I _____________________, have received a copy of the Turner Mental Health Counseling, Inc. Privacy Practices and understand that Turner Mental Health Counseling, Inc. will do all that they can to protect my Protected Health Information. 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, phone sessions are available if you are out of town, sick, or need additional support. If an actual emergency arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet to talk more about it.
ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and email is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some
or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled to.
As the client/parent/guardian of________________________________, I choose to have my child/ward receive treatment through Turner Mental Health Counseling, Inc. I realize that I have freedom of choice to request any provider approved for Outpatient Counseling Services. I realize I can request a list of such providers from Turner Mental Health Counseling, Inc.
While treatment provided through has few risks, it is possible that my child's behavior may worsen through attempted interventions. It is also possible that the treatment recommended by Turner Mental Health Counseling, Inc may not affect any positive change in my child's behavior.
I also realize that adults in my child's life will need to change their pattern of behavior that may be unknowingly reinforcing my child's maladaptive behavior. I also acknowledge that without my active cooperation and the active cooperation of other adults in my child's life, Turner Mental Health Counseling, Inc will be powerless to effect change in my child's behavior.
I agree to compile data as requested and follow recommendations of the treatment team. If I have reservations or disagree about the course of treatment or specific recommendations, I will make those reservations known verbally to members of the treatment team in frank and open discussion.
Information shared with Turner Mental Health Counseling, Inc will be kept confidential unless it contains information relating to a serious threat of death or harm to a named individual or suicidal ideation, physical or sexual abuse which will be reported to authorities as required by law.
This consent will expire 1 year after date signed.
Turner Mental Health Counseling, Inc Consent for Transportation
Client name: _________________________________
I, the parent/guardian/client of the above-named individual, give permission for an employee/subcontractor/agent/volunteer of Turner Mental Health Counseling, Inc to transport me, my child (children)/ward(s) in the employee/subcontractor/ agent/volunteer's personal car.
Furthermore, I give my consent for the employee/subcontractor/agent/ volunteer of Turner Mental Health Counseling, Inc to obtain medical attention for me, my child (ren)/ward(s) if this becomes necessary while under his/her supervision, and under these circumstances I agree to assume responsibility for any medical treatment rendered. I understand that in the event of an emergency illness or injury, the family will be notified as soon as possible.
I release Turner Mental Health Counseling, Inc from any liability arising from or connected with the activities to which this consent relates.
Turner Mental Health Counseling, Inc Authorization for Release of Information
Attention: Individual/Organization: ___________________________________________________ Re: Client’s Name: _______________________________________________________________ Social Security Number: __________________________________DOB: ___________________ I authorize Turner Mental Health Counseling, Inc, 5523 Saxon Blvd. Louisville, KY 40219 to:
_____ obtain from _____ release to
_____________________________________________________ ________________________ Agency/Name Phone Number
_______________________________________________________________________________
Address
The specific information:
___ Discharge/Termination Summary
___ Date of Treatment
___ Medical History and Insurance recorded ___ Treatment Plan
___ Medication History ___ Legal Issues
___ Other: _______________________________________________________________
I understand that the purpose of this disclosure is for:
___ Use in future treatment ___ Billing purposes
___ Other (specify) ________________________________________________________
Turner Mental Health Counseling, Inc. Coordination of Care Form
Client/Patient Name:
Client/Patient DOB:
Medicaid Number:
SSN:
TREATING PROVIDER INFORMATION:
Name:
Turner Mental Health Counseling, Inc.
Phone:
Address:
5523 Saxon Blvd. Louisville, Ky 40219
Fax:
(502) 6994-6118 (502) 963-1594
TREATMENT BEING PROVIDED TO PATIENT BY Turner Mental Health Counseling, Inc.
Outpatient Therapy Psychiatric Medication Management Targeted Case Management
Authorization to Release Information
I authorize Turner Mental Health Counseling, Inc. to release to/obtain from
______________________________________________, _____________________________ Primary Care Phone
_________________________________________________, __________________________. Address Fax
all information needed for services and to treat client.
Client: ______________________________________________ Date________________ Provider: _____________________________________________ Date________________
Mental Health Diagnosis:
Services Being Provided:
Significant information that may impact medical or behavioral health including hospitalization description of chronic medical illness:
Patient is being treated at Turner Mental Health Counseling, Inc. for behavioral/mental health reasons. This letter requires no action on your part unless you would like to further discuss patient’s treatment.