INFORMED CONSENT
Before you start therapy, there are important things to be aware of. This is referred to as "informed consent.” "Informed consent” will help you understand better what to expect from your therapy experience at Vanda Counseling and it will explain certain limitations to what you/we will be doing.
THE THERAPEUTIC PROCESS:
Psychotherapy and mental health services are not easily described in general statements. Due to the many factors that affect the therapeutic process, each individual is going to experience therapy in a different way. Some of these factors include: the personalities of the therapist and client, members of the extended family, the identified concern, personal strengths of the client, previous success and challenges, as well as other unforeseeable variables. There are a number of approaches to therapy which can be utilized to address different problems and concerns. It is different than going to your medical doctor in that it requires a very active effort on your part. Because we believe in a collaborative process, honesty and openness are important in order to achieve the changes you desire.
Psychotherapy has both benefits and risks. Benefits may include: improved relationships with others, a significant reduction of distress and resolution to the specific issues that brought you into therapy. Risks may include: experiencing uncomfortable levels of feelings (such as sadness, anxiety, anger, frustration, loneliness or helplessness), recalling unpleasant aspects of your history. At times, your therapist may challenge you and your old ways of thinking and doing in order to promote change. Therapy is intended to alleviate problems but sometimes, you may feel them even more acutely for a period of time, before coming to a resolution. There are no guarantees about what will happen.
You have the right to terminate therapy at anytime and you have the right to refuse to participate in treatment. If you choose to terminate your therapy before the end of the recommended treatment plan, there are risks. Those risks could include an increase in mental health symptoms, adverse effects on relationships, increased urges for self harm and decrease in ability to emotionally regulate. Your therapist will discuss additional risks specific to your treatment with you if indicated. Lack of participation in your therapy may also result in the above risks.
If we believe that your problems require knowledge we do not have, we may refer you for a consultation with someone with specific training or experience. We will discuss any such referrals with you before we act.
The first meeting will involve an evaluation of your needs. By the end of the session, your therapist will be able to offer you some first impressions of what your work with them may look like if you chose to continue with therapy. We will also create a treatment plan with you to outline what you would like to accomplish in therapy. Every three months we will review that plan to assess progress and see if it needs to be updated.
CLIENT RIGHTS:
If you are a consumer of marriage and family therapy services offered by marriage and family therapists licensed by the State of Minnesota, then you have the right:
1. to expect that a therapist has met the minimal qualifications of training and experience required by state law;
2. to examine public records maintained by the Board of Marriage and Family Therapy which contain the credentials of a therapist;
3. to obtain a copy of the code of ethics from the Board of Marriage and Family Therapy, 2829 University Avenue SE, Suite 330, Minneapolis, Minnesota 55414-3222;
4. to report complaints to the Board of Marriage and Family Therapy by calling (612) 617-2220;
5. to be informed of the cost of professional services before receiving services;
6. to privacy as defined by rule and law;
7. to be free from being the subject of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services;
8. to have access to their records as provided in Minnesota Statutes, section 144.335, subdivision 2; and
9. to be free from exploitation for the benefit or advantage of a therapist.
If you are a consumer of psychological services offered by psychologists licensed by the State of Minnesota, then you have the right:
1. to expect that a psychologist has met the minimal qualifications of training and experience required by state law;
2. to examine public records maintained by the Board of Psychology which contain the credentials of a psychologist;
3. to obtain a copy of the rules of conduct from the State Register and Public Documents Division, Department of Administration, 117 University Avenue, St. Paul, MN 55155;
4. to report complaints to the Board of Psychology; 2700 University Avenue, West; Suite 101; St Paul., MN 55114;
5. to be informed of the cost of professional services before receiving services;
6. to privacy as defined by rule and law;
7. to be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving psychological services;
8. to have access to their records as provided in subpart 1a and Minnesota Statutes, Section 144.335, subdivision 2; and
9. to be free from exploitation for the benefit or advantage of the psychologist.
Consumers of social work services offered by social workers licensed by the State of Minnesota have the right:
1. To be informed of the social worker’s license status, education, training and experience;
2. To examine public records maintained by the Board of Social Work which contains the credentials of a social worker;
3. To obtain a copy of the Grounds for Disciplinary or Corrective Action Standards of Practice and Ethical Conduct from the Minnesota Board of Social Work from the State Register and Public Documents Division, Department of Administration, 117 University Avenue, St. Paul, MN 55114-1095;
4. To report complaints to the Minnesota Board of Social Work; 2829 University Avenue SE; suite 340; Mpls., MN 55414-3237;
5. To be informed of the cost of professional services before receiving the services;
6. To privacy as defined by rule and law;
7. To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving social work services;
8. To have access to their records as provided in subpart 1a and Minnesota Statutes, Section 144.335, subdivision 2; and
9. To be free from exploitation for the benefit or advantage of the social worker.
Consumers of professional counseling services have the right to:
1. Expect that the provider has met the minimal qualifications of training and experience required by state law;
2. Examine public records maintained by the Board of Behavioral Health and Therapy that contain the credentials of the provider;
3. Obtain a copy of the Rules of Conduct from Minnesota's Bookstore, Department of Administration, 660 Olive Street, St. Paul, MN 55155, or its current location;
4. Report complaints to the Board of Behavioral Health and Therapy;
5. Be informed of the cost of professional services before receiving the services;
6. Privacy as defined and limited by rule and law;
7. Be free from being the object of unlawful discrimination while receiving counseling services;
8. Have access to their records as provided in part 2150.7520, subpart 1, and Minnesota Statutes, section 144.292, except as otherwise provided by law;
9. Be free from exploitation for the benefit or advantage of the provider;
10. Terminate services at any time, except as otherwise provided by law or court order;
11. Know the intended recipients of assessment results;
12. Withdraw consent to release assessment results, unless this right is prohibited by law or court order or is waived by prior written agreement;
13. A nontechnical description of assessment procedures; and
14. A nontechnical explanation and interpretation of assessment results, unless this right is prohibited by law or court order or this right was waived by prior written agreement.
SUPERVISORY NOTIFICATION
Vanda Counseling provides supervision for some non-independently licensed mental health professionals that are completing clinical hours to become independently licensed. In those cases, your assessment and treatment at Vanda Counseling will be supervised by an independently licensed professional who will be available for consultation during your care and treatment. You will be notified of the independently licensed professional with their contact information during your first visit. You may also be asked to sign a separate consent notifying you of the supervisory
relationship.
PET THERAPY NOTIFICATION
Vanda Counseling and Psychological Services uses a certified pet therapy dog as a treatment modality in a written, individualized treatment plan with specific, documented goals. You will be notified if a pet therapy dog will be used for your therapy prior to initiation of treatment and the right to refuse this therapeutic modality. You will be asked to sign a separate consent if you desire to work with our therapy dog.
OFFICE POLICIES:
FEES AND PAYMENT:
Vanda Counseling and Psychological Services P.L.L.C. accepts most major insurances. Vanda Counseling and Psychological Services will be glad to bill your insurance as a courtesy and service to you. It is, however, solely your responsibility to contact your paying insurance agency to confirm benefits prior to starting services. Your insurance is billed separately and you'll receive an invoice from Vanda Counseling and Psychological Services. It is not possible to waive or reduce deductibles. The deductible portion, copayments and coinsurances are your responsibility and are due at the time of each session. If for any reason your insurance company will not pay a claim within 90 days, it is your responsibility to pay the balance in full and then attempt to receive reimbursement from your insurance company on your own. In all cases, payment for services is ultimately the responsibility of the client, not the insurance company..
Acceptable forms of payment include: cash, check, or credit card. If a check is returned by the bank for insufficient funds you will be charged a $30 servicing fee and checks will no longer be accepted as payment for future sessions. At any time, please notify your therapist if any problem arises during the course of therapy regarding your ability to make payments. You will be asked to keep a credit card or debit card on file for copays, coinsurance, deductible amounts, and all charges not covered by your insurance company. Your credit/debit card will be charged for any current and/or past due balances.
Your insurance company or managed care company may limit the number of sessions based on their assessment of medical necessity or other factors. Their determination may or may not match what you want or need in treatment. In the event that they will not authorize additional sessions or you exhaust the sessions that your insurance will provide, understand that you will have to pay for the additional services rendered. Using a third party to pay for the counseling implies that some information will be released in order to obtain payment for the services. Most insurance agreements require you to authorize us to provide a clinical diagnosis. Additional clinical information (such as treatment plan, a summary, or, in rare cases, a copy of the entire record) may also be requested. This information will become part of the insurance company files, and although they claim to keep such information confidential, we have no control over what they do with it. For more information please see the HIPAA NOTICE OF PRIVACY PRACTICES section for more information.
CANCELLATION:
Regular attendance to your scheduled appointments is key to a successful outcome in counseling. Because each appointment involves the reservation of time specifically for you, and as this is the basis of your therapist’s livelihood, a minimum of 24 hours’ notice is required to reschedule or cancel an appointment. The fee for appointment failures or late cancellations less than 24 hours in advance is $100 per occurrence. Your insurance will not pay for late cancelled appointments or missed appointments. Excess cancellations or requests for appointment time changes are disruptive to the therapeutic process. Should this become a problem, the therapist reserves the right to terminate treatment and refer you to an alternative provider for continued treatment. If you missed a scheduled session and do not call our office, the therapist will hold your file open for one month, if there is no contact during that month the therapist will accept this as your notice that you have terminated services and wish to discontinue therapy with our office.
CONTACTING YOUR THERAPIST:
If you need to contact your therapist, please leave them a message at (763) 575-8086. By listening to the prompt with their extension number you will be able to leave them a confidential message. We will return all phone calls within 24 hours.
ELECTRONIC COMMUNICATION:
Risk of using email/texting: The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks: Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy. Employers and on-line services have a right to inspect emails sent through their company systems. Emails and texts can be intercepted, altered, forwarded or used without authorization or detection. Email and texts can be used as evidence in court. Emails and texts may not be secure and therefore it is possible that the confidentiality of
such communications may be breached by a third party.
Conditions for the use of email and texts: Therapist cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. Therapist is not liable for improper disclosure of confidential information that is not caused by Therapist’s intentional misconduct. Clients/Parent’s/Legal Guardians must acknowledge and consent to the following conditions: Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time. Email and texts should be concise. The client/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations. All email will usually be printed and filed into the client’s medical record. Texts may be printed and filed as well. Provider will not forward client’s/parent’s/legal guardian’s identifiable emails and/or texts without the client’s/parent’s/legal guardian’s written consent, except as authorized by law. Clients/parents/legal guardians should not use email or texts for communication of sensitive medical information. Provider is not liable for breaches of confidentiality caused by the client or any third party. It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if warranted.
EMERGENCY SITUATIONS AND 24/7 RESOURCES
Due to the nature of your therapist’s work, they are often unable to respond immediately to counseling emergencies. If there is a mental health emergency and you need to talk to someone immediately, please call 911, call the National Suicide Prevention Hotline at: (800) 273-8255; access the crisis text line by texting MN to 741741 to talk with a trained crisis counselor, or go to the nearest emergency room.
We have also provided the following metro area mental health crisis lines for your reference:
Metro Area Mental Health Crisis Lines:
- Anoka County 763-755-3801
- Carver/Scott Counties 952-442-7601
- Dakota County 952-891-7171
- Washington County 651-777-5222
- Ramsey County, Adults 651-266-7900
- Ramsey County, Children 651-774-7000
- Hennepin County, Adults 612-596-1223
- Hennepin County, Children 612-348-2233
- To find your local crisis number, type your county or zip code at www.mentalhealthmn.org .
Other available resources:
- Urgent Care for Adult Mental Health in Ramsey, Dakota, and Washington Counties - 402 University Ave. E., St. Paul, MN 55130, 651-266-7900
- The Behavioral Emergency Center at Fairview serves emergent/urgent mental health crises. Address: 2450 Riverside Avenue South, Minneapolis, MN 55454; Phone: (612) 273-5640
LITIGATION LIMITATIONS: Due to the nature of the therapeutic process and the fact that it often involves making full disclosures with regard to matters that may be confidential and sensitive in nature, it is agreed that should you be involved in legal proceedings, neither you nor your attorney, nor anyone else acting on your behalf, will call on your therapist to testify in court or at any other court proceeding. Disclosure of the therapy records may not be requested.
HIPAA NOTICE OF PRIVACY PRACTICES:
Federal and state laws, as well as professional ethics standards demand protection of the privacy of your health information. We must give you notice of our legal duties and privacy practices concerning your Protected Health Information (PHI). The following constitutes that notice.
CONFIDENTIALITY/PRIVACY:
Your privacy is very important to us. We understand that your Protected Health Information (PHI) is personal and we are committed to protecting it. Please understand that we need the records we create in order to provide you with quality care and to comply with certain legal and contractual requirements. This notice will tell you about the ways we may use and share your PHI. We will also describe your rights and certain duties we have in regards to the use and disclosure of your PHI.
For the purpose of this form, PHI is synonymous with the terms “personal health information” and “medical information.” PHI contained in your therapy file is confidential and protected to the best of our ability. We are only able to disclose your PHI with your expressed, written consent. PHI in your file is used to help provide treatment. It is also used to assess and improve the overall quality of services we provide to you. With your written consent, we may disclose confidential information in your file to other people outside of Vanda Counseling and Psychological Services P.L.L.C., who may also be involved in your treatment. Examples may include: your physician, psychiatrist, previous therapist, case manager, probation officer or another mental health professional. Use of disclosure of the confidential, protected information in your file, for purposes other than those just described, can only occur if we obtain your expressed, written consent.
CONSULTATION:
Vanda Counseling and Psychological Services is committed to providing meaningful treatment services. To that end, therapists may occasionally find it helpful to consult about a case with other professionals. Here at Vanda Counseling and Psychological Services we consult regularly with each other, as well as other outside professionals. The professionals participating in the consultations are bound by the same confidentiality measures listed here and your therapist will not release records to any outside party unless authorized in writing to do so. Unless you object, we will not inform you about these consultations unless we feel that it is important to our work together.
REVOKING AUTHORIZATION:
You may revoke a written authorization to use or disclose PHI in your file at any time, provided your revocation is documented in writing. The following are two examples of times when you are not able to revoke your authorization:
1. Your therapist has already relied on that authorization to use or disclose your PHI;
2. If you provided the authorization as a condition of obtaining insurance coverage (in this case, the law gives the insurer the right to contest a claim under the policy)
HOW WE MAY DISCLOSE PHI:
In certain situations, your therapist may be required to disclose/use your PHI without your consent.
1. Serious threat to health or safety: if your therapist believes that you present a clear and imminent risk of serious physical harm to another person, they may disclose any necessary information to help protect the threatened individual. If your therapist believes you present a clear and imminent risk of serious physical harm to yourself, they may disclose any necessary information to seek hospitalization or other treatment for you, or to contact any person involved in your protection.
2. Abuse of a child or vulnerable adult: If your therapist reasonably believes that a child or vulnerable adult, either in treatment with the therapist or not, is being abused or neglected, the law requires your therapist file a report with the appropriate authorities.
3. Judicial and Administrative Proceedings: If you are involved in a judicial proceeding and a court order has been issued for specific information from your therapy file or information about the services you are receiving, your therapist must provide that information.
4. Health Oversight Activities: If a government health agency or authority, such as one of the boards that licenses mental health professionals in Minnesota, requests information about your treatment here, they are required to provide the specified information under certain circumstances
5. Worker’s Compensation Claims: If you file a worker's compensation claim, your therapist must provide any requested information concerning your physical or mental health condition relative to the claim.
6. Complaints or Lawsuits: If you file a complaint or lawsuit against me, your therapist must provide any requested information, or any information relating to the therapist’s defense of his/herself.
7. Minors: If you are under the age of 18, your parent or guardian may review your record in most cases.
8. If disclosure is specifically required by law.
9. Communication with family or friends involved in your care or paying your bills. If you are able to make your own mental health care decisions, we will ask your permission before sharing medical information about you. If you are unable to make mental health care decisions, our clinicians may disclose relevant information if they believe that doing so is in your best interests.
10. Appointment Reminders: we may use your information to send you reminders about future appointments.
LIMITS ON CONFIDENTIALITY:
You should feel free to refuse to give any information you do not want to disclose at any time. Although withholding information may interfere with the work you do with your therapist, it is your right to do so if you choose. In general, the law protects the confidentiality of all communication between the client and a therapist, and we can only release information about our work to others with your written consent.
The following are some situations where your therapist is permitted or required to disclose information without either your consent or authorization:
1. If a government agency, pursuant to their lawful authority, is requesting the information for health oversight activities, our information may be required to be released to them.
2. If a client files a complaint or lawsuit against the therapist, relevant information may be disclosed regarding that client in order for defense.
3. In most judicial proceedings, you have a right to prevent your therapist from providing any information about your treatment, however, in some circumstances such as child custody proceedings and proceedings in which an emotional condition is an important element, a judge may require our testimony if she/he determines that resolution of the issues before him/her demands it. If the proper legal authority orders your records, we must comply.
4. If a client files a worker’s compensation claim, upon appropriate request of information must be disclosed related to the claim to appropriate individuals, which may include the client’s employer, the insurer, or the Department of Labor and Industry.
There are some situations in which we are legally obligated to take actions, which are necessary, to attempt to protect others from harm and some information about a client’s treatment may need to be revealed. These situations are unusual; should they occur however, we will make every effort to fully discuss it with you before taking any action. The following are some examples: if we have reason to suspect that a child, an elderly person, vulnerable adult or a disabled person is being abused, we must file a report with the appropriate state agency. If we believe that a client is threatening serious bodily harm to another, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If the client threatens to harm him/herself, we may be required to seek a hospitalization for them, or to contact family members or others who can help provide protection. If we learned that you have been abused or exploited by another professional person, we must report it.
As you might suspect, the laws governing these issues are complex and we are not attorneys. While your therapist will be happy to discuss these issues with you, should you need specific advice, formal legal consultation may be desirable. At your request, your therapist can provide you with relevant, important portions or summaries of the applicable state laws governing these issues.
CLIENT RIGHTS REGARDING PHI:
1. You have the right to request restrictions on certain uses and disclosures of your PHI. However, we are not required to agree to a restriction you request.
2. You have the right to request and receive any confidential communications from your therapist by alternative means and at alternative locations.
3. You have the right to inspect or obtain a copy of your therapy file at any time upon written request. Your therapist may deny your request under certain circumstances, but in some cases you may have this decision reviewed. Upon your request, your therapist will discuss with you the detail of the request and denial process.
4. You have the right to request to amend information in your therapy file for as long as your file is maintained at Vanda Counseling and Psychological Services P.L.L.C., however, your therapist may deny your request.
5. You have the right to receive an accounting of disclosures of any information in your therapy file.
6. You have the right to request a paper copy of this notice at any time upon request.
THERAPIST’S DUTIES:
1. We are required by law to maintain the privacy of protected and confidential PHI , and to provide you with a notice of the legal duties and privacy practice of Vanda Counseling and Psychological Services P.L.L.C.
2. Vanda Counseling and Psychological Services P.L.L.C., reserves the right to change the privacy policies and practices described in this document at any time. If the policies and practices regarding privacy are revised while you are currently involved in therapy, you will be given a revised notice in person or by mail. The revised version will be clearly posted in the office.
COMPLAINT PROCEDURE:
Dr. VanStelten is the Privacy Officer at Vanda Counseling and Psychological Services P.L.L.C., and she has the duty to develop, implement and adopt clear privacy policies and procedures for this practice. She is the individual who is responsible for assuring that these privacy policies and procedures are followed by staff at Vanda Counseling and Psychological Services P.L.L.C. Dr. VanStelten will train any employees or affiliates so that they understand our privacy policies and procedures. Client records are kept secured so that they are not readily available to those who do not need them. If you disagree with a decision your therapist has made regarding access to your therapy file, or if you have any questions about your privacy rights, you may contact Dr. VanStelten, LP, PsyD at (763) 575-8086 or tonie@vandacounseling.com. If you believe your privacy rights have been violated, and wish to file a complaint, you may do so with the Minnesota Board of Marriage and Family Therapy or the Board of Psychology.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Complaints to the Secretary may be sent to U.S. Department of Health and Human Services, Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago Ill, Voice Phone: (312) 886-2359. Fax: (312) 886-1807. TDD (312) 353-5693. You have specific rights under the HIPAA Privacy Rule. We understand these rights and will not retaliate against you for exercising your right to file a complaint.
SOCIAL MEDIA:
Today is much different than 15, 10 or even 5 years ago. “Social media” is new to the medical and mental health services and privacy world. We understand and expect that many people are more comfortable with social media than more traditional forms of communication, such as telephone or mail. However, because of connections being so transparent via social media, it is not to be used as a form of client-therapist communication.
On the other hand, small businesses benefit from social media and use it as a valuable marketing tool. In addition, it can be a much more effective tool than traditional advertising and an effective way to reach out to potential clients. That being said, the following is a working model of Vanda Counseling and Psychological Services P.L.L.C.: anyone can like Vanda Counseling on Facebook or follow us on Pinterest. Doing so however, does neither verify nor deny that one is or isn’t a client. It should also be acknowledged that there is a difference between being a friend and being a Facebook “friend.” Client-therapist interaction and treatment will not be done via social media, this includes private messages.
BUSINESS ASSOCIATES AND THIRD PARTIES:
As it relates to your privacy and rights to understand services, the following section is intended to clarify other concerns as it relates to business associates of Vanda Counseling and Psychological Services P.L.L.C., outsourced services thereof, and other parties that may be in contact with you and others involved.
BUSINESS ASSOCIATES:
In 2013, the HITECH Act was added to the Health Insurance Portability and Accountability Act (HIPAA). In accordance with this act, business associates are now directly “on the compliance hook” since they are required to comply with the safeguards contained i n the HIPAA Security Rule (SR). Although this is intended for all the new Electronic Health Records, we would like to make you aware that Vanda Counseling and Psychological Services works with a number of business associates for a variety of purposes. Many of these organizations have their own privacy policies that are available online. Below are some examples of business associates:
Therapy Appointments: Scheduling and Electronic Health Records
Office Ally: Claims Clearinghouse
CPH and Associates: Insurance
ACE American Insurance Company: Insurance
KMR Partners, LLC: Property ownership and management
Square: Credit Card processing
QuickBooks: Accounting
BMO: Banking
Communication: VirtualPBX, Google, SR eFax
Formstack: Forms, consents
The Minnesota State Board of Marriage and Family Therapy: Licensure and Professional Regulation
The American Association of Marriage and Family Therapists (and Minnesota Division): Professional Association
The Board of Psychology: Licensure and Professional Regulation
MN Board of Social Work: Licensure and PRofessional Regulation
Marketing: Psychology Today, Good Therapy, Facebook, VistaPrint, Rogers Printing, WordPress, Pinterest, Everyday Flyers
3rd Party Payers: BlueCross/BlueShield, PreferredOne, MA, UCare, BHP, United Behavioral Health, Health Partners, Ceridian, Cigna, Aetna, Medicare, Magellan. **Some insurances may not be listed but information will be shared as necessary to coordinate benefits and billing.