Consent Form: Mobile

Hey ___,

I need to provide you with some information about my company's policies.

Scheduling for therapy appointments:

1. Shoot me a text each week anywhere between Monday, Tuesday,

   Wednesday, Thursday or Friday

   between 10:00 AM to 6 PM Eastern Standard Time.

2. Let me know in the text what day and time you will be available

   for the following week.

3. Let me know if you would prefer Facetime, Zoom, phone calls or a different

   method for video or voice calls.

4. Let me know if you are okay with me sending text messages and

   automated text messages to confirm appointments, perform wellness checks

   and provide information and consent forms for future treatment.

5. Note that if you want medication management services via associated psychiatrist on staff, please first call 215-533-3660 and leave a message with the information requested for. Please listen to the entire automated message prior to sending in your information.

6. You can leave a message to our business via telephone voice message at the office number 215-533-3660, or via our business e-mails. Dr. Shan Psychiatry Clinic email is: yangshan@msn.com Shan Counseling LLC e-mail is: AliceYingShan@gmail.com

7. Please note that all insurance related payment has to comply with HIPPA laws of the state of PA in the United States and should not be done over the internet alone and should follow the rules based process as indicated by local, state and federal regulations. Please look up the rules of this process here before proceeding with any payment: https://www.hhs.gov/

   If you consent to these agreements, and want to make an appointment, please feel free to donate $20 - $50 via the link below after making an appointment via scheduling service.

   https://www.paypal.com/donate/?hosted_button_id=DGZZP6UMREF6G

8. By clicking and donating above you agree that you have read and understood all applicable rules as here-in stated in this consent form and also have read all applicable rules related to the payment processors utilized to pay for any amount processed.