Please review the following before providing consent.

I understand that counseling is a confidential service. I understand that confidentiality may have legal and ethical exceptions, including situations involving serious and imminent safety concerns, suspected abuse or neglect of a child or vulnerable person, certain legal proceedings or court orders, and other circumstances required or permitted by law.

I understand that I may ask questions about my counseling, my counselor's qualifications and approach, and my rights as a client.

I understand that I may discontinue counseling at any time, subject to payment for services already provided and any applicable scheduling or cancellation policies.

I understand that I have the right to respectful, professional, and nondiscriminatory care and may communicate concerns about my services or request assistance with referral to another provider when appropriate.

• I understand that counseling is a confidential service. I understand that confidentiality may have legal and ethical exceptions, including situations involving serious and imminent safety concerns, suspected abuse or neglect of a child or vulnerable person, certain legal proceedings or court orders, and other circumstances required or permitted by law.

• I understand that I may ask questions about my counseling, my counselor's qualifications and approach, and my rights as a client.

• I understand that I may discontinue counseling at any time, subject to payment for services already provided and any applicable scheduling or cancellation policies.

• I understand that I have the right to respectful, professional, and nondiscriminatory care and may communicate concerns about my services or request assistance with referral to another provider when appropriate.

Wys Wellness may use an AI-assisted transcription or documentation tool to support clinical note-taking. If used, the technology may process audio from a counseling session to generate a draft transcription or clinical note. The counselor remains responsible for reviewing and approving the clinical documentation.

• I understand that AI-assisted technology may be used to support clinical documentation.

• I consent to the use of AI-assisted transcription for this purpose.

• I understand that I may decline or withdraw my consent to AI transcription without affecting my ability to receive counseling services.

• I understand that questions about AI-assisted documentation may be discussed with my counselor before or during treatment.

I understand that Wys Wellness collects and uses my personal and health information as necessary to provide counseling services, coordinate care, process payment or insurance claims when applicable, maintain clinical records, and fulfill legal and professional obligations.

I understand that my information will be handled in accordance with applicable privacy laws and Wys Wellness's Notice of Privacy Practices and Privacy Policy.

I understand that information may be disclosed without my separate authorization when disclosure is required or permitted by law.

I have been provided access to the Wys Wellness Privacy Policy and Notice of Privacy Practices and understand that I may review them before providing consent.

Consent to Treat

I hereby consent, as the client or authorized representative of the client, to receive behavioral health services from a qualified healthcare provider at Wys Wellness or from another professional or legal entity associated with Wys Wellness, as applicable. Services may include, without limitation, counseling, psychotherapy, psychological assessment, and/or other behavioral health services within the provider's scope of practice and applicable licensure.

The Wys Wellness provider responsible for my care has explained, to the extent applicable, the proposed treatment plan, the general nature and purpose of the recommended services, reasonably foreseeable risks and benefits associated with treatment, and available alternative treatment options, if any. I understand that I may ask questions regarding my treatment, participate in treatment decisions, and discuss alternative options with my provider.

I understand that confidentiality is an important aspect of behavioral health services and that Wys Wellness providers are required by applicable law and professional ethical standards to safeguard confidential client information and patient-provider communications. I understand that confidentiality is subject to certain legal and ethical exceptions, including circumstances in which disclosure is permitted or required by federal or state law.

I understand that I may have rights to access or obtain copies of my treatment records as provided by applicable federal and state law. I further understand that, in certain circumstances permitted by law, a Wys Wellness provider may determine, within reasonable professional discretion and consistent with applicable privacy laws, that particular information may be withheld or access may be limited.

By signing this form, I acknowledge that I have had an opportunity to ask questions regarding the nature of services and that I voluntarily consent to receive behavioral health services from Wys Wellness.

I understand that I am financially responsible for charges associated with behavioral health services provided by Wys Wellness, regardless of whether I use health insurance, another third-party payer, or self-pay.

If I elect to use insurance, I understand that insurance coverage is determined by my individual insurance policy and by my insurance carrier. Wys Wellness may submit claims to my insurance carrier as a courtesy when applicable; however, submission of a claim does not constitute a guarantee of payment by the insurance company.

I understand that I am responsible for providing accurate and current insurance and personal information and for notifying Wys Wellness of any changes to my insurance coverage, eligibility, or other information that may affect payment for services.

I understand that I am responsible for all amounts assigned to me by my insurance carrier or other third-party payment entities assigned to me determined to be my responsibility, including applicable copayments, coinsurance, deductibles, non-covered services, denied claims, out-of-network charges, and other amounts not paid by my insurance company or another third-party payer, to the extent permitted by applicable law.

If I elect to self-pay for services, I acknowledge that I am responsible for payment of the applicable Wys Wellness fee for each service received. I understand that self-pay services are not dependent upon insurance reimbursement and that I am responsible for payment according to the fee schedule and payment policies provided to me by Wys Wellness.

If required, I acknowledge that I have reviewed and signed the applicable Acknowledgment of Financial Responsibility and agree to the financial terms associated with my selected method of payment.

I understand that questions regarding my insurance coverage, benefits, eligibility, deductibles, copayments, coinsurance, and limitations are ultimately my responsibility. I understand that I may contact my insurance carrier directly to obtain information regarding my specific benefits and coverage.

Guarantee of Payment

I understand that Wys Wellness renders services with the understanding that an insurance company or other third-party payer may or may not pay all or any portion of the charges associated with my care. Verification of insurance benefits, eligibility, or authorization does not guarantee payment by my insurance company.

I understand that I am personally responsible for knowing and understanding the coverage and eligibility conditions of my own insurance policy, including applicable copayments, deductibles, coinsurance, authorization requirements, exclusions, limitations, and coverage requirements.

I agree to be financially responsible for all charges that are my responsibility and that are not paid by my insurance plan or another third-party payer, to the extent permitted by applicable law.

If I choose to self-pay for services provided by Wys Wellness, I acknowledge that I have reviewed and signed the applicable Acknowledgment of Financial Responsibility and agree to pay the applicable charges according to Wys Wellness's payment policies.

I understand that payment is expected according to the financial policies provided by Wys Wellness. If I fail to pay charges for which I am responsible, and the account remains unpaid after reasonable attempts to obtain payment, I understand that Wys Wellness may take appropriate steps to collect the outstanding balance, which may include referring the account to a collection agency or other lawful collection process. I understand that I may be responsible for reasonable collection-related costs to the extent permitted by applicable law.

I acknowledge that I have had an opportunity to ask questions regarding my financial responsibility and payment obligations and that I understand and agree to the terms outlined above.