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This password will be used to log into University Elite every time you schedule a session.

Which of the follow describes you best? *

• I am an adult seeking care for myself
• I am the legal guardian seeking care for a minor

If you are seeking care for a minor, you must understand and accept these terms as the legal guardian.

Risks and Benefits of mental health treatment: Most people seek treatment with a mental health provider to help them with problems related to mood, anxiety, stress, relationships, school and work. The goal of mental health treatment is reduction of these problems and an improvement in mood and level of functioning at work, school and in relationships. During the course of this treatment, however, some people might experience an increase in anxiety, worsening of symptoms, and thoughts of self-harm that could lead to hospitalization. Therefore, it is important to be completely honest with your doctor, follow recommendations made by the provider and verbalize concerns or side effects of treatment on a consistent basis. *

• Check here if you understand and agree to these terms

No emergency services provided. University Elite PLLC is an outpatient and telemedicine only practice that is not affiliated with any hospital. As such, University Elite PLLC does not offer emergency services. If you ever have an emergency or life threatening situation, please call 911, go to your nearest emergency room or call the National Suicide Hotline at 1-800-273-8255. *

• Check here if you understand and agree to these terms

Communication with your physician. University Elite PLLC is dedicated to giving the best care possible and being responsive to their patient’s needs. We understand that there will be times where it is necessary to communicate with your physician in between sessions. In these cases, the normal communication format between patient and University Elite physicians is an email to notify the physician of needed communication. The physician will then call you back at the first available time. While it is perfectly legal for a patient to include medical information in the email, we recommend avoiding this because email is not encrypted. Please ensure that email is not used for urgent or life threating situations. If you ever have an emergency, life threatening situation or the issue cannot wait for a response to an email, please call 911, go to your nearest emergency room or call the National Suicide Hotline at 1-800-273-8255. *

• Check here if you understand and agree to these terms

No after hours access available. Please recognize that there will be times when the University Elite physicians may be out of town or otherwise unavailable for an extended period of time. Every effort will be made to respond to emails in a timely manner but a rapid response cannot be guaranteed. When in doubt or if your need requires more rapid response, seek urgent or emergency medical care through the emergency room or urgent care clinic as applicable. If a patient’s situation is critical enough to require a provider that is routinely available for in-between session care or after hours calls, University Elite PLLC may not be the best choice for your needs. If our resources don’t meet your needs, we understand. If that is the case, we will always strive to identify this in the evaluation session(s) or to identify such when it becomes apparent in the treatment sessions. In these rare instances, we will be happy to facilitate the transfer of records to the provider you specify. *

• Check here if you understand and agree to these terms

Tricare Beneficiaries or Tricare Eligible individuals. At the current time, some physician(s) of University Elite PLLC are proudly serving their country as a Department of Defense physician(s.) Federal law prevents them from seeing any tricare beneficiaries or tricare eligible individuals in another practice. Therefore, individuals that are eligible or currently insured by Tricare are not allowed to be patients of University Elite PLLC at this time. (We are attempting to resolve this restriction ASAP and this restriction will be eliminated when possible.) *

• Check here if you understand and attest that you are NOT a Tricare eligible or Tricare insured individual.

Place of care. Patients of University Elite PLLC often are participating in care via video (telemedicine.) In addition to the federal requirement, reality shows us that there occasionally arises a situation that requires emergency services to go to the patient’s location. Therefore, patients of University Elite PLLC must commit to only engaging in telemedicine care when in a predetermined location where contact information for emergency services has been identified/provided to the physician. Real life dictates that there may be rare times where the treating physician will pre-approve the patient to do the telemedicine appointment in another location due to extenuating circumstances. This exception will always require pre-approval from the treating physician (always before the appointment time) and the patient must provide contact information for emergency services (local telephone number to local police) at the pre-approved location. *

• Check here if you understand and agree to these terms

Treatment Fees and Payment Policies. University Elite physicians are “out of network providers” and are not contracted with insurance companies. This simply means we don’t take insurance. University Elite is a fee-for- Service Company and accepts payment in the form of credit card. Upon request, we do provide the patient a receipt so they can file for reimbursement from their insurance companies or HSA plans. Our current rate is $300/hour *

• Check here if you understand and agree to these terms

Session Times. All initial sessions are 50 minutes long and are referred to as an “hour.” The remaining 10 minutes are used for administrative requirements (completing paperwork, calling in your meds, etc.) Ongoing care for psychotherapy with medication management sessions will require “hour” long follow up sessions. Appointments that are strictly medication management will be 20 minute appointments and are referred to as a “half hour.” Most new patient appointments consist of 1-2 “hour” long evaluation/treatment planning sessions. Phone calls and paperwork in excess of those routinely required as part of evaluation and treatment will be charged in 15 minute increments pro-rated at $300/ hour. *

• Check here if you understand and agree to these terms

Timeliness. We know your time is valuable and we make every effort to keep on schedule. If we are running late, you will be given the full appointment time you have reserved. If we are late, we may even offer a no-cost reschedule if it better accommodates your situation. (It is our goal that you are never penalized for us being late.) If you are running late, we will be happy to meet with you for the remaining time left in your appointment and any remaining items will be deferred to the next appointment scheduled. *

• Check here if you understand and agree to these terms

Payment. When paying for services, the patient/customer is paying to reserve that time slot with their physician. Therefore, payment is due when the time slot is reserved (purchased.) Contact our office via email or see the FAQ section of universityelite.com for current rates. *

• Check here if you understand and agree to these terms

Scheduling Policies. University Elite is dedicated to patient self-empowerment. One of the many ways we enable this is by giving full autonomy to the patient to schedule their own appointments. While the doctor and patient will agree on a recommended follow-up timeframe, the patient has the full responsibility to reschedule their appointment using the online scheduling function at universityelite.com. *

• Check here if you understand and agree to these terms

Cancellation Policies. We understand that sometimes you may need to cancel or change an appointment. We have attempted to empower the patient by giving the permissions to reschedule themselves using the website scheduling application. Note that appointments can only be cancelled with more than 24-hour notice. Failure to provide 24-hour notice will result in that slot being unavailable for another patient. Therefore, you will not be able to cancel an appointment inside the 24 hour window and will be charged the full fee for the appointment time. When a patient needs to reschedule an appointment, there is no need to notify your physician. Simply log onto the scheduling portal at universityelite.com, cancel your existing appointment and reschedule in an open appointment. Any appointment canceled with at least 24-hour notice will be refunded the full amount minus the credit card company’s processing fee. *

• Check here if you understand and agree to these terms

Confidentiality: Unlike insurance accepting practices, we generally are not required to share your information with anyone unless you request such in writing or when the law requires. (see examples below.) Therefore, our confidentiality is usually much greater than the average practice. *

• Check here if you understand and agree to these terms

Psychiatric treatment and psychotherapy are confidential, with important exceptions: 1. Information may be released to designated parties by written authorization of clients or legal guardians. 2. Mental health providers are required to report suspected past or present abuse or neglect of children, adults, and elders, to the authorities, including Child Protective Services, Adult Protective Services and law enforcement, based on information provided by the client or collateral sources. 3. If clients participate in treatment in compliance with a court order, therapists are required to release information to the relevant court, social service, or probation departments. 4. Mental health providers are required to release information obtained from clients or from collateral sources (other individuals involved in a client’s psychotherapy, such as parents, guardians, spouses) to appropriate authorities when such disclosure may help to avert danger to a psychotherapy client or to others, e.g.; imminent risk of suicide, homicide, or destruction of property that could endanger others. 5. Therapists are required to provide information in response to court orders as determined by a judge. In some proceedings, courts order the entire psychotherapy record. 6. We reserve the right to release financial information to a collections agency, attorney, or small claims court, if you are delinquent on paying your bill.

HIPAA. University Elite takes privacy very seriously and will make every effort to safeguard your medical information at or above the standard set by HIPAA. However, HIPAA limits some of the communication types that patient’s occasionally prefer. Therefore, to meet these patient’s needs, University Elite continues to make privacy a priority but we ARE NOT a “HIPAA provider.” While we prefer to communicate all medical information in person or via our encrypted video conference system, sometimes patients pre-arrange with their doctor to do a session via phone call, facetime or skype (many of these are not HIPAA approved.) We believe that patients should have the right to choose how and when they choose to share their medical information and HIPAA limits such. *

• Check here if you understand and agree to these terms

Controlled substance prescriptions (only a few meds are in this category.) University elite recognizes that while the majority of patients will never need a medication that fits into this category, there are a small set of patients who require medications that have additional restrictions for prescribing. We are experts in identifying when it would be appropriate and inappropriate for these medications and are very comfortable managing them for the right patients. However, the Ryan Haight Act of 2008 makes it illegal to prescribe these medications without first seeing the patient “in person” (Still waiting on the DEA to make their promised acception for psychiatry.) Therefore, in a small number of cases, there might be a requirement for a telemedicine patient to attend an in person appointment prior to receiving the needed prescription. *

• Check here if you understand and agree to these terms

Board Certification. University Elite affiliated physicians strive to give the best and most comprehensive care available. As such, University Elite physicians are evaluated before being affiliated. This evaluation continues even after becoming an affiliated physician. Furthermore, our physician’s only accept patients types (child vs adult vs geriatric) for which they have been appropriately trained and there is ongoing evaluation of their care. While all University Elite physicians have completed a psychiatric residency and have the necessary expertise in treating the different types of patients, not all have taken the extra step of gaining additional board certifications in child and adolescent or geriatric psychiatry. By initialing these terms, the patient or legal representative acknowledges that the physician may be a certified “general psychiatrist” and may not be board certified in child and adolescent or geriatric psychiatry. The patient or legal representative consents to treatment even if it is from a general psychiatrist. *

• Check here if you understand and agree to these terms

Patient Responsibilities and Contract: I, *

have read and understood the office policies of University Elite. I consent to an evaluation and treatment planning. I understand that treatment sessions are used to verify that the doctor’s resources meet the patient’s needs. I understand that in rare cases, completion of the evaluation and treatment planning may reveal that the patient’s needs may exceed the doctor’s resources. In these rare cases, the recommendation may be to find a different provider/clinic that has the needed resources. I commit to being open and honest during the course of the evaluation, treatment planning and treatment sessions in order to receive the most accurate treatment options for my problems.

I certify that I have read, that I understand, and that I agree to each of these terms *

Clear Signature

This is a legally binding signature. By submitting this form, you are legally stating that the information you have submitted is true and accurate. You will be taken to a page where you can choose your Psychiatrist or Psychologist and then schedule your first session. By submitting this form, you are agreeing to University Elite’s Terms of Service and Privacy Policy. University Elite is a HIPPA compliant entity. Your information will be protected as guided by HIPPA regulations and will not be shared with third parties for marketing or other purposes.

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University Elite PLLC 

Mental Health Services  

University Elite is committed to providing elite education & care.  Because our care and results speak for themselves, we also strive for a transparent experience for our patients.  Please read and understand our transparent terms and conditions listed below.

• Risks and Benefits of mental health treatment.

Most people seek treatment with a mental health provider to help with problems related to mood, anxiety, stress, relationships, school, and work. The goal of mental health treatment is to reduce these problems and improve the level of functioning at work, school and in relationships. 

During the course of this treatment, however, some people might experience an increase in anxiety, worsening of symptoms, and thoughts of self-harm that could lead to hospitalization. Therefore, it is important to be completely honest with your doctor, follow recommendations made by the provider and verbalize concerns or side effects of treatment on a consistent basis.  

• Communication with your doctor.  

University Elite PLLC is dedicated to giving the best care possible and being responsive to the patient’s needs.  We understand that there will be times where it is necessary to communicate with your doctor in between sessions.  In these cases, the normal communication format between patient and University Elite Doctors is an email to notify of the needed communication.  The doctor will then call you back at the first available time.

While it is perfectly legal for a patient to include medical information in the email, we recommend avoiding this because email is not encrypted and your privacy could be compromised.  

Please ensure that email is not used for urgent or life-threatening situations.  If you ever have an emergency, life-threatening situation or if the issue cannot wait for a response to an email, please call 911, go to your nearest emergency room or call the National Suicide Hotline at 1-800-273-8255.

• No after-hours access available. 

Please recognize that there will be times when the University Elite Doctor may be out of town or otherwise unavailable for an extended period of time.  Every effort will be made to respond to emails in a timely manner but a rapid response cannot be guaranteed. When in doubt or if your need requires more rapid response, seek urgent or emergency medical care through the emergency room or urgent care clinic as applicable. 

If a patient’s situation is critical enough to require a provider that is routinely available for in-between session care or after hours calls, University Elite PLLC may not be the best choice for your needs.  

If our resources don’t meet your needs, we understand. If that is the case, we will always strive to identify this in the evaluation session(s) or to identify such when it becomes apparent in the treatment sessions.  In these rare instances, we will be happy to facilitate the transfer of your records to the provider you specify.

• Tricare Beneficiaries or Tricare Eligible individuals.

At the current time, some doctors of University Elite PLLC are proudly serving their country as a Department of Defense doctors.  Federal law prevents them from seeing any tricare beneficiaries or tricare eligible individuals in another practice. Therefore, individuals that are eligible or currently insured by Tricare are not allowed to be patients of University Elite PLLC at this time.  (We are attempting to resolve this restriction ASAP and this restriction will be eliminated when possible.) 

• Place of care.  

Patients of University Elite PLLC usually participate in care via video (telemedicine.) In addition to the federal requirement, reality shows us that there are occasional situations that require emergency services to go to the patient’s location.  Therefore, patients of University Elite PLLC must commit to only engaging in telemedicine care when in a predetermined location where contact information for emergency services has been identified/provided to the doctor.  

Real life dictates that there may be rare times where the treating doctor will pre-approve the patient to do the telemedicine appointment in another location due to extenuating circumstances.  This exception will always require pre-approval from the treating doctor (always before the appointment time) and the patient must provide contact information for emergency services (local telephone number to local police) at the pre-approved location.   

• Treatment Fees and Payment Policies.  

University Elite Doctors are “out of network providers” and are not contracted with insurance companies. This simply means we don’t take insurance.  

University Elite is a fee-for- Service Company and accepts payment in the form of credit cards. Upon request, we do provide the patient a receipt so they can file for reimbursement from their insurance companies or HSA plans.

• Session Times.  

All initial sessions are 50 minutes long and are referred to as an “hour.” The remaining 10 minutes are used for administrative requirements (completing paperwork, calling in your meds, etc.)  Ongoing care for psychotherapy with medication management sessions will require “hour” long follow up sessions. 

Appointments that are strictly medication management will be 20 minute appointments and are referred to as a “half hour.”  

New patients usually require between 1-3 intake evaluation/treatment planning sessions.

 Phone calls and paperwork in excess of those routinely required as part of evaluation and treatment will be charged in 15 minute increments pro-rated at the doctor’s hourly rate ($300/ hour for a psychiatrist and $150/ hour for a psychologist.)  

• Payment.  

When paying for services, the patient/customer is paying to reserve that time slot with their doctor.  Therefore, payment is due when the time slot is reserved (purchased.)   

• Board Certification. 

University Elite affiliated doctors strive to give the best and most comprehensive care available.  As such, University Elite Doctors are evaluated before being affiliated and this evaluation continues after becoming affiliated. Our physician’s only accept patients types (child vs adult vs geriatric) for which they have been appropriately trained and University Elite performs ongoing evaluation of their care.  

While all University Elite physicians have completed at least a general psychiatric residency and have training in treating psychiatric conditions in child, adolescent, adult and geriatric patients, not all have taken the extra step of gaining additional board certifications in child and adolescent or geriatric psychiatry.  

The patient or legal representative acknowledges that the physician may be a certified “general psychiatrist” and may not be board certified in child and adolescent or geriatric psychiatry.  The patient or legal representative consents to treatment even if it is from a “general psychiatrist.”

•  Recording Sessions

Both the doctor and patient agree that no sessions will be recorded in any format (audio or video) without written consent from both parties.  Verbal consent is not acceptable.