INFORMED CONSENT

As part of your program you may work with a Guide who is affiliated with WiseFolk Clinic. Your Guide can help you navigate your program, set intentions, and develop your integration plan. Guides are trained in life coaching, best practices for working with psychedelic medicine, and how to best collaborate with your clinician to support your treatment.

While your Guide may be able to support you in changing unwanted thoughts or behaviors and achieve the goals you set for your program, Guides are not licensed therapists, so they are not licensed to treat anxiety, depression, or other diagnoses. That’s the role of your clinician or other licensed mental healthcare provider you may work with outside of this treatment.

Guides aim to reply to client messages within 48 hours (or much sooner), but they do not provide 24/7 support.

Consent to Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual client medical information for the purpose of improving client care. Telehealth services offered through the WiseFolk Clinic platform by Practice’s clinicians may include consultations by video or by phone, chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as client education. The information you provide may be used for diagnosis, therapy, follow-up and/or client education, and may be provided through any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with asynchronous communications; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. It is possible, though unlikely, that your information or data may be lost due to technical failures. You agree to hold WiseFolk Clinic and Practice harmless against any information or data that is lost due to technical failures.

The Practice’s clinicians are an addition to, and not a replacement for, your primary care physician and/or primary mental health provider. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected benefits of telehealth:

• Improved access to care
• More efficient care evaluation and management

Possible risks of telehealth:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies
• In rare events, a provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a visit with your local primary care doctor
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information
• In rare events, a lack of access to complete medical records may result in inaccurate and/or incomplete medical advice.
• The FDA has advised that at-home administration of compounded ketamine may present additional risks because a health care provider is not available onsite to monitor for adverse outcomes resulting from sedation and dissociation.

Alternative Treatments

Before deciding to proceed with ketamine treatment, you should consider the benefits and risks of available mood and anxiety disorder treatment options, such as other antidepressant and anti-anxiety medications, mood stabilizers, or psychotherapy. You should also consider alternatives to telehealth consultation, such as in-person services, before choosing to participate in a telehealth consultation. You can discuss these alternative treatments with your Practice clinician or with your local primary care doctor.

Confidentiality

Your privacy is a priority and all treatment records will be kept confidential. They will be maintained with the same precautions as ordinary medical records. If you would like to provide other individuals or organizations with access to your records, contact us for a release form. You also understand that your personal information may be used and shared.

I confirm that:

1. I have fully read and understand this agreement. I understand the potential benefits, risks, and alternative treatment options, and I freely give my consent to participate in ketamine treatment and receive services via telehealth from Practice providers affiliated with WiseFolk Clinic.
2. I will abide by all of WiseFolk Clinic’s guidelines and requirements outlined in this document and/or those that have been communicated by my clinician, as well as the directions in any prescription I receive. I understand that my failure to follow all guidelines, requirements, and directions may result in the discontinuation of my treatment.
3. I meet the eligibility criteria and do not meet the exclusion criteria listed in the “Eligibility” section above. If there are any changes to my physical or mental health that impact my eligibility for treatment, I will notify my providers immediately and discontinue treatment, if necessary.
4. I will be physically located in my state of residence, as identified in my new client registration, during my telehealth consultation. I will notify my Practice Clinician and WiseFolk Clinic immediately and no later than at the beginning of your telehealth consultation if I am located in a different state.
5. I understand that Practice providers are not able to connect me directly to any emergency services. If I am in a life-threatening situation, I will call the National Suicide Prevention Line at 988 or +1-800-273-8255, call 911, or go to the nearest emergency room.
6. I understand it is up to the Practice clinician to determine whether or not my specific clinical needs are appropriate for a telehealth encounter. The Practice’s clinician may deny care for potential misuse of the telehealth services or for any other reason if, in the professional judgment of the provider, the telehealth encounter is not medically or ethically appropriate.
7. I understand that my healthcare information may be shared with other individuals for the purposes of treatment, scheduling, billing, and other healthcare operations.
8. I understand that I have the right to object to the videotaping or other recording of a telemedicine visit, and I also agree not to record a telemedicine visit without my provider’s permission.
9. I give WiseFolk Clinic and Practice permission to access information regarding my historical medical data through their electronic health record system.
10. I understand that if I participate in a consultation, I have the right to request a copy of my medical records and to request that a copy of my medical records be sent to my local primary care physician or another medical provider.
11. I understand that I may register any complaints regarding my provider to the applicable state professional licensing board.
12. I understand that I may withdraw my consent from treatment and/or the use of telehealth at any time by providing notice to support@WiseFolk Clinic.com. I understand that my revocation of consent may result in me no longer qualifying to receive services and that such consent will not impact the rights and actions of WiseFolk Clinic and Practice while the consent was in effect.
13. I understand that I will have the opportunity to ask my clinician questions about this consent form at any time during my treatment. I understand that I may revoke this consent by following the process set forth in item 12 located above.