Policy Form

THRIVE COUNSELING & PSYCHIATRY

OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

 

CONFIDENTIALITY

 
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure are described in the Notice of Privacy Practices form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Thrive Counseling, Thrive Counseling will only provide the minimum necessary information to the carrier. Unless authorized by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier.

Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Appointment reminders are sent through email and text messaging. Please notify Thrive Counseling at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf will call on Thrive Counseling to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation: Thrive Counseling may consult with other professionals regarding clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained. Thrive Counseling will release information to any agency/person you specify unless it is concluded that releasing such information might be harmful in any way.

 

PAYMENTS & INSURANCE REIMBURSEMENT

 
Clients are expected to pay the standard fee ($150 for therapists, $95 to $235 for psychiatry appointments. Additional fees may apply for sessions outside of normal business hours) at the beginning of each session unless other arrangements have been made. Payments for telehealth sessions are required to be made at the time of the session on our website at www.thrivetrauma.com/payments. An invoice for online sessions will be sent via email at the time of the session; this email will not include any identifying information. Thrive Counseling may also send emails related to past due payments; these emails will not contain identifying information. Please notify Thrive Counseling if any problem arises during the course of therapy regarding your ability to make timely payments. 

Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Thrive Counseling will attempt file insurance claims for some providers. If insurance is accepted, you are responsible for all co-pays and deductibles. Thrive Counseling will, to the best of its ability, attempt to verify benefits in advance but this does not guarantee payment by your provider. If Thrive Counseling does not file claims for your provider, you will, if requested, be provided with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. 

 

 RECORDING OF AUDIO & VIDEO
 
To protect the privacy and confidentially of our clients, Thrive Counseling does not record, or allow the recording of, any audio or video on the premises of any psychotherapy services rendered. For the safety and security of our clients and staff, we do use the recording of video in our facility, but we do not record clients during sessions.

 

THE PROCESS OF THERAPY/EVALUATION

 
Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Thrive Counseling will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc.

 
Thrive Counseling may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Thrive Counseling is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you.

 

DISSCUSSION OF TREATMENT PLAN

 
Within a reasonable period of time after the initiation of treatment, Thrive Counseling will discuss with you a working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Thrive Counseling’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Thrive Counseling does not provide, there is an ethical obligation to assist you in obtaining those treatments.

 

PROVISIONALLY LICENSED COUNSELORS

 
Provisional licensed counselors (refereed to as Associate Licensed Counselor or ALC in Alabama) must meet the same educational and ethical standards as Licensed Professional Counselors (LPC) but do not have as much formal experience. ALC’s work under the supervision of a Licensed Professional Counselor Supervisor, which is intended to insure the welfare of the client, while they build enough professional hours to achieve their LPC licensure. We do not consider the services provided by an ALC to be less than those provided by an LPC but we may, at times, offer those services at a reduced rate.

 
TELEPHONE & EMERGENCY PROCEDURES

 
If an issue arises between sessions, you may call your therapist on their direct number and leave a message if necessary; calls are returned as promptly as possible. If you need to talk to someone right away, you can call the 24-hour crisis line (205) 323-7777, Emergency Services (911), or go to your local hospital emergency room.

 
CANCELLATION

 

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (one day) notice is required for rescheduling or canceling an appointment. Unless a different agreement is reached, there will be a $25 charge for the first occurrence and the full fee will be charged for subsequent sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

We have limited availability for Psychiatry sessions making advanced notice of cancellations especially important. There is a flat $75 fee for sessions missed or rescheduled with less than 24 hours notice.

SESSION LENGTH

 

Sessions are 55 minutes unless otherwise stated or arranged.

 

SERVICE AGREEMENT

 

I have read the above Office Policies and General Information carefully; I understand them and agree to comply with them.

Notice of Privacy Practices

 
LIMITATION OF CONFIDENTIALITY

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

 Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

 Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

 Prenatal Exposure to Controlled Substances

Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. 

Minors/Guardianship

Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers (when applicable)

Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

 
I agree to the above limits of confidentiality and understand their meanings and ramifications.

MEDICAL RELEASE/LIFETIME SIGNATURE

ON FILE/PAYMENT AUTHORIZATION

 
I authorize payment for all insurance benefits for services rendered to Thrive Counseling. I authorize Thrive Counseling to release any information necessary to determine the benefits payable for related services to the appropriate insurance agencies or carriers. This form will serve as a lifetime signature form. I have read and understand the terms of this document. I have had an opportunity to ask questions about the use or disclosure of my health information and about the contents of this form. I acknowledge, consent and agree to the terms and conditions of this document.

TELEBEHAVIORAL HEALTH INFORMED CONSENT

 

As a client or patient receiving behavioral services through telebehavioral health technologies, I understand:

 

Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location.

The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

 Software Security Protocols:

Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

 Benefits & Limitations:

This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face to face communication. There are benefits and limitations to this service.

 Technology Requirements:

I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

Exchange of Information: The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means.

During my telebehavioral health sessions, details of my medical history and personal health information may be discussed with me or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.

Local Practitioners: If a need for direct, in-person services arises, it is my responsibility to contact practitioner.

 Self-Termination:

I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

 Risks of Technology:

These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

 Modification Plan:

My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.

 Laws & Standards:

The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.

 Electronic Transmission of Information:

I agree to participate in technology-based consultation and other healthcare-related information exchanges with Thrive Counseling, a behavioral health care practice. This means that I authorize information related to my medical and behavioral health to be electronically transmitted in the form of images and data through an interactive video connection to and from the above-named practitioner, other persons involved in my health care, and the staff operating the consultation equipment.

 Mobile Application:

It may also mean that my private health information may be transmitted from my practitioner’s mobile device to my own or from my device to that of my practitioner via an ‘application.”

I understand that a variety of alternative methods of behavioral health care may be available to me, and that I may choose one or more of these at any time.

Equipment:

I represent that I am using my own equipment to communicate and not equipment owned by another, and specifically not using my employer’s computer or network. I am aware that any information I enter into an employer’s computer can be considered by the courts to belong to my employer and my privacy may thus be compromised.

 Identification:

I understand that I will be informed of the identities of all parties present during the consultation.

Emergency Protocol:

 In the case of an emergency, contact Emergency Services (911), or go to your local hospital emergency room.