Informed Consent for Counseling Services

 

This document contains important information about professional services and policies. You will also additionally receive a document titled, “Notice of Policies and Practices,” a notice required by the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI). The law requires that your signature is obtained acknowledging that you have been provided with this information. By signing the final consent form you will receive, you will acknowledge that you have received the privacy notice, and you will also be agreeing to the terms in this Informed Consent /Agreement. You may revoke this at any time.
 

 

Psychotherapy

Psychotherapy (also known as therapy, counseling, or mental health counseling) is not easily described in general statements. It varies depending on the personalities of the therapist and client(s), and the issues you are addressing. There are different methods and interventions that may be used to help address different issues. Psychotherapy is not like a typical health care provider visit. Instead, it calls for continuous active effort on your part. For therapy to be most successful, you will have to work in and outside of the sessions. Psychotherapy can have benefits and risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, shame, anger, frustration, loneliness, helplessness, and more. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Psychotherapy has also been shown to have many benefits. Psychotherapy often leads to improved relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees on what you will experience.
 

 

 

The Process of Therapy/Evaluation

During the first few meetings, you will be assessed to determine if the therapist is a good fit for you and your needs. If determined to not be a good fit or benefit for your needs, you will be referred to others who work well with the issues you are requesting treatment for. Within a reasonable period after starting treatment, the understanding of your issues will be discussed, treatment plan proposed, therapeutic objectives, and possible outcomes of therapy. You will receive a clinical recommendation about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about the treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved. If during the work together it is assessed that the therapist can no longer be effective in helping you reach your therapeutic goals, they therapist will be obliged to discuss this with you and if appropriate, terminate treatment and give you referrals and recommendations who may be of help to you.

 

Termination, Transition, and Follow-up

Ideally stopping treatment is meant to be a mutual process. Before stopping treatment, it will be discussed how you will know if or when to come back, or whether a regularly scheduled “check-in” might work best for you. It is recommended to have closure to the therapy process with at least two termination sessions.    

Should you request to terminate and transition to a new therapist, your therapist is more than willing to talk with the therapist of your choice to aid the transition. Your therapist will assist you in finding another qualified therapist with whom to consult if at any time you want another therapist’s professional opinion.
 

Record-Keeping

Very brief records are kept, noting only that you have been here, diagnosis(es), interventions during session, and the minimum regarding the topics we discussed. If you prefer that no records are kept, you must give a written request to this effect for your file, and it will only note that you attended therapy in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that any errors in your file be corrected. You have the right to request that 3 copies of your file are made available to any other health care provider at your written request. Your records are maintained in a secure location. For more information about record-keeping see Notice of Privacy Practices.

 

Consultation

To provide you with the best possible care and service, your therapist may occasionally consult with other professionals regarding their clients. Names and other information which might identify people are never mentioned so that client anonymity and confidentiality is maintained.

 

Contacting

Due to the nature of the work as a therapist, your therapist may not immediately be available by telephone. Phones, texts, and emails will not be answered while in an appointment. When your therapist is unavailable, phone calls are answered by confidential voice mail that is monitor frequently. Your therapist will make every effort to return your call on the same day, if not within 48 hours. If you find yourself in an urgent situation, make a judgment about the prudence of waiting for a call versus calling your primary care physician, 911, or your local 24-hour crisis line. 

If you need to contact your therapist between sessions to alert them of an emergency, please call the office phone line at 1-877-935-6003. Your call will be returned as soon as possible. Voice messages are checked regularly, but with less frequency at night, on weekends, and on holidays, or during scheduled vacation time, about which your therapist will notify all clients in advance.

If an emergency arises that requires immediate attention, call the emergency National Hopeline Network at 1-800-Suicide/1-800-784-2433 or the National Suicide Prevention Lifeline at 1-800-Talk/1-800-273-8255 or dial 911. Hearing and Speech Impaired should call 1-800-799-4TTY/1-800-799-4889. In the event of a life-threatening crisis please contact a crisis hotline, call 911, or go to a hospital emergency room.

 

Cancellations and Lateness

Missed and canceled sessions pose some issues for both of us. First, the work of psychotherapy is sometimes challenging and when we hit a difficult place together, sometimes it can feel easier to want to avoid coming in for treatment. Your therapist would prefer to speak about this with each other openly rather than canceling sessions. It is extremely difficult to fill canceled sessions on short notice. If you are running late for your appointment, please call or text as soon as you can to let your therapist know you will be late. If you are late for your session, your session will still end at the regular scheduled ending time. If you do not contact your therapist 15 minutes into your session, it is assumed you do not plan to attend your session and your session time is forfeit.

 

Confidentiality of Communication

Please be aware that e-mail, messaging using social media/internet messaging services, and text methods of communication are considered to lack the encryption necessary to ensure confidentiality according to HIPAA. Any electronic communication from these methods should be used only to set or verify appointments or for general “bookkeeping” issues. A secure, confidential messaging and email service through a HIPAA-compliant service provider is available upon request. Despite this, please always use caution when using communicating using the internet/phone service. Please do not contact via text or e-mail for emergencies.

 

 

 

Informed Consent for Online Therapy/Counseling Services

Therapy conducted online is technical in nature and problems may occur with internet connectivity. Internet availability may be limited and disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction). Any problems with internet availability or connectivity are outside the control of your therapist. Your therapist makes no guarantee that such services will be available.

Disruption of video sessions due to technical complications can be resumed via telephone for the duration of the scheduled session time. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via telephone, a new appointment will be rescheduled. Please be aware that communication using a cell phone may not be secure and therefore not confidential.

Communication via www.zoom.com & the Zoom application are encrypted and HIPAA compliant. Emails sent from or to personal mail accounts are automatically secure. By signing the consent form you acknowledge and agree that all communication of a clinical nature should be sent via a HIPAA compliant method such as discussed during online therapy sessions or methods of being encrypted/confidential.

As a rule, clinical communications (i.e. communication for purposes other than scheduling) should be reserved for scheduled session time (in person face-to-face sessions, video sessions, phone sessions) except in cases of emergency. Your therapist will not respond to personal or clinical concerns via regular email, phone, or texting outside of your scheduled session time. Regular email nor text should not be used in the event of a crisis or an emergency. 

Your therapist will not accept invitations to personal social media websites such as Facebook or Instagram, personal or professional networking websites such as LinkedIn, or instant messaging applications such as WhatsApp to maintain client confidentiality and privacy of all parties, and to maintain ethical and moral professional codes.

You are welcome to follow public social media platforms as the information provided is specifically for public use and access, such as TeeJuh Behavioral Health on Facebook or Instagram pages.

Online therapy is not a substitute for medication under the care of a psychiatrist or doctor. 

Online therapy is not appropriate if you are experiencing a crisis or having active suicidal or homicidal ideation with the intent to harm yourself or others.

Although substantial steps are taken to ensure the confidentiality and privacy of therapy provided online, your therapist cannot guarantee the security of any internet transmissions or communications. While your therapist takes active effort to assure privacy and continuously maintains awareness if there are other people in the room or  area you are located, your therapist can not be liable for privacy when you allow others to be in the room without their knowledge.

Photos, Audio, and/or video recording sessions are NOT allowed. If you would like to take a picture or record a session, please discuss this with your therapist in advance. If mutually agreed upon, you may.

You, the client, agree TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON YOUR OWN COMPUTER/MOBILE DEVICE AND IN MY OWN PHYSICAL LOCATION. You agree to never record or take pictures during therapy sessions. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law. 

Please read the information below if you will be participating in marriage, couples, or family counseling/therapy services.

 

 

AGREEMENT AND CONSENT FOR RELATIONSHIP THERAPY SERVICES

 

Relationship Therapy Services

Marriage, Couples, or Family therapy works best when the focus is on the relationship. When working with two people (or more), it is expressly understood that all clients are both your relationship and each of you as individuals. To maintain fidelity individually and to the relationship, please consent understanding to the following: 

 

Confidentiality

All information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. Those situations include but are not limited to: (a) when there is reasonable suspicion of abuse to a child or to a dependent or elder adult; (b) when the client communicates a threat of bodily injury to others; (c) when the client is suicidal; (d) when the client has been physically injured due to violence; (e) when disclosure is required pursuant to a legal proceeding.  Your therapist may receive occasional professional consultation. In such cases, neither your name nor any identifying information about you is revealed. 

 

No Secrets Policy 

When a couple and/or families enter counseling, it is considered to be one unit. This means that the therapist’s allegiance is to the couple “unit,” and not to either partner as individuals. This is particularly important in creating a space where both partners/family members can feel safe. Therefore, I adhere to a strict “No Secrets” policy. This means that your therapist will not hold secrets for either partner or family member. This policy is intended to allow for your therapist to continue to treat the couple/family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.  On occasion during the counseling process, individual partners/family members may be seen for an individual counseling session regarding the relationship. In this case, the individual session is still considered as part of the couple’s/family counseling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple/family. If an individual chooses to share such information, your therapist will offer the individual every opportunity to disclose the relevant information and will provide guidance in this process. If the individual refuses to disclose this information within the couple’s/family session, your therapist may determine that it is necessary to discontinue the counseling relationship with the couple/family. If there is information that an individual desires to address within a context of individual confidentiality, your therapist will be happy to provide referrals to therapists who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples/marital/family counseling relationship. 

 

Court Proceedings/Subpoena of Records

It is understood that the purpose of marital/couples/family therapy is for the amelioration of distress within a relationship. Therefore, if both partners/family members request therapy services, they are expected not to use information given during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena the therapist’s testimony or records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case. 

 

Release of Records 

All partners/family members must provide their consent to release marital/couples/family counseling records. If one partner does not provide consent, records will not be released.

 

Course of Treatment

The continued participation by each person is voluntary. Either participant may suspend or terminate the therapy at her/his/their individual request. 

 

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Additional Policies for All Services

 

All information disclosed within groups or sessions is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. These mandated reporting situations include but are not limited to: (a) when there is reasonable suspicion of abuse to a child or to a dependent or elder adult; (b) when there is a report or communication of a threat of bodily injury to others; (c) when there is a report received a person is suicidal; (d) when a report has been made that a person has been physically injured due to violence; (e) when disclosure is required pursuant to a legal proceeding.

 

TeeJuh service providers have a duty to warn if they believe anyone poses a risk to themselves or others. This duty can include breaching confidentiality to notify the intended victim or the police or taking other steps to prevent violence.

 

Photos, Audio, and/or video recording of any service provided are NOT allowed. If you would like to take a picture or record, please discuss this with your service provider in advance. If mutually agreed upon, you may.

 

If your engagement in any services will be inhibited by the excessive use of any substance (ex. alcohol, etc.) please do not attend and notify your service provider to cancel.

 

If you are concerned regarding your attendance for a specific service, receiving a certificate of completion, or any other specific service questions please contact your specific service provider.

Electronic Communication Consent

 

Email, phone, and text reminders are automatically sent using the chosen electronic health records system. This consent includes understanding you will receive them unless otherwise noted. If you would like to opt out of reminders, please consult with the staff member providing services.

I certify and attest that the information in this Patient Registration Worksheet is correct, to the best of my knowledge and belief. I understand I am agreeing and consenting to telemedicine/tele-behavioral health services if I choose to do so. I am signing that I have read and understood the Notice of Privacy Policies, provided below. I understand that falsification of information may subject me to denial of services.

 

Notice of Privacy Practices- HIPAA Compliance - Required to Provide 

 

Your Information. Your Rights. Our Responsibilities. 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.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record:

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We DO NOT charge a fee.

Ask us to correct your medical record:

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications:

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests. 

Ask us to limit what we use or share:

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. (This does not apply as no payment for services is required.)

• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information:

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but DO NOT charge a fee if you ask for another one within 12 months. (Payment is not included as our services are no charge.)

Get a copy of this privacy notice:

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you:

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated:

• You can complain if you feel we have violated your rights by contacting us using the information above.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you:

• We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization:

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services: (Not applicable)

• We can use and share your health information to bill and get payment from health plans or other entities. (Not applicable)

Example: We give information about you to your health insurance plan so it will pay for your services. (Not applicable)

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues:

• We can share health information about you for certain situations such as:

     • Preventing disease

     • Helping with product recalls

     • Reporting adverse reactions to medications

     • Reporting suspected abuse, neglect, or domestic violence

     • Preventing or reducing a serious threat to anyone’s health or safety

Do research:

• We can use or share your information for health research.

Comply with the law:

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests:

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests:

• We can use or share health information about you:

     • For workers’ compensation claims

     • For law enforcement purposes or with a law enforcement official

     • With health oversight agencies for activities authorized by law

     • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions:

• We can share health information about you in response to a court or administrative order, or in response to a subpoena

Our Responsiblities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing.

If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice:

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.