Dear New Survivor,

Welcome to Sexual Violence Resource Center of the Bluegrass (SVRC), and thank you for choosing to work with us! Before your appointment, we ask that you complete the following:

• Client Information Form: You may have given us some of this information via phone, but the form will help verify accuracy. While several items are required (marked with an asterisk *), others may be provided based on your comfort level.
• Client Code of Conduct
• Client Rights
• HIPAA – Use and Disclosure of Protected Health Information
• Client’s Consent Form
• Client's Telehealth Consent Form

In the event of a late arrival, your session will end at its regularly scheduled time.

If you have any language/accessibility needs, please call to let us know before your appointment.

For questions about your appointment, please call our business office at (859)253-2615.

If you wish to talk to someone immediately, please call our crisis line at 1-800-656-HOPE (4763).

Thank you for your confidence in Sexual Violence Resource Center of the Bluegrass. We look forward to serving you!

Please complete the following section regarding your assault as you feel comfortable.

SVRC is committed to insuring that our offices are a safe and comfortable place for clients and staff alike. In order to insure that we can meet everyone’s need for respect, safety, and comfort, we ask you that you follow our Client Code of Conduct. We value you as our client. Please let us know if these or other issues surface that make you uncomfortable.

1. Please be respectful of our property, staff, and other clients:

• SVRC is a smoke-free facility and smoking is only allowed in designated areas outside of the building.
• Presence of weapons, threats or occurrence of violence is prohibited.
• Please do not park in accessible parking spots without the proper permit.
• Any damage to SVRC offices will be the responsibility of the individual, parent or guardian.
• Be considerate of others in our waiting room. Please avoid talking on cell phones, speaking loudly, or other behaviors that might disturb those around you.
• Coming to sessions under the influence of alcohol or other substances hampers effective therapy and you may be asked to reschedule your appointment.

2. Please respect our appointment policies:

• We are not an emergency medical center. If you are experiencing an emergency, please go to the nearest Emergency Room for evaluation, or call 911.
• After setting up initial services, appointments can be made/changed/cancelled by calling your individual counselor or therapist.
• Please be considerate and call your counselor or therapist if you are going to miss an appointment.

3. Please supervise your children:

• A parent, guardian or caretaker is expected to be responsible for children while in our offices.
• Young children should not be left unattended at any time. SVRC does not have staff to supervise unattended children.
• If you have an older child (13 or older) and wish to leave the premises during their session, please make sure that you return prior to the scheduled conclusion of your child’s session.
• Please clean up and remove any trash or disposable items such as diapers

4.  Additional Client Responsibilities

• To provide all personal and health information needed to provide you with appropriate care.
• To participate to the best of your ability in making decisions about your care, and to comply with the agreed upon plan of care.
• To ask questions of your provider when you do not understand any information or instructions.
• To maintain appointments as scheduled, or to reschedule in a timely fashion.
• To inform your provider if you anticipate problems in following recommended treatment.
• To be considerate of others receiving or providing support at SVRC.

As a client, you have the right:

1. To receive considerate and respectful care in a safe setting.
2. To be informed of your rights and have them explained in language that you understand.
3. To receive care without regard to your age, race, color, creed, national or ethnic origin, religion, gender, marital status or lifestyle, mental or physical disability, sexual orientation, HIV status, or criminal record.
4. To know the identity of those involved in your care -- your therapist, their supervisors, and the Director of Clinical Services.
5. To expect that your privacy will be respected. You will be asked to identify those who you consent to know that you are in therapy. Otherwise, we will not acknowledge that you are a client here.
6. To review the Clinical Records pertaining to your therapy, & to have the information explained or interpreted as necessary and to have a copy of the records.
7. Confidentiality: Confidentiality is your right as a client. Your case will not be discussed with anyone else unless you give permission to do so by signing a release of information form. There are three exceptions to this policy as mandated by state law:
   • If you are a danger to yourself or others;
   • If you disclose known or suspected abuse of or a child or vulnerab le adult (this includes children who are presently at risk of being abused by your perpetrator; adults with a guardian or power of attouney due to mental health concerns);
   • If you disclose the abuse of a dependent.
   • If you disclose intimate partner violence in which a child is present at the domestic event
   • Lastly, your counselor/therapist will occasionally seek professional consultation and may discuss your case with another peer for supervision purposes. Your full name is not used in these instances. You have the right to be informed of who the consultation is with.
     • Note: At your request, if someone subpoenas your records, SVRC will take legal action to maintain the confidentiality of your records.
8. Touches: Given that sexual abuse survivors have been exploited by touch and in order to create a safe environment, it is SVRC's policy that no touch is exchanged between counselor/therapist and client.
9. Crime Victims Compensation: Any victim of a crime has the right to file a Crime Victims Compensation claim. The Crime Victims Compensation Board can award money for medical expenses, mental health counseling/therapy expenses, and lost wages that directly result from the crime. An application must be filed with the board. You may contact the board directly at 1-800-469-2120 for more information regarding requirements and to request a claim form. Your counselor/therapist can also provide you with a form and assist you in filling it out.
10. Client Grievance Procedure: The purpose of the grievance process is to ensure fair and equitable provision of services to all program participants and resolve problems so that constructive programming can be maintained for the benefit of all. If a program participant at the SVRC is of the opinion that she/he has been discriminated against, the following process should be initiated within thirty (30) days of the action which promoted the grievance.
    • The grievance shall be discussed first with the counselor/therapist working with the program participant.
    • If no resolution is found in the above process (a), the grievance shall be presented in a written concise statement of facts. (Provisions will be made on an individualized basis to assist clients who are unable to read and write, so as to not eliminate their participation in this process. The client will be referred to the supervisor for assistance in writing the complaint.) It should include specific reference to the policies, procedures or practices which are allegedly discriminatory. The written statement shall be given to the Executive Director within ten (10) days of the meeting with the counselor/therapist.
    • Within two weeks from the receipt of the grievance, the Executive Director shall investigate and strive to find resolution with the aggrieved party and any workers named in the grievance.
    • If the client is dissatisfied with the response from the Executive Director, a final process involves submission of all written documents to the Board of Directors of the SVRC for final review as to whether or not discrimination has occurred. The Board of Directors will submit findings within a two-week period. The client has the option of appearing before the Board when the appeal is reviewed. The Board of Director’s ruling is final.
    • If the grievance is not resolved to the client’s satisfaction, the client has a right to appeal to KASAP (P.O. Box 4028, Frankfort, KY 40604).
    • If the client is not satisfied with the results of the appeal to KASAP, the client has the right to appeal to the Cabinet for Health & Family Services (Performance Enhancement Branch; Quality Assurance Section; 275 E. Main St.; 3E-K; Frankfort, KY 40621).

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Sexual Violence Resource Center of the Bluegrass is required by law to maintain the privacy of protected health information and to provide you with notice of its legal duties and privacy practices. SVRC must abide by the terms of the notice currently in effect, but SVRC reserves the right to change the terms.

If there is a change, SVRC will provide you with a written, revised notice as soon as practicable by mail or hand delivery. As a client of SVRC, information about you must be used and disclosed to other parties for purposes of treatment, payment, and health care operations. These uses and disclosures require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning psychiatric diagnosis and treatment records, medical history, treatment progress and/or any other related information to:

1. Any hospital or other health care facility to which you may be admitted;
2. Any physician or therapist providing you care;
3. Any other individual or organization designated by you.

These disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time.

SVRC is permitted to use or disclose information about you without consent or authorization in the following circumstances:

1. In emergency treatment situations;
2. As required by law (including by statute, regulation or court order);
3. Public health activities;
4. Victims of abuse or neglect;
5. Health oversight activities;
6. Judicial and administrative proceedings;
7. Law enforcement purposes;
8. Decedents;
9. Organ, eye, or tissue donation;
10. Research;
11. Serious threat to health or safety;
12. Essential government functions;
13. Workers’ compensation.

You have the right, subject to certain conditions, to:

1. Request restrictions on certain uses and disclosures of information about you. However, SVRC is not required to agree to the requested restriction;
2. Receive confidential communication of protected health information;
3. Inspect and copy protected health information;
4. Amend protected health information;
5. Receive an accounting of disclosures;
6. Obtain a paper copy of this notice, if you had agreed to receive this notice electronically.

COMPLAINTS

You may complain to SVRC and the Secretary of the U.S. Department of Health and Human Service if you believe that your privacy rights have been violated. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing with SVRC and should state the specific incident(s) in terms of subject, date and other relevant matters. A complaint to the Secretary must comply with the standards set out in 45 CFR $160.306. For further information regarding filing a complaint with ASVRC contact the Executive Director at (859) 253-2615.

I hereby consent to telehealth services as part of my care. I understand that telehealth is the practice of delivering Counseling/Advocacy services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand that telehealth is the practice of delivering Counseling/Advocacy services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telehealth:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risk and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. I understand that the care provider or I can discontinue the telehealth encounter if it is felt that the videoconferencing connections are not private or adequate for the situation. 

3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).

5) To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. 

6) Telehealth is NOT an Emergency Service and in the event of an emergency, I will call 911.  I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required. 

7) I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, we will end and restart the session. If we are unable to reconnect within ten minutes, I will call my provider at the direct number they have provided to me to determine next steps.  If our scheduled session time concludes before I am able to reach my provider, I will leave a message. 

8) I understand that telehealth may utilize my personal cellular data if I am on a cell phone or other device which uses cellular data.  I take responsibility for ensuring the security of that connection and I am responsible for ensuring I have sufficient data to support a telehealth session prior to my session.  SVRC is not responsible for any costs associated with the use of phone service or data.