Asheville Holistic Healthcare, LLC
Kris Hanvey, PMHNP-BC, CCIT
5 Ravenscroft Dr.
Asheville, NC 28801
828-333-7064
www.Ashevilleholhealth.com
email: hanvey.kris@gmail.com
Treatment consent Form
Thank you for allowing me to provide care to you. I am a psychiatric mental health
nurse practitioner board certified to treat children and adults. I am able to prescribe
medicine within the scope of psychiatry only. I work under the supervision of David
Cook, MD a psychiatrist in private practice in Weaverville, NC. We consult at least twice
yearly and as needed when difficult cases arise.
Additionally I have a master’s certification in complementary and integrative therapies
from Drexel University. This certification includes courses in herbology, aromatherapy,
nutrition and self-care. I am a Phoenix Rising Yoga Therapist; having received a 650
hour training certification. I have been a Reiki Master since 2003 and a yoga teacher
since 1999.
I am not… a doctor, psychiatrist or dietitian.
I hope this answers your questions on my credentials. If not, please do not hesitate to
ask questions. I feel strongly that you are a partner in your own care.
Services Offered:
Psychotherapy
Psychotherapy or talk-therapy is a powerful treatment for many mental complaints. It offers
benefits of improved interpersonal relationships, stress reduction and a deeper insight into one’s
own life values, goals and development. It requires a great deal of motivation discipline and
work on both parties for a therapeutic relationship to be an effective one. Clients will have
varying success depending on the severity of their complaints, their capacity for introspection
and their motivation to apply what is learned outside of session.
Clients should be aware that the process of psychotherapy may bring about unpleasant
memories, feelings and sensations such as guilt, anxiety, anger or sadness, especially in its
initial phases. If this occurs, it is very important to address these issues in session. Usually
these unpleasant sensations are short lived.
At your initial visit, I will conduct a thorough review of your current complaints and of your
background. By the end of the initial visit I will offer my preliminary impression, and we will
discuss your treatment options. Sometimes, psychotherapy alone will suffice. Often times,
however, a combination of psychotherapy, medication and other modalities will be
recommended.
Medication
Medication may be indicated when your mental symptoms are not responsive to psychotherapy
alone. When a mental illness impairs your day to day functioning, medication often can bring
relief especially for acute symptoms like impairment in sleep, eating, crying, suicidality. If this is
the case I will discuss different medication options for you so together we can decide on the
best treatment plan. It is always within your right to choose not to take medication or to engage
in therapy. I will present information in language that is understandable and will go over
risks/benefits; major known side effects and any concerning drug interactions to be aware of
and then you can decide to opt for meds or other treatment modalities.
If you are receiving therapy from another source you can receive medication management
alone. It is important to let me know this so I can coordinate care with other providers. It is
important to not have more than one provider prescribing your psychiatric medications.
Frequency and duration of visits
The initial appointment will be at least an hour. Subsequent therapy sessions will average 45
minutes in duration. Medication follow up appointments will take approximately 30 minutes.
Clients initially will be scheduled every week until stabilized and then monthly thereafter.
Occasionally when stable with medications; appointments will be every two to three months.
Fees
Initial Assessment $150
Medication management: $70
Medication management with psychotherapy (inclusive of mind/body training) $100
Individual Psychotherapy (inclusive of mind/body training) $90
Family Therapy with Patient: $100
Family Therapy without patient: $90
Phoenix Rising Yoga Therapy $75
Reiki $60
Missed appointment: 50% of office charge
Cancellation and No Shows
If you must cancel or reschedule an appointment, I require at least 24 hour notice. Canceling
that occurs with less than 24-hour notice or failure to show will result in 50% office charge.
Payment
I expect payment at the beginning of each session, unless otherwise agreed upon. At this time I
take cash or check only.
Insurance policies
At this time I am considered out of network with most plans. I will work with your insurance
carrier to give information for out of network reimbursement. Most PPO reimburse at 20-60% of
fees after deductibles are met.
Medical Records
I am required by law to keep complete medical records. My medical records will be kept in a
locked and secure place in my office. I will be the only one to have access to them. If you
would like a copy of your records you are entitled to this (See HIPAA privacy law copy
document). There may be a nominal fee to print/copy. I will be glad to review your records with
you at any time, if you would like for me to do this with you, please ask.
Confidentiality
The security of your sensitive information is of utmost importance to me and I am bound by law
to protect your confidentiality. There are exceptions to confidentiality, when disclosure is
mandatory.
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If you a danger to yourself or others
In legal hearings if I am court ordered to release information
If you are suspected of being abuse (as a minor) or are abusing a child
If mental illness prevents you from taking care of yourself and you are at risk of death or
severe injury
My Practice
While I share an office with other medical health professionals, I am not a part of a group. I will
be the only person who will be able to access your records unless you have signed a consent
for me to share information with another provider.
Contact Information
My phone number is: 828-333-7064 my mobile phone is password protected. I will answer each
call within the same business day if received before 3 pm. If after 3 pm I will answer routine
calls by the next business day. If you are experiencing an emergency, do not delay in receiving
immediate medical or psychiatric attention through the nearest emergency room or by dialing
911. For urgent calls, I will return as soon as I receive.
Your Rights Regarding your Protected Health Information (PHI):
Right to Inspect and Copy: You have the right to inspect and copy your PHI that may be used to
make decisions about your care.
Right to Amend: If you feel that any PHI we have about you is incorrect or incomplete, you may
request an amendment as long as the information is maintained at my office.
Right to an Accounting of Disclosures: You have a right to request a list of disclosures that have
been made of your PHI.
Right to request Confidential Communications: You have the right to request that we
communicate with you regarding your PHI in a certain way. For example, you can ask that you
only be contacted you at home or by mail.
Treatment
By signing below, you certify that you have read and understand the terms stated in this
Treatment Consent Form and privacy notice and have received a copy of this. You indicate that
you understand the scope of my services, session structure, fees, cancellation/no-show policy,
payment policy, insurance reimbursement, the nature of my practice, and my contact
information, HIPAA Privacy Notice and that you agree to abide by the terms stated above during
the course of our therapeutic relationship.
Client Name (please print): __________________________________ Date:_______________
Client
Signature:____________________________________________________________________
Witness:_________________________________________________________Date:________