INFORMED CONSENT

Thank you for choosing Western Reserve Counseling.   We realize that starting counseling is a major decision and you may have many questions.  This document is intended 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. The therapists at Western Reserve Counseling are licensed to practice counseling, substance abuse treatment, or marriage and family therapy by the state of Ohio. Treatment practices, philosophy, and risks will be discussed with you today. Your signature indicates you understand this information and wish to receive the services as described. You have the right to withdraw your consent for treatment at any time and reasonable efforts will be made for you to be referred to alternative treatment approaches.

 

POTENTIAL RISKS, BENEFITS, AND HAZARDS:     Behavioral Health Counseling is a shared effort and success is the result of the collaborative efforts of both the therapist and client.  Potential benefits are outlined in the treatment plan.  General benefits may include relief of symptoms, increased understanding, improvement of interpersonal relationships, and improvement in functioning in daily living.  Possible risks associated with counseling include increased stress due to the focus on problem areas and/or developing dependency on the therapist.  Other potential risks may include a worsening of symptoms if the service is suddenly stopped or refused. With Telehealth, the possibility of technical equipment failure is a possibility, so please call to reschedule should the connection be lost.

 

CONFIDENTIALITY AND EMERGENCY SITUATIONS:     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, sexual or elder abuse; then, by Ohio State Law, I am obligated to report this to the Department of Children and Family Services, c) where you sign a release of information to have specific information shared and d) if you provide information that informs me that you are in danger of harming yourself or others e) information necessary for case supervision or consultation and f) or when required by law. If an emergency for which the client or their guardian feels immediate attention is necessary, please contact the emergency services in the community (911) for those services.  Western Reserve Counseling will follow those emergency services with standard counseling and support the client or the client's family.  E-mail, text messages and social networking sites are not confidential, and we may not be able to respond. You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services are not appropriate.  

 

COMMUNICATION RESPONSE TIME:   This practice is an outpatient facility and is set up to accommodate individuals who are reasonably safe and resourceful. Our therapists do not carry beepers nor may be available. If at any time this does not feel like sufficient support, please inform us, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. We typically will return phone calls within 24 hours during business hours. However, we do not return calls, emails, or texts on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.

FINANCIAL/INSURANCE ISSUES:   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 you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise, you will be billed $35.00.  This will be an out-of-pocket expense to you as insurance companies will not pay no-show fees. Any more than 2 broken appointments with less than 24 hours' notice results in the closure of the client’s case at Western Reserve Counseling, LLC. If your balance exceeds $300.00, we will ask that you pay for services when rendered. 
If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time.

We utilize Square as the company that processes credit cards in the office and for transactions for Telehealth. [This company may send the credit cardholder a text or an email receipt indicating that you used that credit card for my services, the date you used it, and the amount that was charged. This notification is usually set up two different ways - either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit card holder has the automatic receipt notification set up to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will also appear on your credit card bill. The name on the charge will appear as Western Reserve Counseling, LLC.]

COORDINATION OF TREATMENT:      It is important that all healthcare providers work together. As such, we would like your permission to communicate (to and from) with your primary care physician and/or psychiatrist. Please understand that you have the right to revoke this authorization, in writing, at any time by sending notice. However, a revocation is not valid to the extent that we have acted in reliance on such authorization. If you prefer to decline consent no information will be shared.