INFORMED CONSENT FOR OUTPATIENT SERVICES
This document contains important information about our professional services and business policies. Read this contract in its entirety prior to submitting your signed summary. By signing our Informed Consent for Outpatient Services, you agree to all sections in the present document.
HIPAA PRIVACY INFORMATION
The Hope Springs Behavioral Consultants HIPAA Privacy Notice is located on our website on our Forms page. You can request to have a printed copy at any time.
CONFIDENTIALITY
The privacy of all communications between a client and a provider is protected by law, and we can only release information about our work to others with your written permission. We may ask you to sign a release of information to share details with your physician, other providers or school.
Your provider may occasionally find it helpful to consult other health and mental health professionals about a case. Your provider will note all consultations in your Clinical Record, which is called “PHI” (Protected Health Information) in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of your provider.
If a client threatens to harm themselves, your provider may be obligated to seek hospitalization for her/him, contact family members, or contact others who can help provide protection. Please provide up-to-date emergency contact information to our front desk.
If a government agency is requesting information for health oversight activities, we may be required to provide it for them. If a client files a complaint or lawsuit against our office, we may disclose relevant information regarding that client to defend our practice. If a client files a worker’s compensation claim, we must, upon appropriate request, provide any information concerning the employee’s physical or mental condition relative to the claim.
If a client communicates an imminent threat of serious physical harm to an identifiable victim, we are required to disclose information to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.
In teletherapy, we have a legal and ethical responsibility to make our best efforts to protect all communications. However, the nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).
CONSENT FOR TREATMENT OF MINORS
Parents with joint legal custody have equal rights in consenting to medical treatment, unless otherwise noted in a custody or divorce decree. For many reasons, it is critical that both parents agree that treatment is appropriate and that both parents agree on a mental health provider. If consent is not received from both parents, it is likely that your provider will not move forward with treating your child. If this situation arises, your provider will work with both parents to recommend a different mental health provider.
GENDER-AFFIRMING CARE
At Hope Springs Behavioral Consultants, we support the scientific evidence that for transgender and nonbinary people, gender-affirming care is crucial to overall health. Gender diverse people, particularly minors, face significant health disparities compared to their cisgender peers, including mental health issues, substance use, and suicide.
After consultation with our professional organizations (American Psychological Association and Iowa Psychological Association), we were advised that we are ethically compelled to provide evidence-based therapy that affirms and supports the person’s gender identity as they know it to be, even if they are a minor.
We do not provide medical treatments like hormone blockers, hormones, or surgery, as these practices are beyond the scope of our practice and as such, we are prohibited from doing so by law. If requested, we will provide referral information to clinics that may provide this type of care.
While there are new Iowa laws that prohibit trans-affirming care for minors, we have been advised that this legislation is targeted at medical procedures, and not psychotherapy or psychological evaluations. If you do not want your child to receive gender-affirming psychological care, and you share this information with us, you will be referred out of our practice, and your/your child’s care at Hope Springs Behavioral Consultants will be terminated.
INSURANCE AUTHORIZATION & ASSIGNMENT
If you want insurance to cover your care, you will need to authorize Hope Springs Behavioral Consultants to release mental health information to the full extent specified under Iowa Code Chapter 228, or as subsequently amended, to your insurance company and to any organization contracting with this insurance company to administer claims submitted or to be submitted for payment, conduct a utilization and quality control review of mental health care services provided or proposed to be provided, or conduct an audit of claims paid.
You should be aware that insurance companies require your provider to provide them with a clinical diagnosis. Sometimes psychologists must provide additional clinical information such as treatment plans or summaries, or, in rare cases, copies of the entire record. This information will become part of the insurance company files and will probably be stored on a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. It is important to remember that you always have the right to pay for our services out-of-pocket to avoid the potential problems described above.
You may inspect the information disclosed at any time and may revoke this authorization at any time if you furnish written revocation to Hope Springs Behavioral Consultants. In the event you revoke authorization, you will need to accept financial liability for mental health care services provided if your insurance company or its affiliates or subsidiaries deny claims for benefits because of the inability to examine our mental health records.
By signing our Informed Consent for Outpatient Services, you agree to assign all insurance benefits directly to Hope Springs Behavioral Consultants for payment of any services rendered. You authorize the use of this signature for all insurance submissions. You authorize the release of medical records necessary to process health insurance claims. You understand that in the event your insurance company does not pay for services, you will be financially responsible for payment. You acknowledge that you were provided or directed to a copy of the Hope Springs Behavioral Consultants HIPAA Privacy Notice and you give authorization for treatment.
NEUROPSYCHOLOGICAL/PSYCHOLOGICAL ASSESSMENT
Neuropsychological/psychological assessment may help you to better understand you or your child and problems at home, work, relationships, or school. This information helps plan effective treatment. The testing process varies from person to person, based on individual needs. Some commonly tested areas include learning, memory, attention, concentration, language skills, problem solving skills, academic skills, motor skills, emotional functioning, personality functioning, and adaptive functioning.
Testing will be completed by your provider who has received supervision and training in the tests they will be administering. Testing appointments typically are scheduled in increments of two (2) hours at a time. However, on occasion up to four (4) hours of testing can be scheduled. Breaks, rest periods, or multiple appointments will be offered.
Charges reflect reviewing records, interviewing important persons, completing the test battery, scoring test data, interpreting test data, and preparing/finalizing a written report. This often takes from can take up to twenty-five (25) hours. Assessment involves several steps:
• initial interview with the client and/or parent(s) to gather all needed information and to plan testing;
• testing with the client: you and/or your child will be asked to complete various tests;
• scoring and interpretation of tests by a psychologist or a psychological assistant;
• preparation/finalization of a written evaluation report;
• and a feedback session in which assessment findings are reviewed with the client and/or parent(s).
Hope Springs Behavioral Consultants believes that our clients often need to self-advocate in schools, hospitals, governmental agencies, et cetera. Often, this advocacy requires test data, results, and interpretations. We also believe that clients are allowed access to their test data if it is not harmful nor compromises test security.
While most enjoy their testing experience, some occasionally report frustration, confusion, anger, or embarrassment. If these reactions occur, every effort will be made to make you as comfortable as possible.
PSYCHOTHERAPY SERVICES
Therapy is a partnership between you and your provider to find new ways of handling problems of daily living. Psychotherapy calls for a very active effort on your part. For therapy to be most successful, you will likely have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves addressing difficulties in life, you may experience uncomfortable feelings like sadness, frustration, and worry. However, therapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience. However, we will work with you as best we can to provide a positive therapy experience.
If you decide to pursue psychotherapy, we will usually schedule a series of sessions (53-minutes), usually on a weekly or bi-weekly basis. It will be important for you to come on time, so you receive the benefit of a full-length session.
Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time.
Please note: we do not evaluate or provide letters of support for emotional support animal(s). An emotional support animal (ESA) is different from a trained and certified service animal used by individuals with disabilities (ex: blindness, diabetes, seizures, etc.). Writing these letters is outside of our scope of practice, as we cannot certify any claims for disability benefits nor are we trained to assess disabilities. Our job is to work with our clients only in ways that we expect will benefit them. As such, we will not provide letters of support for emotional support animal(s) at this time.
TERMINATION
Services are provided at our discretion. If we have reached a point of termination, your provider will attempt to notify you, document the termination in your file, and your file will be closed. We reserve the right to terminate services if:
• parent/guardian or client behaves inappropriately toward us or our staff;
• we are court-ordered to testify, thus causing a dual-role relationship with your child;
• there is consistent failure to attend scheduled appointments, either by frequent cancellations/reschedules or no-shows;
• there is failure to complete payment or payment arrangement for services
• either parent does not consent for services;
• we are not able to effectively meet your needs, or provide you with the appropriate treatment;
• it has been more than ninety (90) days since your last appointment and there are no further appointments scheduled.
NO-SHOW/LATE CANCELLATION
Once an appointment is scheduled, you can cancel for any reason. However, you will be expected to attend unless you provide one days’ notice of cancellation – unless we both agree that you were unable to attend due to circumstances beyond your control.
If you fail to attend a scheduled session or cancel a session with less than one days’ notice, you will be charged according to our fee schedule. If this is a continuing pattern (two or more occurrences), your care may be discontinued in this clinic. Please note that some sessions, such as testing appointments and feedbacks, are typically scheduled for more than one hour. If you fail to attend or cancel with less than one days’ notice, these appointments are charged based on the number of hours scheduled.
It is important for you to understand that our schedules are often quite full. You may not always be able to reschedule easily for the same week in which you cancelled/missed an appointment.
Providers are typically not able to offer times outside of regular school/work hours.
WAITING ROOM
Our staff is not responsible for watching your child(ren). Poor waiting room behavior can result in termination of care from our office.
EMAIL & PHONE CONTACT
We will use email, phone calls, and texts to communicate with you regarding appointment information, session information, or answer your questions. With a release of information, we may also use email to correspond with other providers or important persons.
You have the right to decline this option at any time. We will use reasonable means to protect the security and confidentiality of any information sent and received by email and phone.
Clients should understand that there are known and unknown risks that may affect the privacy of personal health care information when using email or phone/texts to communicate. Those risks include, but are not limited, to:
• email and texts may be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without a client’s knowledge or agreement;
• email may be sent to the wrong address by any sender or receiver;
• phone calls and texts may be made to the wrong phone number by any sender or receiver;
• email may be easier to forge than handwritten or signed papers;
• copies of email or texts may exist even after the sender or the receiver has deleted his or her copy;
• email and phone service providers have a right to archive and inspect emails;
• email may spread computer viruses;
• email, phone call, and text delivery are not guaranteed. They may be intercepted, altered, or used without detection or authorization.
You should understand and agree that it is your responsibility to follow up with us if you have not received a response to an email, phone call, or text within a reasonable timeframe.
Expect to pay out-of-pocket for any phone calls between you and your provider. We do not offer phone therapy between sessions. It is important that your therapeutic work is done in your therapy sessions.
If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room. If you are a parent and have questions about your child, it will be important for you to ask these questions during the session.
PROFESSIONAL RECORDS
The laws and standards of our profession require that we keep treatment records. Legally, you are entitled to a copy of your records, or we can prepare a summary for you.
Parents/Legal Guardians: recent legal developments indicate that parents do not always have full access to their child’s mental health and substance abuse treatment records. To protect your child’s need for privacy, it is our policy to not provide parents with copies of their child’s treatment records. We will provide you only with a copy of an intake assessment report, neuropsychological/psychological evaluation report, and/or general information about your child’s work in therapy, unless we feel there is a risk that your child will seriously harm himself/herself, engage in high risk activities, or harm someone else.
Normally, our clients are allowed access to a copy of their PHI whenever they request it, but there are several instances access may be denied. By law, access to your PHI may be denied for any of the following reasons, which are not subject to review:
• the information that exists only in private notes written by your therapist;
• the information has been compiled in reasonable expectation of legal proceedings, or for use therein;
• the information was obtained from another party to whom I promised confidentiality. Allowing access would reveal that person's identity, which would be an ethical breach;
• the requested information is not in my possession;
• you are an inmate of a correctional institution; therefore, access to this information might jeopardize the safety of an officer, staff member, or other person at this institution, or a person responsible for transporting you.
The following reasons are subject to review by another licensed health care provider:
• granting access to information may endanger the life or physical safety of you or another person.
COURT TESTIMONY
Unless pre-arranged with us prior to initiating services, we will not provide therapy notes, test data, or testimony to the court as a part of litigation. If we are required to provide test data, testimony, or records to the court (under court order), we reserve the right to terminate services. If you are currently involved in court proceedings and a request is made for information concerning the professional services provided in our clinic, such information is protected by your provider-client privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. It is our strong preference not to be involved in court proceedings, even with your permission.
In addition, we have an ethical responsibility to only release records and/or test data to persons who are qualified and trained to interpret the information. Most court personnel have not received sufficient mental health training to meet these criteria and providing records and/or test data can be damaging for clients. Finally, legislation and ethical standards mandate that your provider protects privacy of mental health records. Because your provider cannot control the number of people that have access to the mental health records in the court setting, concerns for the client’s privacy may exist.
CLIENT RESPONSIBILITY
Your insurance policy is a contract between you and your insurance company. The services provided by our office are services you have elected to receive which may imply a financial responsibility on your part. Please be aware that all charges are your responsibility whether or not your insurance company pays your claims.
You must inform the office of all insurance changes and authorization requirements, referrals, and precertification. If your insurance company does not pay within ninety (90) days from the date of service, the client or guardian seeking care for a minor will be responsible for payment of services.
CREDIT CARD & DRIVER’S LICENSE
We may require a valid credit card to be kept on file to cover unpaid charges on your account. Federal laws on identity theft require that we keep a copy of your driver’s license on file.
PAYMENT FOR SERVICES
We accept cash, checks, and all major credit cards. We expect payment in full within ninety (90) days of your statement. There is a $70 fee for all chargebacks. Where minors are concerned, the parent or guardian that signs this informed consent is the only party that will be held financially responsible. If the client is not a minor, then the client is the only person held financially responsible. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Any payment exceptions will be agreed upon in writing.
DELINQUENT ACCOUNTS
If your account balance has not been paid for more than ninety (90) days and arrangements for payment have not been agreed upon, our office has the right to use legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such an action is necessary, the court costs and collection costs will be included in the claim. Your original balance will incur a 40% fee that will be included in the amount sent to collections. Returned checks will incur an additional $70 fee. Accounts no longer maintaining a financial “good faith” status will result in you and your immediate family members being discharged from this office.
FEE SCHEDULE
The following items may be priced in time increments determined by your provider, or on a per occurrence basis. This fee schedule shows out-of-pocket rates for services with no insurance coverage, as well as rates for services that are not billable to insurance or are out-of-network. Cost for services that are billable to insurance have a different fee schedule if you are using in-network coverage. All rates are subject to change.
In addition to weekly appointments, we may charge for other professional services you may need (e.g., telephone conversations, attendance at meetings with other professionals you have authorized, completion of paperwork, records requests, et cetera).
Any legal proceedings with your child/family will need to be discussed prior to our participation, and a separate legal service fee contract will need to be discussed and signed. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time your provider spends on your legal matter, even if the request comes from another party. See our fee schedule below for detailed amounts.
Time Increments
• Phone Call: $75/half-hour
• Letter*: $150/hour
• Forms/Paperwork: $150/hour
• Rushed Forms & Other Paperwork (less than two business days): $200/hour
• Neuropsychological/Psychological Assessment (Adult): $200-250/hour
• Professional Services (Legal Matter): $400/hour
Per Occurrence
• Late Cancellation: $175/hour scheduled
• No-Show: $175/hour scheduled
• Records Requests & Printing: $2/page
• Psychotherapy: $175
• Neuropsychological/Psychological Assessment (Child): $4,000
The same fee rates will apply for telepsychology as apply for in-person appointments. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy assessment sessions, you will be solely responsible for the entire fee of the service. Please contact your insurance company prior to our engaging in telepsychology services in order to determine whether they will be covered.
*Please note: We do not evaluate or provide letters of support for emotional support animal(s). An emotional support animal (ESA) is different from a trained and certified service animal used by individuals with disabilities (ex: blindness, diabetes, seizures, etc.). Writing these letters is outside of our scope of practice, as we cannot certify any claims for disability benefits nor are we trained to assess disabilities. Our job is to work with our clients only in ways that we expect will benefit them. As such, we will not provide letters of support for emotional support animal(s) at this time.
BLOG DISCLAIMER
The information provided by Hope Springs Behavioral Consultants on our blog is for educational and informational purposes only and does not constitute legal or medical advice. Hope Springs Behavioral Consultants may provide links on the website to other websites that are not under the control of Hope Springs Behavioral Consultants. These links are for convenience and informational purposes only and are not intended as an endorsement of the organization or individual operating the website. Hope Springs Behavioral Consultants cannot always guarantee that information on linked websites is accurate, complete, and up to date.
CUSTODY, VISITATION, & COURT-MANDATED THERAPY
We cannot and will not make any recommendations about custody or visitation issues. If custody and visitation issues are a concern, your provider may speak with you about a referral to another psychologist for a formal custody evaluation, a mediator, or guardian ad litem. It is assumed that both parents want to work toward the best interest of their child, which includes maintaining a safe, therapeutic environment with your provider. Your provider will not provide records to attorneys or testify in court in a custody or visitation dispute. Mandated therapy participation or therapy recommendations should not be included in the divorce decree without our previous consent.
BENEFITS & RISKS OF TELEPSYCHOLOGY
Although there are benefits of telepsychology, there are some differences between in-person psychotherapy or neuropsychological/psychological assessment and telepsychology, as well as some risks. For example:
Risks to confidentiality. Because telepsychology sessions take place outside of the provider's private office, there is potential for other people to overhear if you are not in a private place. On our end, we will take reasonable steps to ensure your or your child's privacy, but it is important for you to make sure you or your child finds a private place where you or your child will not be interrupted. It is also important for you to protect the privacy of the appointment on your phone or other electronic device. You should participate only while in a room or area where other people are not present and cannot overhear the conversation. For assessments, we may decide ahead of time to have another person in the room where you or your child are being tested. Other than that person, please be sure to take the test(s) in a place where there are no other people, and where other people cannot overhear. We ask that you do not contact us while driving, and that you close out all games and other applications while working with us.
Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Efficacy. Therapy: most research shows that telepsychology is about as effective as in-person psychotherapy. However, some providers believe that something is lost by not being in the same room. For example, there is debate about a provider’s ability to fully understand non-verbal information when working remotely.
Assessment: there are not many studies on taking these kinds of tests over the phone or online. Studies seem to show that tests may give similar results, but there are many things we still do not know. Because of that, we will be less certain about what your results mean. This could make us less certain about what we recommend. Because we will not be in the room with you or your child, we also may not be able to learn as much. You may need to have a re-evaluation in person when the pandemic ends or when it is safer to have in-person appointments.
We will decide together which kind of telepsychology service to use. You may have to have certain computer or phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology. Hope Springs Behavioral Consultants uses HIPAA-compliant software (Zoom or TherapyNotes) for all telepsychology services.