Private Access Psychiatry

Adult Intake Confidentiality Agreement

This agreement accompanies the Adult Intake Packet and is intended to support a private, respectful intake process.

Important: This document is an administrative confidentiality acknowledgment. It does not replace the practice’s Notice of Privacy Practices, informed-consent materials, emergency guidance, or any legal rights and obligations that apply to your care.

Confidential handling of intake information

I understand that the information I provide in my intake packet is sensitive health information. I will use the practice’s secure intake process to return completed materials and will avoid sending completed forms through ordinary email, text message, or other unsecured channels.

My responsibilities

I agree to provide accurate information, keep my portal access private, and notify the practice promptly if I believe my account or documents may have been accessed by someone else. I understand that I may ask questions about privacy, records, and communication preferences before or during my consultation.

Limits and questions

I understand that confidentiality is governed by applicable law and the practice’s privacy materials. I may contact Private Access Psychiatry with questions before signing or submitting this acknowledgment.

Adult patient name

Signature

Date