INFORMED CONSENT
TIME COMMITMENT: Your initial appointment will take approximately 1 hour. We realize that starting counseling is a major decision and you may have many questions. This document, along with the HIPPA Information form, strives to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need.
EMERGENCIES: If an emergency situation for which the client or their guardian feels immediate attention is necessary related to this office’s services, please contact your counselor via their cell phone number. However, if your counselor is unavailable, you may call the office number to obtain contact info for Jodi (336-984-7591) or Kenneth Province (336-981-5938). If no contact can be made the client or guardian understands that they are seek a natural support, contact 911 or visit a local emergency room for services as a last resort, or contact Vaya Health MCO at 1-800-849-6127 or Partners MCO 1-888-235-HOPE, Cardinal Innovations MCO (704) 939-7700, or mobile crisis at 877-492-2785 or 336-838-9936. This agency will follow those emergency services with standard counseling and support to the client or the client's family. For any grievance you may also contact the above MCO for your covered region. If you have any grievance you may call the number above.
In the case of a medical emergency, while you or anyone in your party is present in our office, this agency will contact 911.
RISKS AND BENEFITS: Please note there are risks and benefits to counseling. These will be discussed with you today as it relates to your case specifically. Alternative methods to treatment will also be discussed today. Each licensure board has a grievance process or system. If you wish to make a grievance, please contact the appropriate licensure board to file a complaint.
CONFIDENTIALITY: Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process your claims, b) information you and/or your child or children report about physical or sexual abuse; then, by North Carolina State Law, your counselor is obligated to report this to the Department of Social Services, as well as any report that c) you the client have an infectious disease that you will intentionally spread to harm others d) where you sign a release of information to have specific information shared and e) if you provide information that informs your counselor that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and g) or when required by law.
APPOINTMENTS, PROFESSIONAL FEES, AND CANCELLATIONS: Appointments are generally 45 to 60 minutes in length. Initial intakes are $160.00, Counseling sessions are $140.00, *Psychological testing fees are dependent on the amount of time involved and are billed per hour. Because they vary we will discuss fees with you in advance. Other services including report writing, telephone conversations longer than 10 minutes, attendance and meetings with other professionals, court appearances/involvement, etc. can be charged at hourly rates. A $100 up-front fee is charged for any court appearances. Letter/report fees: $45.
As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If your account has not been paid for 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment.
This may involve but not be limited to hiring a collection agency or going through small claims court. If that were necessary you will be responsible for all cost of litigation including attorney’s fees. In most collection situations the only information released would be the client’s name and address, nature of services provided, and the amount due. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You should also be aware that most insurances companies require you to authorize us to provide them with confidential information such as clinical diagnoses, treatment plans/summaries, or copies of records. This information becomes part of the insurance company's files. All insurance companies claim to keep such information confidential, however we have no control over this information once received by the insurance companies. It is important to remember that you may always pay for services yourself to avoid the potential problems described above.
PRIVATE PRACTICE SOCIAL MEDIA POLICY:
By signing below you acknowledge that we may we contact you at the numbers you provided on your patient profile. This also allows us to leave you a message at these numbers from our office. You also consent to allow us to contact you via your email. This section outlines our office policies related to use of Social Media. Please read it to understand how we conduct ourselves on the Internet as mental health professionals and how you can expect us to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, we encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when we need to update this policy. If so, we will notify you in writing of any policy changes and make sure you have a copy of the updated policy.
Friending: We do 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 we meet and we can talk more about it. Fanning: As of May 2015, we have deleted our professional Facebook Page after concluding that the potential risks of maintaining such a Page outweigh any potential gains. Some therapists keep a Facebook Page for their private or professional use. They may allow people to share their blog posts and practice updates with other Facebook users. You are welcome to view www.jodiprovincecs.com. However, in regards to blogs or post, we do not accept clients as Fans of this Page. We believe having clients as Facebook Fans creates a greater likelihood of compromised client confidentiality and feel it is best to be explicit to all who may view my list of Fans to know that they will not find client names on that list. In addition, the American Psychological Association’s Ethics Code prohibits my soliciting testimonials from clients. We feel that the term “Fan” comes too close to an implied request for a public endorsement of this practice.
Following: If we publish a blog on our website or any other social media and if you use an easily recognizable name on Twitter (for example) and we happen to notice that you’ve followed us there, we may briefly discuss it and its potential impact on our working relationship. Our primary concern is your privacy. If you share this concern, there are more private ways to follow us on Twitter (such as using an RSS feed or a locked Twitter list), which would eliminate your having a public link to a therapist’s content. Note, we will not follow you back. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy hour.