Informed Consent, Patient Services, and Financial Agreement

Last modified: 12/15/2025

By having provided LifeStance with my email address, I agree that we may send notices related to appointments, information on LifeStance services that are available, notices regarding online health portal messages, outstanding tasks, follow-up care, prescription(s), referral(s), billing/account balance, and other operational and informational messages.

By having provided LifeStance with my phone number, I agree to receive calls and text messaging (SMS) notifications for notices related to appointments, information on LifeStance services that are available, notices regarding online health portal messages, outstanding tasks, follow-up care, prescription(s), referral(s), billing/account balance, and other operational and informational messages.

A. INFORMED CONSENT TO TREATMENT

Mental Health, Behavioral Health, and Specialty Services. I am consenting to participate in and give Lifestance1 and its staff and employees permission to perform all necessary care and treatment involved in the mental or behavioral health care services provided to me including therapy and/or specialized services. I understand and acknowledge that engaging in such services involve assessment and treatment through various therapeutic approaches, which may help relieve symptoms, but could also involve risks such as experiencing uncomfortable emotions, discomfort, and emotional distress. I understand that I am encouraged to discuss any such symptoms with my clinician immediately. I also understand that any lifestyle and/or behavioral changes I choose to make from these services could adversely affect my romantic, family, and other relationships. However, I understand that these services also have many benefits, and I am willing to put forth the effort required, maintain an open and motivated approach to sessions, and tell my clinician(s) if I believe an aspect of services needs to change. I understand that there are no guarantees about projected outcomes and that additional referrals to better address the presenting challenges may be warranted. I recognize that outcomes vary and depend on my active participation in treatment. No specific results are guaranteed. My provider will discuss recommended treatments, the material risks and benefits, and any reasonable alternatives with me, and I have the right to ask questions, refuse any treatment, or withdraw consent at any time. I understand that I will no longer be considered a patient of LifeStance if I have 1) not been seen by a LifeStance clinician in the past 90 days, 2) no future appointment is scheduled, and 3) have not expressed a desire to continue services. We may change the services provided and/or advertised at any time without notice. I agree that my relationship with my LifeStance clinician will at all times remain professional and that I may review their qualifications and credentials on the LifeStance website or by asking them directly. If I have concerns about my care, I may share feedback with my clinician or through LifeStance’s Patient Feedback Form.
Minor Patients. If the patient is a minor and unable to consent to treatment independently, I represent to LifeStance that I am the patient’s parent or legal guardian, and I understand that the challenges described above pertain to my child/adolescent and may also apply to me as the parent/guardian. I acknowledge the potential increase in behavioral issues that may arise as difficult issues are processed and strategies to modify the behaviors are implemented. I understand there is a risk of disagreement between parents/guardians or between parents and mental or behavioral health services providers regarding treatment. LifeStance will work to resolve these differences in the interest of my child/adolescent’s mental health. However, parents/guardians will ultimately decide whether services will continue. I have received the Minor Patient Addendum and understand that it must be completed prior to the first service appointment. I have received the Caregiver Policy Acknowledgment and understand it must be completed prior to the first service appointment. I understand that a minor able to consent to treatment independently under state law will be deemed to have done so. I understand that once a minor is legally able to consent to treatment independently and does so, I will only have access to the minor’s mental and behavioral health care records and information if the minor consents to that access, or as otherwise required by law or a Court order. I agree to provide LifeStance Health with a copy of all legal documents, including divorce orders, custodial agreements and parenting agreements that specify or authorize individuals responsible for Medical Decision-Making (including Medication Management) for the minor, at or before the first appointment, and to supplement those documents as new orders or agreements are received. I also understand that if 60 days elapse following a request for these records without a response, LifeStance may discontinue treatment. For parents/guardians signing this agreement, if at any point the patient reaches the age of majority or independently consents to care and treatment, the minor’s parent/guardian is not the personal representative of the minor and does not automatically have the right of access to health information specific to the situation, unless the minor requests that the parent act as the personal representative and have access.
Couples, Family, or Group Therapy. I understand that if I participate in couples, family, or group therapy, the couple, family, or group (rather than myself, individually) will be considered the patient for confidentiality and other purposes. Accordingly, I acknowledge that the following will apply in such circumstances:
1. During couples, family or group therapy, the therapist will not reveal any individual’s confidences to others in the couples, family, or group therapy without the prior permission of that individual.
2. If one participant in the couples or family therapy requests the records from the therapy session, those records will NOT be provided to that individual without receipt of a written authorization from all individuals participating in the therapy session who are legally able to consent to disclosure of those records under applicable state law. Group therapy records are individualized, so the patient or their representative may request and receive those records with appropriate authorization.
3. If a request is made for couples or family therapy records as part of a court proceeding, those records will NOT be provided without written authorization from all individuals participating in the therapy session who are legally able to consent to disclosure of those records under applicable state law unless subpoenaed, or court-ordered to do so. If my records are subpoenaed or if a judge issues a court order for the therapy records, my therapist is legally obligated to comply. In the case of a subpoena, we will contact all individuals participating in the therapy session so I (and/or my attorneys) can take steps to contest the subpoena. If I do not contest the subpoena after being notified, we will obey it.
4. While LifeStance encourages all participants in couples, family or group therapy to keep such matters confidential outside of the therapy session, LifeStance is not responsible for one group participant’s disclosure of another’s confidential information. LifeStance does not permit participants in couples, family, or group therapy to record the session without express permission of all participants in the session.
Risk of In-Person Services. I understand I may have the option to receive treatment by telehealth and that by coming to the office, I assume the risk of exposure to airborne infections like COVID-19, the Flu, and other public health risks.
Telehealth Services. I understand that LifeStance clinicians may provide me with services via telehealth, and I authorize my LifeStance clinicians to do so at times in lieu of an in-person practitioner-patient office visit, when permitted by state and federal law. I also understand that telehealth is the delivery of healthcare services using technology when the healthcare provider and the patient are not in the same physical location. I acknowledge and agree to the following with respect to telehealth services:
1. Telehealth-based services and care may not be as complete as face-to-face services for certain patient needs and circumstances. LifeStance therapy services are not intended for and should not be used for urgent or emergency situations.
2. There are potential risks associated with telehealth technology, including interruptions, unauthorized access and technical difficulties, and neither LifeStance nor my healthcare provider will be liable for technology failures.
3. My healthcare provider or I may unilaterally choose to discontinue the telehealth encounter if it is determined the technology is not appropriate under the circumstances.
4. I have the right to withhold or withdraw my consent to the use of telehealth and/or telehealth services during my care at any time, without affecting my right to be referred for future care or treatment to a qualified provider who provides in-person care.
5. A variety of alternative methods of health care may be available to me from other healthcare providers, such as an in-person encounter in lieu of a telehealth encounter, and I may choose one or more of those options at any time from a provider who may, or may not be affiliated with LifeStance.
6. Telehealth may involve electronic communication of my personal healthcare information to other healthcare practitioners who may be located in other areas, including out of state or internationally when appropriate for providing me with care that I request.
7. All existing confidentiality protections apply to telehealth encounters, and I have the right to access all healthcare information related to telehealth encounters and to receive copies of such information at cost upon request.
8. All patient health information will be treated in accordance with LifeStance’s Notice of Privacy Practices.
9. People other than my healthcare provider may be present in order to facilitate the telehealth consultation, and I will be informed of their presence and have a right to object to any other individuals being present for an appointment.
10. I have the right to access healthcare records created as a result of a telehealth encounter in accordance with applicable state and federal patient privacy laws, and all records will be maintained in a manner that complies with state and federal patient privacy laws.
11. When using technology to facilitate healthcare delivery, there may be cultural or language differences that may affect the delivery of services.
12. There is the possibility of the denial of insurance benefits for telehealth encounters.
13. If requested, I will be provided with information regarding my healthcare provider(s)’ license number, physical location and contact information.
14. If requested, I will be provided with LifeStance’s social media policy, encrypting policy, policies on the collecting, documentation, tracking, and storage of my personal information.
15. It is my duty to inform my healthcare provider of electronic or in-person interactions regarding my care that I may have with other healthcare providers.
16. I may ask my healthcare provider any questions I may have regarding this consent before proceeding with a telehealth encounter.
Medication Data. I understand that information regarding medications currently in use can assist providers in tailoring therapy to be more effective and to assist in avoiding side effects or adverse reactions due to conflicting prescriptions. As an exercise of my individual right of access, I authorize my provider to access and import into LifeStance’s electronic patient record, all available information regarding drugs dispensed to me at any time in the past (collectively, “Dispensed Drug History”), regardless of source or circumstance. I understand that LifeStance will incorporate my Dispensed Drug History into its legal patient record and will only use or disclose my Dispensed Drug History as described in its Notice of Privacy Practices or as permitted or required by applicable law.
State Addendum. I acknowledge that I have accessed and reviewed the state-specific addendum applicable to the LifeStance location(s) providing my care.
Communication via Patient Portal. I understand that the best way to communicate with LifeStance providers and staff is via the secure and safe patient portal. I understand and appreciate that communication via the patient portal is strongly encouraged, so I agree to utilize the portal for communication as much as possible and as necessary.
Text/Email Communication. Prompt communication is paramount to addressing my mental health needs and as a result LifeStance utilizes multiple avenues of communication to ensure engagement. I understand that LifeStance may need to communicate with me about its services, my health, and my appointments via email or text messages. By providing my email address and telephone number, I hereby authorize LifeStance (and its service providers) to send me emails and texts regarding appointments, information on LifeStance services available, notices regarding online health portal messages, outstanding tasks, follow-up care, prescription, referrals, billing/account balance, service offerings, educational information, other operational and informational messages during my active care and after my last session, treatment until I unsubscribe or opt out of communications. I understand that I can opt out of receiving that type of text messages by texting “STOP” to the phone number from which I received the text message, and I can opt out of receiving emails by clicking the unsubscribe link in the email. I also understand that sending this information over unencrypted email or text creates the potential for unauthorized parties to intercept the information and that if someone else has access to my email or text account, they may see this information. I acknowledge that these kinds of unauthorized access could allow someone to know that I am receiving mental and/or behavioral health care or, in extreme cases, when combined with other information that may be available about me from other sources, lead to medical identity theft. I understand that message and data rates may apply for any messages sent between myself and LifeStance. I have been made aware that if I have any questions about my text plan or data plan, it is best to contact my wireless provider. I understand that LifeStance requires seventy-two (72) business hours’ notice to respond to medication refill requests. I understand that receiving text messages is voluntary and does not waive other communication rights. These text messages may be sent using an automatic telephone dialing system. My consent is not required as a condition of receiving medical care. I accept these risks. I specifically consent to receive marketing text messages.
Health Information Exchange. I understand that my medical information may be accessed and shared with a health information exchange (HIE) in the state that I reside. The HIE allows health care providers and patients to securely share and access medical information electronically to improve patient outcomes. I have the option to opt out and prevent my health information from being shared or viewed in my state’s HIE system. If I choose to opt out, my providers may not have immediate access to all the important information needed to make the best decision about my health care. I understand that more information is available on the sharing and accessing information in the HIE upon request. By signing this Patient Services Agreement, I agree to HIE access, sharing of all my medical information including sensitive health information, and understand that if I opt out, I may request to opt back in at any time. To opt out complete the opt out form which is available upon request from [email protected].
Consent for Recorded Communications and Appointments. By signing below and engaging with LifeStance via phone or during clinical appointments, I consent to the recording of these interactions. Phone calls may be recorded for clinical assessments, quality assurance, and internal training purposes, while appointments may be recorded through a digital note taker to create an accurate and timely record of care. This allows clinicians to focus fully on the conversation, enhancing the quality of care. Recordings of appointments may capture my voice and are transcribed shortly after the session, after which the audio is permanently deleted. All recordings, storage, and use of my data will comply with the Health Insurance Portability and Accountability Act (HIPAA) and LifeStance’s Online Privacy Policy. If I do not agree to these terms, I must notify LifeStance in writing to opt out and notify my treating clinician. My continued engagement signifies my acceptance of these conditions. I understand that I have the right to withdraw my consent at any time and am encouraged to discuss any questions or concerns with my clinician.
Use of Artificial intelligence (AI) and Technology Tools. I hereby consent to the use of artificial intelligence (AI) technology tools. These tools may assist my clinician with tasks such as drafting visit notes, analyzing clinical data (e.g., coding suggestions, test results, treatment plans), providing clinical insights, or automating administrative and communication functions, solely to augment my provider’s expertise. AI tools are not used to independently deliver care nor will it be used to engage in “therapeutic communication” with patients. The tools may record and retain calls or appointments, ambient recordings, in accordance with our applicable privacy and security standards. These tools are strictly limited to supporting my clinician’s professional judgment and improving administrative efficiency and do not provide mental health care to patients. All AI-generated content is thoroughly reviewed by my licensed clinician, who retains full responsibility for my care. My Protected Health Information (PHI) will be processed in accordance with HIPAA and applicable privacy standards, which may include the recording or transcription of interactions. I understand I have the right to opt out of AI-assisted services at any time without affecting the quality of my care.
Training Organization Consent. I understand that LifeStance is a training organization dedicated to education and development of future mental health professionals. As part of this mission, students, residents, clinical interns, fellows, preceptors, observers, or provisionally licensed clinicians may be present during my sessions and/or treatment. I consent to their participation in my care under supervision, even if they are unlicensed, provisionally licensed, or in training. I retain the right to withdraw this consent at any time, even temporarily, without affecting the quality of my care, my relationship with LifeStance or my clinician.
Treatment Plan Acknowledgment. By executing this Patient Services Agreement, I acknowledge and agree to the Treatment Plan developed by my treating clinician. This plan will be reviewed with me periodically, and I agree to actively participate in these discussions. I will communicate any concerns, updates, or desired changes to ensure the Treatment Plan accurately reflects my goals and needs. I acknowledge that my involvement is essential to maintaining a collaborative and effective treatment process.
Patient Rights and Acknowledgments. By signing below, I acknowledge that I have received and had an opportunity to ask any questions about LifeStance’s Notice of Privacy Practices and the Patient’s Rights and Responsibilities. I agree and acknowledge that I have received, reviewed, and agree to abide by the Rights and Responsibilities document which outlines mutual expectations, including but not limited to that I will: participate in my care, not recording care sessions, be respectful of all LifeStance staff, etc. I understand that violations of these terms may result in corrective action, up to and including termination of services.
Non-Discrimination, Disability Assistance, and Limited English Proficiencies Support. I understand that LifeStance complies with applicable federal civil rights laws and does not discriminate, exclude, or treat any person differently on the bases of race, color, national origin, age, religion, disability, physical gender, sexual orientation, gender identity, or health status. LifeStance complies with Americans with Disabilities Act of 1990 or ADA (42 U.S.C. § 12101), and I understand that if I need assistance or tools, that I should let my LifeStance care center know so they can provide the appropriate accommodations and tools. I understand that I can email [email protected] for assistance and escalation. LifeStance desires to provide language assistance to individuals with limited English proficiency, so if I require translation or interpretation services or documents in another language, I should please inform the health care center prior to your appointment. I understand an outside vendor is used for these services and consent to their support as LifeStance’s HIPAA compliant business associate.
Digital Communications. I understand that LifeStance offers virtual telehealth care services and the ability to send and receive emails to and from the care team via the online health portal. Telehealth care uses technology to enable LifeStance providers to evaluate and treat patients as an alternative to an in-person office visit. I understand that my provider will determine whether a telehealth care visit is clinically appropriate. During my appointment, details of my medical history, examinations and diagnoses will be discussed. There are potential risks and technical failures when using telehealth care including interruption and/or disconnection of audio/video. I understand that patients have the option to withhold/withdraw consent to treat virtually at any time. While LifeStance takes many precautions to protect my information and the security of the emails it sends and telehealth care appointments, I appreciate that there are still risks and LifeStance cannot guarantee all digital communications are secure and confidential. I understand that LifeStance recommends that I do not send sensitive information through mobile text messages. Text messages can remain stored on portable mobile devices for an indefinite period and may be exposed to unauthorized third parties. I am responsible for protecting my email account password, mobile device or other means of access to my email and telehealth care appointments. LifeStance is not liable for improper disclosure of confidential information that is not caused by LifeStance’s misconduct. I understand that I am responsible for informing LifeStance Member Services if I want to cease or limit communications with LifeStance. I may do so at any time without reason or explanation. By signing this agreement, I acknowledge that I have read this section and understand the risks and benefits of using LifeStance’s digital communication methods. LifeStance’s electronic communications are secure and designed with the Health Insurance Portability and Accountability Act (HIPAA) standards in mind. However, transmitting sensitive information electronically has the inherent risk of a third-party’s unauthorized access. By permitting digital communications, I acknowledge and agree that I am aware of and accept these risks.
Website and Patient Portal. I understand that I must not attempt to bypass security protections on the LifeStance websites, introduce viruses or other harmful code, or use a LifeStance website to attack other website(s) or service(s). By registering for a user account on a LifeStance website, I understand and agree to keep my password confidential and not allow other people to use my account. I understand that if I input, send or upload information to a LifeStance website (other than the patient portal), that information may be used for any purpose, including commercial uses, product development, and advertising. Personal information will be handled in accordance with our Online Privacy Policy. I understand that I should not provide information that I want to keep confidential or that I do not have the right to post.
International Vendors. To support efficient response times on billing and administrative issues for patients, LifeStance Health may from time-to-time partner with international administrative vendors. This means my Protected Health Information (PHI), including claims data and demographic information, may be accessed by vendors outside the United States for processing purposes. All data continues to be stored securely within U.S. systems. I agree that by receiving care from LifeStance, I acknowledge and consent to this arrangement. LifeStance maintains strict contractual safeguards with all vendors to protect your PHI in accordance with all applicable HIPAA and privacy requirements.
Reviews and Social Media Consent. By posting reviews, testimonials, or social media content related to my experience with LifeStance, I understand that any public posting (e.g., on review platforms, social media, or forums) may disclose my status as a LifeStance patient or the status of another individual under my legal authority. I acknowledge and agree that LifeStance may, in its sole discretion, reproduce, modify, or display my publicly posted reviews, testimonials, or feedback (collectively, “Content”) for promotional, marketing, or informational purposes, including but not limited to, third-party review platforms (e.g., Zocdoc, Google Reviews), LifeStance’s official website, brochures, or advertisements, or welcome materials or communications for prospective patients. LifeStance will make reasonable efforts to avoid associating my full name with reused Content if my original post discloses such information. However, I acknowledge that other identifying details (e.g., usernames, partial names, or treatment specifics) may remain visible. I agree that LifeStance may use the Content without obligation to provide attribution, payment, or additional consent. LifeStance affirms that its use of Content will adhere to applicable laws, including HIPAA regarding protected health information and FTC guidelines for endorsements and testimonials. Requests to remove or modify Content must be made via the Patient Feedback Form located on the Company website, Contact Us page. LifeStance will comply with such requests where feasible but cannot guarantee removal from third-party platforms. I confirm that I have read and voluntarily agree to these terms.

B. FEES, THIRD-PARTY PAYORS AND SELF-PAY TIERS

I agree to pay LifeStance for all charges incurred for services LifeStance renders to me, and I assign to LifeStance any monies due and owing under my health insurance plan or other third-party payor, including government payors, worker’s compensation payors, personal injury case defendants, and medical benefits accident insurance payors (“Med Pay”). I understand that LifeStance may amend the fee schedule and its Terms of Service from time to time in its sole and absolute discretion and without prior notice but understand it will be available on the company’s webpage or upon request. I also understand and agree that:

Primary Payment Responsibility. I understand I am responsible for payment for all services provided by LifeStance and understand that some services may not be covered by insurance. It is my responsibility to ensure my health plan benefits can be used for LifeStance services. To verify, please call the number on the back of your insurance card. All LifeStance invoices for services and costs are due upon receipt, and all copay, coinsurance, and deductible amounts are due at the time service is delivered. LifeStance accepts credit and debit card (collectively “credit card”) payments. I understand that LifeStance uses a third-party service that facilitates in-person and online payment transactions and that LifeStance will not directly keep my credit card information on file. I grant LifeStance the right to automatically charge my credit card on file in each of the circumstances specifically identified in this agreement through the third-party service that LifeStance uses to facilitate credit card transactions.
Authorization to Bill Credit Card on File. I authorize LifeStance to charge the credit/debit card provided (the “Card”) for all outstanding balances, including but not limited to, co-payment and co-insurance amounts, self-pay fee schedule amounts, no-show/cancellation fees, other administrative fees, and any balance remaining after insurance adjudicates the claim relating to services provided to the patient. I understand that it is my responsibility to ensure that the information for the Card on file is current at the time of service, as necessary, and that if payment is declined, LifeStance may decline to provide new services until payment is received or a new Card is put on file. I certify that I am an authorized signer for the Card with all necessary rights to authorize the charges. While most charges will usually occur within ninety (90) days after care is rendered, this timeline may vary depending on insurance claim processing. The Card will be used to collect any unpaid co-payments due, on or within three (3) days of the date of service. All other balance payments will be charged to the Card or other payment methods as determined by the patient after adjudication with the patient’s insurance company. Patients with a Card on file may receive an electronic notification detailing their outstanding balance at least five (5) calendar days before processing the charge. Terms may be updated periodically. The most current billing policies can be found in the online Credit Card On File and Financial Responsibility Policy. The exception to this process is for balances exceeding $500 will follow a separate collections process and will not be automatically charged to your Card without additional authorization. This process is subject to change and notice will be provided on the company’s website. Payments paid via a credit card may no longer be considered medical debt and are not subject to certain protections. I understand that I must notify LifeStance of Card changes/expirations. I may cancel this authorization in writing with thirty (30) days’ notice but understand that may disqualify me from receiving services at LifeStance as permissible under state law. THE CARDHOLDER NAMED ON THE CREDIT CARD ON FILE WITH US, OR ANY AUTHOIRZED USER OF THAT CARD, IS ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF ANY OUTSTANDING BALANCE ON THE ACCOUNT.
Patient Responsibility and Commitment, Cancellations and Missed Appointments. I understand that it is important to show up for my appointments with my clinicians, and to show up on time. A minimum of two (2) business days’ notice is required to avoid any fees for cancelled and missed appointments. If this notice is not received or if the patient fails to show for the appointment within the first fifteen (15) minutes of a scheduled therapy appointment or five (5) minutes of a scheduled medication appointment, I agree to be personally responsible for payment for the full amount for the time reserved for the appointment. I agree to and understand my obligation to pay the Late Cancellation/No Show Appointment fee stated in the State-Specific Addendum to this Patient Services Agreement. I grant LifeStance the right to charge my credit Card on file for that fee if applicable. I understand that health insurance does not pay for fees incurred for missed appointments. If unforeseen situations beyond my control arise, such as illness, bereavement, and accidents, etc., I will promptly provide LifeStance with documentation of same to avoid being billed for the full amount of the fee.
Third-Party Payors, Generally. I am responsible for all monies due and owing for services rendered by LifeStance that are not paid by a third-party payor. LifeStance will use the insurance information on file to bill for all applicable services. It is ultimately my responsibility to ensure that any third-party payor covers, and makes timely payment for LifeStance services. If any monies received by LifeStance from a third-party payor are later recouped from LifeStance any time after their receipt, I will be responsible for those monies recouped. I grant LifeStance the right to charge my credit card on file for all requested services or tests: (i) at the time of service; (ii) upon notice from a third-party payor that any full or partial charges are not covered by the third-party payor and/or (iii) if any previously paid amounts are recouped by the third-party payor.
Self-Pay Only with Health Insurance Coverage. If I have health insurance coverage that may cover some or all the services provided by LifeStance, but I choose to self-pay and not use insurance to cover any LifeStance services, I understand that I will be fully responsible for payment of all services at the time of service. I grant LifeStance the right to charge my credit card on file for all requested services or tests. By choosing this self-pay only option, I agree to not submit claims for LifeStance services to my health plan for reimbursement, and I understand that any payments I make to LifeStance will not be credited toward satisfying any deductible or cost-sharing obligations I may have under my health insurance plan.
Self-Pay Combined with In-Network Health Insurance Coverage. I understand that if my LifeStance provider is an in-network provider for my health insurance plan, LifeStance may not bill me directly for any services that are otherwise covered under my health insurance plan. I certify that I have verified that any self-pay services I request from my LifeStance provider are not covered services under my health plan. For any services or tests that are not covered by my health insurance plan, I grant LifeStance the right to charge my credit card on file for all requested services or tests at the time of service or upon insurance denial of coverage. For cost sharing, the right to charge my credit card on file for all requested services or tests at the time of service delivery or upon notice from the health insurance company that any LifeStance charges are the patient’s responsibility.
Self-Pay and Government Payors. I understand that most LifeStance clinicians are participating providers for government-sponsored health plans and that LifeStance may not bill me directly for any services that are otherwise covered for me by government payors. I certify that I have verified that any self-pay services I request from my LifeStance clinician are not covered services under any government-sponsored health plans under which I am a covered participant. I grant LifeStance the right to charge my credit card on file for all requested services or tests at the time of service or upon notice from the government payor that any LifeStance charges are the patient’s responsibility.
Self-Pay and No Health Insurance. If I do not have health insurance or qualify for government payor benefits for LifeStance services, I understand that I will be fully responsible for payment of all services at the time of service, and I grant LifeStance the right to charge my credit card on file for all requested services or testing. I understand that being a Medicare beneficiary disqualifies me from being a self-pay patient for LifeStance services unless my clinician has opted out of participation and I sign an annual private-pay services agreement.
Right to a Good Faith Estimate. I understand that if I am not enrolled in a health benefits plan or choose to not use my health benefits to pay for therapy services I have the right to receive a Good Faith Estimate for the total expected cost of services. Please submit a request for a Good Faith Estimate by calling LifeStance’s Billing Office. I agree that if I receive a bill from LifeStance that is at least $400 more than the Good Faith Estimate, I can dispute the bill by calling the LifeStance Billing Office. For questions or more information about my right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 844-256-9902.
Off-Label Treatments and Tests, Generally. Many clinically appropriate medications, assessments or treatments are not currently FDA-approved or are considered experimental by third-party payors and may not be reimbursable from third-party sources. I grant LifeStance the right to charge my credit card on file for all requested off-label treatment or testing not covered by third-party payors at the time of service or upon notice of denial of payment by a third-party payor.
Full Coverage for Testing and Assessments. Coverage and cost for psychological and psychiatric assessments and testing vary across different third-party payors, and I am responsible for the costs for the testing regardless of whether the costs are reimbursable by third-party payors on my behalf. This is because not all psychological testing services are covered by third-party payors. At times, third-party payors do not fully reimburse psychological testing services, even if provided by an in-network provider. There are a variety of situations when this occurs; for example, when: (a) the third-party payor does not consider psychological testing “medically necessary” for “experimental” or “investigational” diagnoses; or (b) when the third-party payor reimburses for fewer hours than those billed by LifeStance. I understand that I will be fully responsible for payment of all services upon service delivery or upon notice of denial of payment by a third-party payor. I grant LifeStance the right to charge my credit card on file for all requested services or testing not covered by third-party payors at the time of service or upon notice of denial of payment by a third-party payor.
Collections. If my account is turned over to an attorney or agency for collection, I agree to pay all costs of collection including, but not limited to, court costs and legal and collection fees. If my account is not paid when due, a service fee and/or interest will accrue as permitted by law.
Other Insurance or Litigation Payor Sources. Regarding any administrative or personal injury cases, I am responsible for fees incurred when due regardless of the outcome of pending litigation. The fees incurred will be in accordance with LifeStance’s standard fees for court testimony, depositions, and other litigation support as itemized in LifeStance’s then-current chargemaster. I grant LifeStance the right to charge my credit card on file for all requested services, fees or tests at the time-of-service delivery. If there are any remaining balance(s) due at the time of case settlement, I authorize and will require my attorney to pay my outstanding accounts with LifeStance in first priority for payment from the settlement proceeds. LifeStance does not accept contingency fee arrangements.
Med Pay Coverage. If I have Med Pay coverage, I permit LifeStance to classify and treat the Med Pay payor as the primary insurer over any other third-party payors. I irrevocably agree to a waiver permitting payment of Med Pay funds directly to LifeStance first in priority over me personally and any other potential claimant to the funds.
Forensic Legal Requests. I understand that forensic legal requests, conferences, and telephone calls involve additional time and record-keeping for LifeStance, and I am responsible for all direct costs and expenses incurred by LifeStance, and its attorneys and agents, in responding to discovery requests (including depositions and subpoena duces tecum time and labor costs) and relating to conferences (including, but not limited to, court appearances, preparation of reports, photocopying, faxes, , out of office travel, overnight delivery, and courier services). I grant LifeStance the right to charge my credit card on file for all such requested forensic legal services and documentation time.
Assignment of Benefits. I acknowledge and agree that LifeStance may receive payments directly from any third party for the non-covered health care services provided to me by LifeStance. I authorize LifeStance to release any information needed to determine whether the benefits are payable by a third party or their agents. In the event that I receive any payment from a third party for a non-covered health care service, I agree to turn over the payment in full to LifeStance. In addition to assigning all payments to LifeStance for services rendered, I hereby agree to assign all of my related rights and obligations under my insurance plan to LifeStance and its representatives, grant this limited power of attorney, including specifically the right to file claims, litigate and appeal claim denials and pursue causes of action under the Employee Retirement Income Security Act (ERISA) or other laws. I hereby permit a signature on file or copy of this Agreement to be used in place of my original signature.
Health Savings Account. Per IRS regulations, if I participate in a high-deductible health plan with a health savings account (HSA) feature, I may be required to pay a fair market value fee for certain available non-preventive and urgent services until my deductible has been satisfied. I understand that if I have an HSA and I do not pay on a fee-for-service basis for these services, I may lose my ability to contribute to my HSA.
Your Information. You agree to provide and update LifeStance with accurate personal information including but not limited to contact information and insurance information. Your failure to update this information may result in denied payments or inaccurate charges.

C. LEGAL PROCEEDINGS OR LITIGATION

Denial of Requests for Minor Records. I understand and agree that my child(ren) deserve to have a safe place to talk about his/her/their thoughts, feelings, concerns, and mental health. I understand that to the extent permitted by law, LifeStance and its employees will honor my child’s privacy to the extent it is possible to do so and will treat anything said in a session between a LifeStance clinician and my child(ren) as confidential. While I, as the parent, may be legally entitled to some information about my child’s therapy, especially if there are any safety risks to my child or others, I understand that LifeStance has the right to deny any request from me for a copy of my child(ren)’s confidential mental health care records, if in the good faith opinion of the clinician, circumstances warrant denial and/or that denial is permitted under or required by applicable state or federal laws.
No Subpoenas. Should there be legal proceedings (including but not limited to divorce and custody disputes), neither I, my attorneys nor anyone acting on my behalf will subpoena records from LifeStance or subpoena a LifeStance employee to testify in court, or in any legal proceeding such as, but not limited to, a deposition. If LifeStance or its employee is subpoenaed to provide records or give testimony in violation of this agreement, I understand that LifeStance will obey the subpoenas as required by law. However, I understand that this may present a conflict of interest for LifeStance, so LifeStance may terminate its professional, therapeutic relationship with me immediately and refer me and/or my child(ren) to other mental/behavioral health providers.
No Custody Evaluations or Recommendations. If a LifeStance employee is subpoenaed to give testimony in violation of this agreement, LifeStance and its employees will NOT provide custody evaluations or recommendations regarding access to or visitation with minor children. LifeStance employees will NOT provide legal advice or provide expert testimony or opinions.
Payment for Legal Work. I understand that if a LifeStance employee is subpoenaed to provide testimony in a court proceeding related to LifeStance services provided to me and/or my family, I will pay LifeStance for all of the employee’s services relating to that subpoena and testimony, including, but not limited to: travel, reasonable expenditures (copies, parking, meals, and the like), time spent speaking with attorneys, reviewing records, subpoenas, and other documents, and otherwise preparing for the testimony, as well as the time spent waiting to testify and testifying, at the rate of $75 per 15-minutes. The minimum rate for deposition and hearing testimony will be 3 hours or $900. I understand that while LifeStance may try to secure some payment from the requesting attorney for those fees, that assistance is not guaranteed, and I am obligated to pay any difference between what is recovered from the requesting attorney and the total amount I am billed for the LifeStance employee’s time on that legal matter.
Terms of Service. By using the LifeStance website, signing this Agreement and consenting to ongoing care, I understand that LifeStance has the right to revise the terms of this Agreement at any time in our sole discretion by posting the revised Agreement on the LifeStance.com website, without notifying patients before or after the changes. I agree that continued use of the Service after any such changes constitutes my acceptance of the revised Agreement. When changes are made to this Agreement, they will become immediately effective when published unless otherwise noted. I understand I should periodically review to see if changes have been made that may affect me. I have bene informed that if I do not agree to the Agreement as modified, then I must discontinue my use of LifeStance and its services and website. I agree that LifeStance may assign this Agreement at any time with or without notice. I understand that I may not assign or sublicense this Agreement or any of my rights or obligations under this Agreement without LifeStance’s prior written consent.
US Residents Only. The Services provided by LifeStance are only available to US residents and in the territory in which LifeStance has licensed clinicians. Those who choose to access a LifeStance website do so on their own initiative and at their own risk, and are responsible for complying with all local statutes, orders, regulations, rules, and other laws. I am subject to United States export controls and are responsible for any violations of such controls, including without limitation any United States embargoes or other federal rules and regulations restricting exports. LifeStance may limit a LifeStance’s website availability, in whole or in part, to any person, geographic area or jurisdiction it chooses, at any time and in its sole discretion. This Agreement, as well as all other documents related to it, including notices and correspondence, will be in the English language only unless otherwise requested.

D. PATIENT DISCHARGE OR TERMINATION

Discharge by a LifeStance Clinician. I understand that if any of the following occurs, my clinician MAY discharge me as a patient and provide referrals to other mental health professional(s), within LifeStance and/or at other health care facilities: (A) my provider believes that their approach, skills, and/or training are no longer appropriate for my (or my child/ren’s) specific concerns; (B) my provider believes that the goals of my (or my child/ren’s) treatment have been met and further services are no longer needed; (C) my provider believes that my continued failure to adhere to clinical advice creates a conflict of care for my provider, and/or has damaged the provider-patient relationship; (D) I (or my child/ren) move to a state where my provider is not licensed to practice; (E) I schedule a session, and then I (or my child/ren) do not show up for that session, and then do not call my provider within 14 days of that session, or if I (or my child/ren) frequently cancel or do not attend sessions with my provider; or (F) I choose to involve LifeStance or my provider in legal proceedings by issuing a subpoena for treatment records or testimony in court or in a deposition, or otherwise involving LifeStance or its employees in a lawsuit that I am a party to, and LifeStance determines that this creates a conflict of interest, or otherwise could damage the provider-patient relationship. In addition to any right or remedy that may be available to LifeStance under applicable law, LifeStance may suspend, limit, or terminate all or a portion of my access to services or its website or any of its features at any time with or without notice and with or without cause, including without limitation, if LifeStance believes that I have violated or acted inconsistently with the letter or spirit of this Agreement or the LifeStance Patient’s Rights and Responsibilities. LifeStance may be protected for liability from these actions under the Communications Decency Act, 47 U.S.C. § 230. This is not an exclusive list of the reasons why a LifeStance clinician may discharge me from their services.
Termination by LifeStance. I understand that if any of the following occurs, my clinician MAY terminate my (and/or my child/ren’s) care with that clinician AND with LifeStance, and LifeStance will provide referrals to other mental health professional(s) at other health care facilities: (A) LifeStance believes that I (or my child/ren’s) behavior, communications, and/or actions are oppressive, violent, abusive, a safety threat to LifeStance employees or patients, or constitutes harassment, stalking, discrimination, or a violation of federal or state laws; or (B) LifeStance believes that I have failed to comply with LifeStance’s financial policies and procedures. This is not an exclusive list of the reasons why LifeStance may terminate my care with that clinician and/or with LifeStance.
Final Decision. I understand that my provider’s discharge or termination decision will be final. If I request and authorize it in writing, my provider will confer with my new provider(s) to help with the transition.
Death, Incapacity, or Disability. I understand that in the event of my provider’s death, incapacity or disability, LifeStance will arrange for another provider to meet with me (or my child/ren), and to make appropriate referrals to other providers, if necessary, and will provide me with written notification of that transition and transfer.