FORMS
Adult 18+
FULL INTAKE PACKET download here
Adult Needs & Strength Assessment (ANSA) – download here
Brief Addiction Monitor (BAM) – download here
McLeod EAP Authorization – download here
Payment Authorization Form – download here
Referral Form – download here
Wilson Senior Care EAP Authorization-download here
Children 3-13
FULL INTAKE PACKET download here
Adolescents 14-17
FULL INTAKE PACKET download here
McLeod EAP Intake – download here
Payment Authorization Form- download here
Referral Form – download here
PRACTICE POLICIES & INFORMED CONSENT FOR ASSESSMENT AND TREATMENT BELOW
I understand that I am requesting services from Advanced Practice Mental Health & Wellness of South Carolina. Services may include assessment, diagnosis, treatment planning, therapy, medication management, case management, referral coordination, substance use-related services, court-related services, and other behavioral health services as clinically appropriate.
The type, frequency, and length of services recommended will be determined after an initial assessment and ongoing review of my needs, symptoms, safety, diagnosis, treatment goals, and level-of-care needs. Treatment recommendations will be discussed with me, and I have the right to ask questions about my care.
Participation in treatment is voluntary. However, if I choose not to follow treatment recommendations, miss appointments, fail to complete required paperwork, or do not comply with practice policies, this may affect my ability to continue receiving services through the practice.
Scope of Services and Level of Care
I understand that this practice provides outpatient behavioral health services. Outpatient treatment may not be appropriate for all conditions, symptoms, or levels of risk.
If my provider determines that I need a higher level of care, such as emergency care, inpatient hospitalization, intensive outpatient treatment, partial hospitalization, substance use detoxification, residential treatment, medical clearance, or another specialized service, I may be referred to a more appropriate provider or facility.
If I am experiencing a medical emergency, suicidal thoughts with intent or plan, homicidal thoughts, severe medication reaction, psychosis, withdrawal symptoms, overdose, or any immediate safety concern, I should call 911, go to the nearest emergency room, or contact the 988 Suicide & Crisis Lifeline.
Use of AI-Assisted Documentation
I understand that clinicians may use secure AI-assisted documentation tools to help prepare clinical notes, summaries, or documentation. AI tools are used to support documentation only and do not replace the clinical judgment of my provider. My provider remains responsible for reviewing, editing, and approving all clinical documentation.
Any use of documentation technology will be handled in accordance with privacy and confidentiality requirements, including HIPAA and practice policy.
Controlled Medication Policy
Patients prescribed controlled medications, including but not limited to stimulant medications, benzodiazepines, sleep medications, and certain other controlled substances, must attend an appointment at least every three months, or more often if required by the provider.
Controlled medication refills are not guaranteed and are based on clinical judgment, safety, compliance with treatment, appointment attendance, medication monitoring, and applicable laws and regulations.
Urine Drug Screen Policy
Initial medication management appointments may require a urine drug screen for patients age 12 and older when clinically indicated or required by practice policy. Urine drug screens may also be required during ongoing treatment based on medication type, provider discretion, safety concerns, treatment compliance, or applicable program requirements.
Medication management urine drug screens may be billed to insurance when allowed. If not covered by insurance, the self-pay rate is $25.00.
Therapy-related urine drug screens, when required, are self-pay only and cannot be billed to insurance.
Refusal to complete a required urine drug screen, suspected tampering, inability to provide a specimen when required, or inconsistent results may affect medication prescribing, treatment recommendations, or continuation of services.
Telehealth Appointment Policy
Telehealth may be offered when clinically appropriate and allowed by law, insurance requirements, and provider discretion. Not all services or situations are appropriate for telehealth.
All patients must have a completed Payment Authorization Form and a valid card on file before scheduling or attending telehealth appointments. Payment is due by 10:00 a.m. on the day of the appointment unless other arrangements have been approved in advance.
Patients are responsible for being in a private, safe, and appropriate location for telehealth appointments. Patients may not attend telehealth appointments while driving, in a public place where confidentiality cannot be protected, or in any situation that interferes with safe and effective care.
A telehealth link may be sent by text or email at the time of the appointment. Patients are responsible for ensuring that their phone number, email address, and portal information are current.
Billing Practices and Financial Agreement
If I choose to use insurance, my provider must submit certain information to my insurance company for billing purposes. This may include my name, date of birth, diagnosis code, service date, type of service, CPT/procedure code, provider information, and other information required to process my claim.
By providing my insurance information and requesting that the practice bill my insurance, I authorize the practice to release the minimum necessary information required to process claims, obtain payment, complete authorizations, respond to audits, and conduct healthcare operations.
I am responsible for all amounts not paid by insurance, including copayments, coinsurance, deductibles, denied claims, non-covered services, missed appointment fees, late cancellation fees, and any balance remaining after insurance processes the claim.
Copays are due at the time of service. Required copays must be paid in full in order to attend the appointment. If I have an outstanding balance, at least 30% of the balance must be paid before being seen unless a payment arrangement has been approved by the practice.
Acceptable forms of payment include cash, check, debit card, credit card, and flexible spending or health savings cards. If a check is returned for insufficient funds, I understand that I will be charged a $35.00 returned check fee.
The practice reserves the right to temporarily suspend scheduling, cancel future appointments, or require payment arrangements if my account has an unpaid balance.
No-Show, Late Cancellation, and Late Arrival Policy
Appointments are reserved specifically for each patient. A minimum of 24-hour notice is required to cancel or reschedule an appointment.
If I cancel or reschedule with less than 24-hour notice, I may be charged a $25.00 late cancellation fee.
If I miss an appointment without notice, this is considered a no-show and I may be charged a $50.00 no-show fee.
Insurance companies do not pay for missed appointments or late cancellations. I understand that I am personally responsible for these fees and that they must be paid before my next appointment.
Patients are expected to confirm appointments through the practice’s text, email, or reminder system when confirmation is requested. Failure to confirm may result in the appointment being canceled or offered to another patient.
If I arrive late, my provider may not be able to see me, and the appointment may be considered missed or canceled late depending on the circumstances and provider availability.
Repeated Missed Appointments and Discharge from Practice
I understand that repeated no-shows, late cancellations, missed appointments, or failure to follow treatment recommendations may result in discharge from the practice.
Patients may be discharged if they have two consecutive missed appointments or three total no-shows. If discharged, I may be provided with referral resources when appropriate.
Controlled medication refills, routine medication refills, forms, letters, and ongoing treatment may not be continued after discharge except as required by law, ethical standards, or provider discretion.
Treatment Termination and Referral
Treatment may end when goals are met, when services are no longer clinically appropriate, when the patient chooses to stop treatment, when the patient does not comply with practice policies, or when the provider determines that the patient needs a different level of care or service.
If, after intake or during treatment, my nurse practitioner, therapist, or other provider determines that my needs are outside the scope of the practice or provider, I may be referred to another provider, specialist, emergency service, or higher level of care.
Communication with the Practice
Patients should contact the practice by calling 843-945-1452 during regular business hours for scheduling, billing questions, records requests, medication questions, portal assistance, or general concerns.
Patients should not contact clinicians or staff through personal social media accounts, including Facebook, Instagram, TikTok, personal email, or personal phone numbers. This protects patient privacy, confidentiality, and professional boundaries.
The practice may use phone calls, voicemail, text messages, email, and the patient portal for administrative communication, appointment reminders, paperwork reminders, billing reminders, and other practice-related matters. Patients are responsible for keeping contact information up to date.
Text messages and email may not be appropriate for emergencies or urgent clinical concerns.
Medication Questions and Refill Requests
If I miss, cancel late, or fail to attend a required medication management appointment, my medication may not be refilled until I am seen by my provider. Prescription and refill requests may take 3-5 business days to process, therefore it is patients responsibility to call the nurse line or send their provider a patient portal message.
Refill requests are not reviewed after hours, on weekends, or on holidays unless otherwise stated by the practice.
Medication changes, side effects, controlled substance requests, early refill requests, and urgent medication concerns may require an appointment.
Early refills, replacement prescriptions for lost or stolen medication, dose changes, and medication changes are not guaranteed and must be reviewed by my provider.
If I am experiencing a serious medication reaction, allergic reaction, chest pain, difficulty breathing, severe confusion, suicidal thoughts, or other emergency symptoms, I should call 911 or go to the nearest emergency room.
Crisis and Emergency Policy
This practice is not an emergency crisis response provider and does not provide 24-hour crisis services.
If I am experiencing a life-threatening emergency, danger to myself or others, suicidal thoughts with plan or intent, homicidal thoughts, overdose, severe medication reaction, or any immediate safety concern, I should call 911 or go to the nearest emergency room.
For mental health crisis support, I may call or text 988 to reach the Suicide & Crisis Lifeline.
Confidentiality and Privacy
I understand that my treatment information is private and protected by law. The practice will not release my protected health information without my written permission except as allowed or required by law.
Exceptions may include, but are not limited to, suspected abuse or neglect of a child, vulnerable adult, or elder; risk of serious harm to self or others; court orders; medical emergencies; insurance billing; healthcare operations; audits; licensing or regulatory requirements; or other situations required or permitted by law.
Additional privacy information is provided in the Notice of Privacy Practices.
Patient Portal and Paperwork Policy
Patients are responsible for completing required intake paperwork, consent forms, annual updates, screening tools, insurance updates, demographic updates, and payment forms as requested by the practice.
Failure to complete required paperwork may delay scheduling, prevent the appointment from occurring, or result in cancellation of the appointment.
Patients are responsible for keeping portal access, contact information, insurance information, emergency contacts, pharmacy information, and payment information current.
Minor Patients and Guardian Consent
For patients under the age of 16, a parent or legal guardian must provide consent for treatment unless otherwise allowed by law.
The practice may request custody paperwork, guardianship documents, court orders, or other legal documents before providing treatment to a minor.
Parents and guardians are expected to participate in treatment as clinically appropriate and to follow provider recommendations regarding appointments, paperwork, safety planning, medication management, and coordination of care.