In the event you are unable to keep your scheduled appointment, it is your responsibility to notify Aura Counseling and Wellness 24 hours in advance. Frequent Cancellations could result in the loss of services.
As a behavioral mental health treatment facility that offers substance abuse treatment, we are required to protect the fundamental human, civil, constitutional and statutory rights of each client receiving services with us. The following is a listing of your rights while receiving services here.
If individual therapeutic indications necessitate restrictions on visitors, telephone calls or other communications, those restrictions shall be evaluated for therapeutic effectiveness by a qualified professional at least every three (3) days. Any restrictions to communication will be fully explained to you and your family.
You have the right to privacy with respect to visitors including but not limited to:
You and, where there is a valid release of information, your family and significant others have the right to be fully informed regarding:
In accordance with the requirements of any applicable law or any applicable standard for substance abuse treatment, a written, dated and signed informed consent form shall be obtained from you or your family or your legal guardian, as appropriate, for participation in any research project or other procedures or activities where consent is required by law.
Client work shall be permitted only under certain conditions. These conditions include the following:
EMAIL/TEXT MESSAGING CONSENT
In order to communicate with you by email, we need to be sure you are aware of the privacy issues that could arise when we communicate this way, and to document that you are aware of these issues and agree to them. If you want to communicate with your care provider through email or text messaging, please read and sign the form below.
Potential Risks of Using Text Messaging:
Aura Counseling and Wellness may offer clients the ability to stay in touch via text messaging if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Text messaging has a number of risks one should consider before making a final decision about its use. These include, but are not limited to, the following:
Potential Risks of Using Email:
Aura Counseling and Wellness may offer clients the ability to stay in touch via email if the client chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Emailing has a number of risks that consumers should consider before using email.
These include, but are not limited to, the following:
Aura Counseling and Wellness will use reasonable methods to protect the security and confidentiality of email information sent and received. However, because of the risks listed above, ACW cannot text any Protected Health Information unless you specifically request him/her to do so.
Conditions for the Use of Text Messaging and/or Email:
Email and/or text message correspondence must be specifically requested and initiated by the consumer or the minor consumer’s parent/guardian.
Your care provider shall not email or guarantee the security and confidentiality of text or email communication, and is not responsible for improper disclosure of confidential information that is not caused by ACW’s intentional misconduct.
Consent to the use of texting or email includes agreement with the following terms:
Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted.
Emails and/or text messages containing clinical content will become a part of your medical record.
Although ACW staff will endeavor to read and respond promptly to an email or text message, ACW cannot guarantee that any particular text or email will be read and responded to within any particular period of time. Thus, you should not use text messaging or email for medical emergencies or other time-sensitive matters.
You are responsible for informing the provider of any types of information that you do not want sent by text message and/or email.
Your email/text will not be forwarded to a third party without your expressed permission, (or as required by law) unless you have already signed a release for ACW to communicate with a third party.
You may withdraw consent to communicate by text or email via written communication to the provider at any time.
If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room immediately.
You are responsible for protecting your password and access to your phone and/or email account and any text or email you send or receive from ACW to ensure your confidentiality.
Your care provider cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
INFORMED CONSENT & MEMORANDUM OF UNDERSTANDING
General Information: The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your therapist or the Clinical Director. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Our Agency cannot promise that your behavior or circumstance will change. Our Agency can promise to support you and do our very best to understand you, as well as to help you clarify what it is that you want for yourself.
Confidentiality: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
victim is the perpatrator, observier of physical,
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of a child under the age of 18.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4. 5. 6.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally members of our staff and/ or your therapist, may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, you will not be acknowledged first. Your right to privacy and confidentiality is of the utmost importance to Our Agency, and we do not wish to jeopardize your privacy. However, if you acknowledge your therapist or other staff member first, that person will be more than happy to speak briefly with you, but we feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
By selecting 'I Agree' below for each statement listed, you have identified that the following information has been explained and you have an understanding of its contents.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I can change the terms of this Notice, and such changes will apply to all information I have about you. Should a change to this Notice occur, the new Notice will be available upon request, in my office, and on our website
1 - MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.
I am required by law to:
2 - HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
3 - CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
4 - CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
5 - CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
6 - YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
This notice went into effect on October 1, 2016
Acknowledgement of Receipt of Privacy Notice
I hereby acknowledge that I have received a copy of the Aura Counseling and Wellness Notice of Privacy Practices (“Notice”):
USE OF INFORMATION: Provider intends to utilize WITS to record your health and financial Information. This information usually includes a record of your condition, the treatment provided, and payment for your treatment. By allowing the Provider to utilize WITS for your information, you are granting use of your information as follows:
DISCLOSURE OF INFORMATION: Information collected in WITS will only be disclosed to third parties to the extent required by law or authorized by you. If you have concerns about your Protected Health Information, please discuss your options with Provider.
ACKNOWLEDGMENT AND CONSENT: I hereby acknowledge and consent to the storage of health and financial information by Provider in the electronic systems of the State of Idaho, also known as WITS. I hereby acknowledge that I am entitled to a copy of this notice upon request. I acknowledge that I have the right to file a complaint if I believe my privacy rights have been violated.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
If you need to contact a staff member between sessions, please leave a message on our voice mail or with the front desk staff. Often our staff may not immediately be available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
Due to the importance of your confidentiality and the importance of minimizing dual relationships, Our Staff does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you meet with your primary therapist and we will be happy to talk more about it.
Aura Counseling and Wellness and their staff cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, our agency will do so. While our agency may try to return messages in a timely manner, our agency cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Idaho. Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Our agency may terminate treatment after appropriate discussion with you and a termination process if your therapist determines that the psychotherapy is not being effectively used or if you are in default on payment. Our agency and therapists will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating unless you are in violation of the SUD Treatment Rules and/or a behavior contract. If therapy is terminated for any reason or you request another therapist, you be provided with a list of qualified psychotherapists and/or agencies to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, f or legal and ethical reasons, our agency must consider the professional relationship discontinued.
am requesting substance abuse services from Idaho's publicly funded substance abuse system of care. As such I voluntarily authorize BPA Health, those Substance Abuse Treatment and Recovery Support Services (RSS) providers who are contracted to provide Treatment and RSS under Idaho's publicly funded substance abuse system of care, and the Department of Health and Welfare (Department) to disclose my name, all necessary treatment information and my social security number to each other and the Department. This information will be disclosed for the following purposes: 1) To assist with referring me to appropriate types of care and guiding my treatment and recovery support; 2) To be entered into the Department's common client database so that I will have one client number for any services received from the Department; 3) To process payment of costs for my treatment and recovery support services; 4) For monitoring compliance in the program; 5) For program audit and research including independent peer reviewers, contract monitors or researchers appointment by the Department; 6) For investigations related to fraud. Furthermore, I authorize the disclosure of personal substance abuse treatment and recovery outcomes data collected by contracted Substance Abuse Treatment and RSS Providers, BPA Health and the Department to the Federal Center for Substance Abuse Treatment and its contracted data collection Agents. Client Initials
The purpose of my participation, as a client, in the Idaho publicly funded substance abuse treatment program is to acquire knowledge, skills and attitudes supportive of a sober and more satisfying lifestyle. In addition to the potential positive outcomes likely to occur as a result of my participation, the following reasonably foreseen risks may occur, as they would in any other alcohol and drug treatment program: breach of confidentiality; negative reactions of group members; emotional stress from requirements of group interaction, self-disclosure; stress to relationships resulting from open discussion of issues, past traumas; and, stress to relationships resulting from participant behavioral changes, positive or negative, need to attend recovery support meetings, spend time in group and doing assignments. Providers will take steps to minimize or protect participants against potential risks by adhering to standards of confidentiality found both in Federal and State Code, and by informing and verifying client group rules. And, by intervening in and guiding appropriate disclosure, confrontation and understanding of resolution self-help groups in group and in family conflict. Providers will assist clients in accessing sober support services and where acceptance and stress reducing support is available.Client Initials
This release may be revoked at any time either orally or in writing, except to the extent that action has already been taken in reliance on the release. I acknowledge that some information may include material that is protected by State and Federal regulations including Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Information Portability and Accountability Act (HIPAA). Unless revoked as stated above, this consent expires automatically on: ONE YEAR FROM DATE OF DISCHARGE
I have read the above Consent to Release of Information, Informed and Voluntary Consent for treatment and the Revocation Clause. I agree I have been given the opportunity to question the above disclosures and consent for care and hereby do agree to the above identified Disclosures and Consent to Treatment.
I have received a brochure explaining how ICANS is a secure electronic health system used to administer the ICANS assessment, and make the results available to providers who participate in the ICANS system.
I authorize the following Agency: AURA COUNSELING & WELLNESS LLC to release, use, receive, mutually exchange, communicate with and disclose information to the ICANS system, and with Agencies/Authorized Users with access to ICANS.
WHO MAY DISCLOSE INFORMATION. The agency I have named at the top of this form may disclose protected health information to ICANS.
WHAT MAY BE DISCLOSED. By signing this consent, I specifically understand that protected health information or records will be released, used, disclosed, received, mutually exchanged or communicated to, by, among, or between any person, entity, or agency named in this authorization. I understand this information may include material protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 C.F.R. Part 2; the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 & 164; and the Medicaid Act, 42 CFR Part 431, Subpart F. Federal rules restrict any use of the information to criminally investigate or prosecute and to redisclose records relating to any alcohol or drug abuse patient.
PURPOSES. I understand this authorization will allow my treatment team to plan and coordinate services I need and allows any person, entity, or agency named in this authorization to be actively involved in my case coordination, evaluation, treatment, planning, or legal proceedings. I hereby request and give my permission for an open exchange of information to, by, among, or between, any person, entity, or agency named in this authorization.
REVOCATION. I also understand that I may revoke this Informed Consent at any time, except to the extent that action has been taken in reliance on it and that in any event this authorization expires automatically as indicated with each disclosure item identified above. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as this original.
EXPIRATION. This authorization shall expire one (1) year from the date the Minor Client and Parent or Legal Guardian signs below.
CONSENT. I understand that my information cannot be disclosed without my written consent, except as otherwise provided by law, and that federal and Idaho law will be followed for using and disclosing my ICANS information.
By signing this form, I am authorizing providers assessing or treating my child/ward to provide my child/ward’s information to ICANS. I understand that failure to sign this authorization may limit determine of eligibility, enrollment, or treatment for my child/ward.
I have read this Informed Consent/had this Informed Consent read/explained to me and I acknowledge an understanding of the purpose for the release of information. I am signing this authorization of my own free will.
PLEASE NOTE: IF BOTH PARENTS HAVE LEGAL RIGHTS REGARDING THE CHILD’S CARE (PER A PARENTING PLAN) OR IF THERE IS NO LEGAL PARENTING PLAN IN PLACE - AURA COUNSELING AND WELLNESS RESERVES THE RIGHT TO MAIL AN INFORMATIONAL LETTER TO BOTH PARENTS WHEN A MINOR CHILD IS ENROLLED IN MENTAL HEALTH AND/OR SUBSTANCE USE DISORDER THERAPY.
STATEMENT OF UNDERSTANDING: MY SIGNATURE ACKNOWLEDGES THAT I UNDERSTAND AURA COUNSELING WELLNESS STAFF WILL NOT GET INVOLVED WITH REGARDS TO PRESENTING AT COURT, MAKING RECOMMENDATIONS FOR RESIDENTIAL TIME, VISITATION, OR CUSTODY. AURA COUNSELING AND WELLNESS THERAPISTS WILL TREAT THE CLIENT FOR PRESENTING ISSUES AND NOT GET INVOLVED IN THE CUSTODY ISSUES BETWEEN THE PARENTING PARTIES.
How Our Therapy Meets Technology
Evidence-Based Therapy Services offer the most effective forms of therapy and treatment services to anyone using or participating in such programs and curriculum. At Aura Counseling and Wellness, we firmly believe in the use of these practices as a way to bring you the most up-to-date, effective, and client-focused therapy techniques.