The undersigned, client/client's legal guardian, voluntarily consent to outpatient treatment for mental health, co-occurring, and/or substance use disorder(s) and authorize Mindfully, LLC (MINDFULLY) to provide such outpatient treatment that is determined to be medically necessary or otherwise appropriate. These services may include individual or group counseling/therapy, Diagnostic Assessment, and Psychological Testing.
DESCRIPTION OF SERVICES
Our clinicians typically see clients Monday through Saturday, although sometimes Sunday appointments are available. We share this suite with our colleagues, and we provide ongoing supervision for each other. Many of our clinicians do offer tele-therapy as a service as well.
We provide Individual, Family, Couples and Group Counseling and are happy to discuss these options with you.
If a crisis occurs when we are not in the office, you may call our main number 888-830-0347 and you will be directed as to how we may be reached.
Your clinician cannot engage in multiple relationships with you. This means the clinician can only have one role in a family. The clinician cannot be the individual clinician for family members or siblings unless the therapy is 'family therapy' or 'couples counseling'. In any case where there are multiple persons involved in the treatment, only one will be the primary client and all documentation is kept under that client name (as well as billing is done under one client). This means that not everyone present would have the same access to the chart. Your clinician can explain this to you/your family. Furthermore, no multiple relationships means that your clinician cannot purchase items from you, receive gifts from you or be in any other relationship with you (spiritually, financially, emotionally, familial, political, administrative, legal, through social media, etc.).
We view the therapeutic relationship as a partnership that is principally dedicated to your growth and to finding solutions. Part of our job is to remind you of your own strengths and abilities while you go about the business of creating more of the type of life that you want.
As with any type of treatment, there is the chance that it may not be helpful. The "fit" between client and clinician is important to an effective treatment outcomes. In the beginning of treatment, you may feel worse before you feel better. Therefore, we want to hear from you throughout our work together about how we are doing - so that we can make any adjustments needed to help you more effectively. it is your right to transfer clinicians if you feel your clinician is not a good fit. Please call and let us know, we are happy to assist in this process.
If you believe your rights have been violated, you have a right to discuss your concerns with our clinical director by calling our office and requesting the call, filing a complaint with the State Clinician, Social Worker, and Marriage and Family Clinician Board, transfer to a different clinician within Mindfully and/or terminate services at Mindfully.
CONFIDENTIALITY
Information discussed within the therapy setting is held confidential and will not be shared without written permission except under limited situations which under reasonable circumstances would be discussed with you before disclosure is made. These situations include revelations of unreported child or elder abuse, imminent suicide or harm to others, or reports of exploitation by a clinician.
Our practice is only to release clinical notes generated from your contact with us. We do not release raw materials or records obtained from third parties.
WAIVER OF LIABILITY FOR NON-APPROVED SERVICES
State law requires MINDFULLY to inform the undersigned that if your insurance company did not give prior approval for therapy services and you choose to have services provided, you would be required to pay for the services. My signature acknowledges I have read and understand the above. If my insurance company denies payment, I agree to be personally and fully responsible for the payment of all services incurred. These services include both formal and informal letters, appearances in court, reports, and extended phone calls.
Possible Risks of Tele-Mental Health Treatment
There can be difficulty for both parties to pick up on visual, non-verbal, or gestural cues.
Differences in connection speed can lead to disconnection or interruption.
We will make every effort to eliminate disruptions and interruptions on our end, however we cannot predict whether you will feel completely secure in the privacy of the session.
Feeling anxiety if symptoms increase during session. Loss of confidentiality if using a public computer, a computer on a shared network, or if others are present in your setting.
CLIENT FINANCIAL RESPONSIBILITY AGREEMENT
Payment is expected at the time of service. You are responsible for the charges. If you are paying through your insurance, you are responsible for your co-pay or deductible at time of service and for any amount left unpaid by your insurance. We can provide you with an estimate of what you will owe per service. It is your responsibility to call your insurance to verify.
Additional fees will be charged for letters, appearances in court, reports, and extended phone calls. These services are not covered by insurance. Your clinician will discuss any additional fee with you before it is charged. These additional fees can include phone calls between you and your child's clinician if the child is a minor. Payment is required prior to any letters being released or calls made on your behalf at your request to third parties. Written consent for these services involving third parties will be required prior to the contact as well via a completed release of information form.
In consideration of services received or to be received, the undersigned requests that payment of authorized insurance benefits, including Medicare, if the client is a Medicare beneficiary, be made on the client's behalf to MINDFULLY for any services provided to the client. It is my responsibility to notify MINDFULLY of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined by MINDFULLY and/or my mental health care insurer if the submitted claims or any part of them are denied for payment. The undersigned acknowledges that by signing this form I am accepting financial responsibility as explained above for all payment for services received. I acknowledge that I am financially responsible for all charges associated with mental health services provided by MINDFULLY to me. I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance.
I authorize the release of any information concerning my health care, advice and treatment provided for the purpose of evaluation and administering claims for insurance and/or employee assistance program benefits. I also hereby authorize payment of insurance and/or employee assistance program benefits otherwise payable to me directly to the clinician/MINDFULLY.
AUTOMATIC PAY AT TIME OF SERVICE BILLING
Appointments require a credit card on file. This card will be run after your appointment time has ended. If you do not already have a card on file with Mindfully please do so using your Inbox health billing portal.
To be sure our billing team has your most accurate information, please update your insurance information by bringing your insurance card to your next appointment or by calling our office.
MEDICARE PAYMENT
I, the undersigned, certify that any information given by me in applying for payment under Title XVII of the Social Security Act is complete, accurate, and current. As a Medicare Beneficiary, My child has the right to receive Medicare covered services. I acknowledge that I have the right to be involved in any decisions about my treatment and services and who will pay for them.
LATE CANCELLATIONS, MISSED APPOINTMENTS
I understand that I am required to provide at least 24 hours' notice if I (or the client named below) are unable to keep a scheduled appointment. In the event that I do not provide 24 hours advance notice, I acknowledge that MINDFULLY has the right to charge me for the scheduled appointment. If I fail to cancel a scheduled appointment, and do not come to set appointment at my (or the client's) scheduled appointment time, I understand that MINDFULLY will charge me $50 for the scheduled appointment. I agree to pay MINDFULLY $50 for late cancellation or missed appointment charges incurred.
Returned Check Fee: MINDFULLY charges a fee for any check returned by my financial institution, regardless of reason. In such event, I agree to pay MINDFULLY the returned check fee of up to $50.
Delinquent Account: I understand that MINDFULLY may turn my account over to a collection agency if I do not pay on a timely basis. MINDFULLY has a separate collection policy, which will be provided to me if I ask for it. I also understand that if my account is sent to a collection agency a 35-50% surcharge will be applied to the balance by the collection agency.
ANCILLARY SERVICES - Prices are based on State regulations and are subject to change. These are any extra services not covered by your insurance.
1.Letter or Report writing- Payment is required prior to writing the letter.
2.Telephonic Services-Coaching calls will not apply if enrolled in full DBT.
3.Court Related Charges-Your clinician will not go to court voluntarily. Please understand that when your clinician goes to court other clients have to have their appointments cancelled for the week. The Magistrate or Judge hearing your case must subpoena the clinician.
The office may receive a retainer cost of $500.00 prior to the clinician blocking out their schedule to appear in court. Cost is hourly from portal to portal.
Any additional charges over that will be billed to you following the hearing.
In the event the clinician believes that testifying in court would be detrimental to the therapy process the clinician may hire their own attorney to have the subpoena overruled. Any legal fees resulting from this action will be charged to the client that has requested the clinician's appearance.
Electronic Communication
If you elect to communicate with your child's clinician by e-mail or text messaging througout your child's counseling treatment, please be aware that e-mail and texting is not completely confidential. There are risks associated with e-mail and text messaging as outlined below:
All e-mails and text messages are retained in the logs of the e-mail/phone/internet service provider.
Although under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers.
Copies of e-mails and texts may exist even after the sender and/or the recipient has deleted his or her copy. E-mail and text senders can easily misaddress an e-mail or text and send the information to an undesired recipient.
E-mails and texts can be intercepted, altered, forwarded or used without authorization or detection.
Conditions for the use of email and texts:
As your clinician, I cannot guarantee but will use reasonable means to maintain the security and confidentiality of e-mail and text information sent and received, including a passcode lock on my phone.
E-mail and texting are not appropriate for urgent or emergency situations. I cannot guarantee that any particular e-mail and/or text will be read and responded to within any particular period of time.
E-mail and texts should be concise. Unless we have agreed to a specific exception, sensitive or complex situations should be discussed in a phone call or during a scheduled appointment, not on e-mail or text.
If texts or e-mails contain information relevant to your child's treatment, they may be retained in your medical record, or a summary of the content may be included in a clinical note in your record.
If you choose to use e-mail or text messaging, you agree that I may reply to your email and text messages, and that I may include any information that I deem appropriate, including information that would otherwise be considered confidential.
You agree that if you do not receive a timely response from an e-mail or text message to me, that you will follow up with a phone call to me.
If you choose to use e-mail or text messaging, you agree not to hold me liable for improper disclosure of confidential information that is caused by you or any third party.
By signing below, you agree that you have read and understand the risks associated with communication via e-mail and text messaging, and that you consent to the conditions outlined above.
Communication Plans and Policies
In the event that there is a technical failure, both parties should re-launch the program and attempt to re-connect. If this is not successful, the clinician will call you at the phone number provided at intake.
You child will be able to join the virtual 'waiting room' prior to the appointment start time. Please plan on signing on for your session 5-10 minutes prior to be sure that your child's webcam, microphone and internet connection are all working as expected.
Please note that in order for us to provide tele-mental health services the clinician that you see must be licensed in the state in which you live. Please verify the time zone of your appointment times.
SUPERVISED TRAINING CONSENT
Part of our mission here at MINDFULLY is to provide excellent training to upcoming professionals. All of our professionals in training work under the close supervision of qualified supervisors. We sometimes use audio/video recording for training purposes. Those present are made aware and always have the option to refuse. These recordings are used strictly for training purposes. Without exception, the staff at MINDFULLY is trained in and expected to adhere to privacy practices. (Please check the appropriate box)*
I agree and consent to my child's participation in supervised training sessions with audio/video recordings upon my permission.
I agree and consent to my child's participation in supervised training sessions without audio/video recordings.
I do not consent to my child's participation in supervised trainings.
I, the undersigned, agree to abide by MINDFULLY's policies and procedures and recognize that my compliance will minimize the danger of accidents or injury to myself, other clients and employees of MINDFULLY. I, the undersigned, acknowledge responsibility for myself and my actions and liability arising or resulting from my actions/omissions while I am being treated at MINDFULLY. I, the undersigned, acknowledge that MINDFULLY is not responsible to me or my property for the actions/omissions or any liability arising from the actions/omissions of any other clients at MINDFULLY.
* All the checkboxes below are mandatory.
I read and understand the Description of Services
I read and understand the Client Financial Responsibilities Agreement
I read and understand the Supervised Training Consent
I understand that a copy of the Notice of Privacy Practices (HIPAA) is available for me to read (link - https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html?)
I, the undersigned, understand that at any time I may elect to participate in other services or refuse any services, treatment, or therapy upon full explanation of the expected consequences of such refusal.