law provides additional confidentiality protections for certain substance use disorder patient records. Where those protections apply, the practice will use and disclose such records in accordance with applicable federal law.

Our Responsibilities

• We are required by law to maintain the privacy and security of protected health information.
• We will notify affected individuals as required if a breach compromises unsecured protected information.
• We must follow the duties and privacy practices described in the Notice currently in effect.
• We will not use or disclose information other than as permitted by law or described in the Notice unless you authorize us in writing.

Privacy Questions or Complaints

Privacy Contact / Title: Theonie Labee-Walker, MSN, PMHNP-BC | Phone: 253-509-1612 | Email: theonielabee@gmail.com

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. The practice will not retaliate against you for filing a complaint.

The current Notice will be available upon request and on the practice website if the practice maintains a website describing its services.

I acknowledge that I have received or been provided access to the Notice of Privacy Practices of I Once Was Lost, But Now I'm Found, PLLC. I understand that the Notice describes how my protected health information may be used and disclosed and explains my privacy rights. I may request a paper or electronic copy of the Notice at any time.

You have the right to be treated with dignity, privacy, respect, and without unlawful discrimination; to participate in treatment decisions; to ask questions; to discuss reasonable alternatives; and to decline treatment to the extent permitted by law.

As a participant in your care, please:

• Provide accurate and complete health, medication, pharmacy, and contact information.
• Ask questions when you do not understand your treatment plan.
• Inform your provider of significant changes in symptoms, medications, health, or safety.
• Attend scheduled appointments or provide appropriate notice when unable to attend.
• Use medications according to the agreed treatment plan and discuss concerns promptly.
• Treat staff and others respectfully and participate in treatment decisions.

By signing below, I acknowledge that I have had an opportunity to review this packet, ask questions, and receive clarification. My signature confirms receipt and acknowledgment of the policies and consents I have signed; it does not waive rights provided by law.

Purpose

To allow your provider to focus more fully on you and the conversation during your appointment rather than primarily on typing or taking notes, I Once Was Lost, But Now I'm Found, PLLC may use Twofold Health, an artificial intelligence (AI)-assisted clinical documentation tool, with your permission.

How It Is Used

During an appointment, Twofold may process audio from the conversation to help create a transcript and draft clinical documentation. According to Twofold Health, encounter audio is processed for documentation and is not retained as a session recording after processing. Twofold also states that patient information is not used to train its AI models.

The AI-generated documentation is a draft only. Your psychiatric provider remains responsible for reviewing, correcting, and approving the final clinical note. Twofold does not independently diagnose you, prescribe medication, or make treatment decisions.

Privacy

Information processed for clinical documentation may include protected health information (PHI). The practice will use the service in accordance with applicable privacy and security requirements and its agreement with the technology provider. The final clinical documentation may become part of your medical record.

Your Choice

Use of AI-assisted documentation is voluntary. You may decline without affecting your ability to receive care, the quality of your treatment, or your relationship with your provider. Even if you consent, you may ask that Twofold not be used during a particular visit or withdraw permission for future visits.

I understand that AI-generated documentation may contain errors or omissions and that my provider is responsible for reviewing the final clinical note. I have had an opportunity to ask questions about the use of AI-assisted documentation.