Website Notice and Consent

I acknowledge that I am providing to Mountainside Mental Health, PLLC (“MMH”) health information about myself or my child. I understand that such information will be available to those individuals at MMH involved in my or my child’s mental health care service. I understand the inherent risks in participating in this treatment, and that I may refuse or discontinue my or my child’s treatment at any time, other than after treatment has concluded. I also understand that MMH cannot guarantee any results of treatment.

I understand that my or my child’s health information will be kept confidential by MMH and will not be disclosed without my consent. However, regardless of consent, my or my child’s health information may be used and disclosed by MMH for treatment, payment, healthcare operations, in cases of emergency or when required by State and Federal Law. I understand that I have certain rights with respect to my or my child’s health information that I can exercise by submitting a written request to MMH. I understand that I may revoke this consent at any time, but that such revocation will not be retroactive.

If I am or my child is a current patient or become(s) a patient of MMH, I understand that I will be required to agree and give consent for MMH to provide me or my child mental health treatment, which may include any care, treatment, service or procedure to maintain, diagnose, treat or provide for mental health including any medication program, and to perform any tests or diagnosis that may be helpful to care for my or my child’s mental health.

By clicking the “Request an Appointment” link below, I acknowledge that I have read and agree to MMH’s website notice and consent.