3 OF 4 Informed Consent (Patient/Guardian: keep pages 1-3. Office retains page 4
Google Reader: We do not follow current or former clients on Google Reader and we do not use Google Reader to share articles. If there are things you want to share with us that you feel is relevant to your treatment whether they are news items or things you have created, we encourage you to bring these items of interest into our sessions. Business Review Sites: You may find our counseling practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of Social Media Policy whether the business has added itself to the site. If you should find our listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client. Of course, you have a right to express yourself on any site you wish. But due to confidentiality, we cannot respond to any review on any of these sites whether it is positive or negative. We urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with us about your feelings about our work, there is a good possibility that we may never see it. If we are working together, we hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide you and your counselor or clinician are not a good fit. None of this is meant to keep you from sharing that you are in therapy wherever and with whomever you like. Confidentiality means that we cannot tell people that you are a client and we will follow our Ethics Code. But you are more than welcome to tell anyone you wish about your therapy or how you feel about the treatment, in any forum of your choosing. If you do choose to write something on a business review site, we hope you will keep in mind that you may be sharing personally revealing information in a public forum. We urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you feel we have done something harmful or unethical and you do not feel comfortable discussing it with your counselor, you can always contact the Board of Counseling for NC, which oversees licensing, and they will review the services we have provided. P.O. Box 77819, Greensboro, NC 27417. Email: By signing our informed consent, you acknowledge and are giving us permission to email you regarding any need in your counseling as an active or inactive/closed client. You are acknowledging that email is not completely secure or confidential. If you choose to communicate with us by email, be aware that all emails are retained in the logs of your and our Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails we receive from you and any responses that we send to you become a part of your legal record. Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to your clinician's attention so that we can discuss them.
By signing below, you also acknowledge receipt of our ""Client Rights and HIPAA Information". We are happy to provide you a copy at your request, or you may review these at www.jodiprovinceccs.com
SCHEDULED APPOINTMENTS: Please be respectful of our time. If you must reschedule or cancel, please phone 24 hours in advance in order not to be charged for the session. A pattern of missed appointments will lead to additional charges that are not covered by insurance and may result in an end to treatment. Three no-shows (or failure to cancel without 24 hours notice) will result in termination of services at the discretion of your counselor. By signing our informed consent you acknowledge the following: Non-Medicaid clients can be charged $50 for sessions missed or cancelled with less than 24 hours notice. These fees are not covered by insurance and payment will be required prior to any further services being provided. All clients with three no-shows/failure to cancel within 24 hours can be terminated with this agency.
1260 College Ave #1, Wilkesboro, NC 28697 336-818-0733