Inge Gisela Bundchen, FPMHNP-BC
Serenity Psychiatric Health/In Sync Psychiatric Clinic
143 N. McCormick St., Suite 103
Prescott, AZ 86301
928-899-7784
Welcome to the practice of Inge Gisela Bundchen, FPMHNP. Every effort will be made to be sensitive
to your needs and assist you in addressing the concerns that brought you here. In order to help you, it
is important for you to understand the following policies. Please read and sign this form to
acknowledge your awareness.
Confidentiality
All matters regarding your psychiatric treatment will be kept confidential except when disclosure is
required by law. Disclosure is required where there is a responsible suspicion that a child, elderly or
disabled person is being abused. It is also required when a client presents a serious danger to
themselves or others. It may also be required as part of a legal proceeding. In the case of minors and
those under a guardian’s care, the right to confidentiality is protected in the same way. Sometimes
other professionals are consulted by the clinician. Names are not used without permission from the
client.
Availability
My office hours are ordinarily Monday through Friday from 8:00 to 5:00. I typically return phone calls
within 24 hours. I do not accept text messaging or e-mail, due to liability concerns. Please feel free
to call if you are having any significant problems that you feel require intervention before your next
appointment. For urgent matters you may leave a message for me at the phone number above.
Medication refills should be requested at least two business days in advance, to ensure a timely
refill.
If you need to reschedule or cancel an appointment, please do so as soon as possible, to avoid
a late cancellation charge (see financial responsibility policy).
Emergencies
In the case of a mental health emergency or severe adverse medication reaction, please go to the
nearest emergency department or call 911. Please be aware that I do not provide emergency
mental health services and that I am often not available outside of my business hours.
Client Rights
You have the right to receive information about treatment methods, progress of treatment (if
measurable) and fee structure. You also have the right to participate in setting treatment goals, to seek
a second opinion from another clinician, or to terminate the treatment at any time.
Patient Signature: _____________________________________ Date: ___________________
Guardian Signature: ___________________________________ Date: ___________________