Sex (biological): Gender (how you identify):

Informed Consent

At Uniquely Centered Therapeutic Service, LLC, it is your therapist job to assist you in experiencing relief and new growth after the droughts of life. Your therapist is excited and grateful to work with you, and looks forward to sharing in your transformations as we go forward.

This document contains information regarding both my business policies and my professional services.  It will inform you about the Health Insurance Portability and Accountability Act (HIPAA), which is a federal law that provides you with protection and rights regarding the disclosure and use of your protected health information (PHI) for the purposes of payment, treatment, and health care operations.  

Documents like this one are often long and complex. However, it is important to read it thoroughly. We will go over its contents with you as well and answer any questions you may have during your first session. Your signature on this document, as well as ours, represents an agreement between us. So it is imperative that we are clear about what we are agreeing to. Thank you for being patient and reading it carefully.

The relationship that you and your counselor will establish is part of what makes therapy and/or the evaluation successful. Trust is an essential part of that relationship. In order for you to be able to trust us, it is necessary that you are aware of both your rights and responsibilities, and of the legal limitations to those rights. We also have responsibilities to you as your counselor which you should be aware of. These are all described in the following sections of this document.

Credentials, Professional Organizations, and Ethics

In our professional work, we are firm and enthusiastic believers in professional organizations and codes of ethics as methods by which we hold ourselves accountable and by which you, as our client, can hold us accountable. They offer guidance in difficult situations. It is important for you to know our credentials, so that you know what standard of care we should be providing you, as well as who to contact should you feel your therapist and school psychologist is doing something unethical. We are licensed by the state of Ohio as a Licensed Professional Counselor.

As all professional counselors in Ohio do work under supervision and direction. This ensures that providing you with the highest quality of care possible, and provides you with a person to contact, should you ever need to, regarding the care we have provided.

Counseling Goals

Throughout the course of our time together, we will set many goals for the outcome of counseling. Some will be short term (such as what you would like to discuss in a given session). Some will be long term (like lessening feelings of discomfort and improving the overall quality of your life). These goals will be set by you according to what you want to accomplish. I will work with you in establishing these goals and of course work with you toward achieving them. But you will have the control and will ultimately determine which direction our work together will take.

Evaluation Goals

At the beginning of our time together, we will set goals for what you hope to gain for you or your child from this evaluation.  These goals will be set by you according to what you want to accomplish and learn about your child or yourself. I will work with you in establishing realistic goals and towards achieving them. 

Risks and Benefits of the Counseling Process

Counseling can be a difficult and intense process at times. We will discuss topics which may initially cause you discomfort, such as unpleasant experiences or emotions. There are also no guarantees that it will be successful for you. Sometimes clients make progress only to regress after a time. It will challenge your ways of thinking, your previously held beliefs, and will identify areas for change.  

Most important to know is that the counseling process takes time and commitment. It requires patience from both of us. Some clients will experience some relief after one or two sessions, and will then cease counseling, feeling that they are better. Your therapist does NOT recommend this, as it can be far more detrimental over the long term. Lasting change is best accomplished by engaging the full process from initial consultation through goal setting and feedback, through treatment planning, through implementation, all the way to termination. Each step is carefully planned and engaged by both yourself and by your therapist. Throughout the process, as well, you will have to work on things that we discuss outside of our session time. You may have new behaviors to try, things to read, or a journal to write. These “homework assignments” are completely voluntary. Your therapist will never ask you to undertake anything that you are not willing or able to do.

Risks and Benefits of the Evaluation Process

Discussing learning disabilities and past and present experiences in school can be a difficult and intense process at times.  We will discuss topics which may initially cause you discomfort, such as unpleasant memories or emotions. There are also no guarantees that  will be successful for you. Sometimes the evaluation process does not give the client the answer they were hoping to find. This can be difficult for both adults and families seeking evaluations.

Most important to know is that an evaluation can take time and a commitment from you to see it through. It requires patience from all involved. Each step will be carefully planned and engaged in by both yourself and me. Throughout the process you may have to complete forms outside of our actual planned session time. Your school psychologist will never ask you to undertake anything that you or your child are not willing or comfortable doing.

The benefits of counseling and a full evaluation are many. Your school psychologist does not agree to take on any client that he/she does not fully believe he/she can provide some new insight into their life.  So from the outset, he/she undertakes the process with optimism and confidence that our outcomes will be to your benefit.

A in depth evaluation can uncover habits which can help you make changes to your life and your behavior. It can help you develop healthy boundaries in relationships. It can uncover learning disabilities that may be wreaking havoc on your life, but you didn’t really know it. It can help you learn to enjoy life and living, and to improve the quality of your life. These are just a few of the many benefits of this process. Your school psychologist is committed to helping you maximize these benefits to the best of my ability.

Confidentiality

We will do whatever is legally and ethically appropriate and allowable, to the best of our skills and abilities, to keep your personal information private. What you say in our sessions together is covered by legal confidentiality, so long as it falls within the legal limitations. Those limitations are as follows: 

• If your therapist or school psychologist has a concern that you are in any way in danger of hurting yourself or others, we are required by law to contact the appropriate authorities. 
• If your therapist or school psychologist has a concern that a child or an elder is being abused by anyone (not necessarily yourself) as a result of our conversations in session, we are required to report it to the appropriate authorities.                                                                                 
• If we are subpoenaed by a court of law to present information regarding your care, or to testify regarding your care, we may be required to do so depending on the situation. 

In all situations where confidentiality must be broken, your therapist or school psychologist is committed to informing you as much as is ethically required and appropriate. Your therapist or school psychologist, in any of these situations will consult with his/her supervisor, his/her director, and other professionals prior to taking any action. And your therapist or school psychologist will limit any such release to only what is required by law and my code of ethics.

In all other circumstances, such as coordinating care with another counselor, psychologist, or psychiatrist, your therapist or school psychologist requires that you sign a release of information authorization so that I may discuss your treatment.  

Record Keeping

Your therapist or school psychologist will be keeping records of your sessions, such as names of people that you mention, details of experiences which we think are therapeutically important, goals we discuss, or impressions that we have. These notes are kept so that we do not forget important details, so that we can ensure a direction with your care, and to ensure continuity of care should anything happen to me. These records will not be shared with anyone except with respect to the limits of confidentiality detailed above. Should you wish to have copies of your records or have them released, we will require a signed release, and will release whatever is ethically appropriate and maintain your privacy to the best of my ability. Our records at Uniquely Centered Therapeutic Service, LLC are kept both electronically and manually (on paper). Our online system is HIPAA compliant, secure, and paper files are kept in a locked filing cabinet. Records are kept for an indefinite amount of time.

Therapist or School Psychologist Inability to Render Care

Should anything happen to your therapist, such that we are no longer able to provide you care (such as accident or death), you will be contacted by one of our partners here at Uniquely Centered who will ensure the continuity of your care. He or she will access your records only as is necessary to provide continuity of care. In addition, should you wish to be provided with a contact during times when your therapist is on vacation, we are  happy to connect you with our partners so that they can provide care for you while your therapist is gone at your request.

Appointments

Therapist appointments last for fifty minutes and are typically once per week in frequency at a regular time. Evaluation appointments last anywhere from one to two hours and are typically once per week in frequency at an agreed upon time. However, if you would prefer that they be more or less frequent, we can schedule them as needed. If you need to cancel or reschedule a session, notice must be provided at least 24 hours in advance in order to avoid a cancellation fee equal to your session fee (unless we both agree that you were unable to come due to circumstances beyond your control).

Self-Pay Fees

Therapist professional fees are $102 per hour for individuals, $160 for couples, and $250 for family counseling. It is due at the beginning of each session. 

You may pay by cash, credit, or debit card. I reserve the right to involve an attorney or collection agency to collect fees that are owed if necessary.

Professional fees are subject to change due to continuing education, licensure, and specialization. If our fees increase, you will be notified no less than four sessions in advance, so that we can discuss any concerns that you have prior to the increase.

If at any point during our time together you anticipate being involved in a court case which will require my involvement, we will need to discuss this in advance, as payment is required for the professional time that your therapist will spend on your case.

Insurance

At this time we are only accepting Ohio medicaid plans. We will notify you when other insurances is accepted.

Contacting

Each therapist and school psychologist will provide their work cell number to you at the end of your first session. Please contact your therapist to reschedule or cancel an upcoming session.

If it is an emergency, please call the Ohio Crisis and Access line at 1.800.273.8225, go to your local hospital emergency room, or call 911 for help.

Email and Technology Use

We will provide you with our work email addresses. We do utilize the tool of email as long as you are comfortable with it for the purpose of rescheduling or canceling an upcoming session. If you prefer not to receive emails, please let us know by indicating in the space below.

It is our policy not to connect with clients on social media outlets such as Facebook or Instagram. We maintain an Instagram page (Uniquely Centered Therapeutic Service, LLC) to which you are welcome to subscribe. However, it is highly important to maintain professional and ethical boundaries within our therapeutic relationship. For that reason, please do not be offended if we do not accept friend requests.

 

 

Session Expectations

It is the policy that when attending sessions to please be prompt and on time. There will be a 10 minute courtesy for those individuals who have notified the therapist of his/her tardiness. In addition, for family and couples sessions, the expectation is that all parties involved are respectful to one another and participate throughout the entire session. 

Termination

The termination process of counseling can be difficult. We will move toward termination at whatever pace is comfortable and therapeutically beneficial for you. We will discuss the termination process beginning no less than four sessions prior to its occurrence, and your therapist/school psychologist will do his/her best to help ensure that the transition is smooth and successful for you. Please know that after we have terminated our regular sessions, your therapist/school psychologist will remain available for “check-ins” by phone and email, as well as occasional “well visits.”

If you so choose, you are within your rights to terminate your care at any time. All records of your care will be kept confidential (within the limitations detailed above) even after your care has been terminated. Please know that your therapist will do his/her due diligence in assuring your well-being if you have ended counseling suddenly. Your therapist/school psychologist will do this by calling, emailing, and sending a follow up letter to formally terminate care if that is your desire.

In all cases of termination, please expect an email and/or letter from your therapist/school psychologist terminating care and requesting your feedback by various methods (such as an online survey). He/she will also conduct occasional follow up calls to see how you are doing.

 

Consent to Care in Counseling

Your signature below indicates that you have read this document and agree to its terms.

Parent/Guardian Signature (if applicable)

NOTICE OF PRIVACY PRACTICES

I. COMMITMENT TO YOUR PRIVACY: Uniquely Centered Therapeutic Service, LLC is dedicated to maintaining the privacy of your protected health information (PHI PHI is information that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This Notice of Privacy Practices is required by law to provide you with the legal duties and the privacy practices that Uniquely Centered Therapeutic Service, LLC maintains concerning your PHI. It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI. Please read carefully and discuss any questions or concerns with your therapist.

II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state aw,Uniquely Centered Therapeutic Service, LLC is required to ensure that your PHI is kept private. This Notice explains when, why, and how Uniquely Centered Therapeutic Service, LLC would use and/or disclose your PHI. Use of PHI means when Uniquely Centered Therapeutic Service, LLC shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when Uniquely Centered Therapeutic Service, LLC releases, transfers, gives, or otherwise reveals it to a third party outside of the Institute. With some exceptions, Uniquely Centered Therapeutic Service, LLC may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, Uniquely Centered Therapeutic Service, LLC is always legally required to follow the privacy practices described in this Notice.

III. CHANGES TO THIS NOTICE: The terms of this notice apply to all records containing your PHI that are created or retained by Uniquely Centered Therapeutic Service, LLC. Please note that Uniquely Centered Therapeutic Service, LLC reserves the right to revise or amend this Notice of Privacy Practices. Any revision or amendment will be effective for all of your records thatUniquely Centered Therapeutic Service, LLC has created or maintained in the past and for any of your records that Uniquely Centered Therapeutic Service, LLC may create or maintain in the future. Uniquely Centered Therapeutic Service, LLC will have a copy of the current Notice in the office in a visible location at all times, and you may request a copy of the most current Notice at any time. The date of the latest revision will always be listed at the end of Uniquely Centered Therapeutic Service, LLC * Notice of Privacy Practices.

IV. HOW Uniquely Centered Therapeutic Service, LLC MAY USE AND DISCLOSE YOUR PHI:Uniquely Centered Therapeutic Service, LLC will not use or disclose your PHI without your written authorization, except as described in this Notice or as described in the "Information, Authorization and Consent to Treatment" document. Below you will find the different categories of possible uses and disclosures with some examples.

            1. For Treatment: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If you are also seeing a psychiatrist for medication management, Uniquely Centered Therapeutic Service, LLC may disclose your PHI to her/him to coordinate your care. Except for in an emergency,Uniquely Centered Therapeutic Service, LLC will always ask for your authorization in writing prior to any such consultation.

           2. For Health Care Operations: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to facilitate the efficient and correct operation of its practice. Example: Quality control: Uniquely Centered Therapeutic Service, LLC may provide your PHI to its office personnel, accountants, practice consultants, attomeys and others to make sure that Uniquely Centered Therapeutic Service, LLC is in compliance with applicable practices and laws. It is Uniquely Centered Therapeutic Service, LLC practice to conceal all client names in such an event and maintain confidentiality. However, there is still a possibility that your PHI may be audited for such purposes.

         3. To Obtain Payment for Treatment: Uniquely Centered Therapeutic Service, LLC may use and disclose your PHI to bill and collect payment for the treatment and services Uniquely Centered Therapeutic Service, LLC provided you. Example: Uniquely Centered Therapeutic Service, LLC might send your PHI to your insurance company or managed health care plan, in order to get payment for the health care services that have been provided to you. Uniquely Centered Therapeutic Service, LLC could also provide your PHI to billing companies, claims processing companies, and others that process health care.claims for Uniquely Centered Therapeutic Service, LLC's office if either you or your insurance carrier is not able to stay current with your account. In this latter instance, Uniquely Centered Therapeutic Service, LLC will always do its bestto reconcile this with you first prior to involving any outside agency.

 

        4. Employees and Business Associates: There may be instances where services are provided to Uniquely Centered Therapeutic Service, LLC by an employee or through contracts with third-party "business associates." Whenever an employee or business arrangement involves the use or disclosure of your PHI, Uniquely Centered Therapeutic Service, LLC will havea written contract that requires the employee or business associate to maintain the same high standards of safeguarding your privacy that is required of Uniquely Centered Therapeutic Service, LLC.

         Note: Ohio and Federal law provides additional protection for certain types of health information, including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how Uniquely Centered Therapeutic Service, LLC may disclose information about you to others.

 

V: USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES: Uniquely Centered Therapeutic Service, LLC may use and/or disclose your PHI without your consent or authorization for the following reasons:

        1. Law Enforcement: Subject to certain conditions, Uniquely Centered Therapeutic Service, LLC may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: Uniquely Centered Therapeutic Service, LLC may make a disclosure to the appropriate officials when a law requires Uniquely Centered Therapeutic Service, LLC to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

        2. Lawsuits and Disputes: Uniquely Centered Therapeutic Service, LLC may disclose information about you to respond to a court or administrative order or a search warrant. Uniquely Centered Therapeutic Service, LLC may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. Uniquely Centered Therapeutic Service, LLC will only do this if efforts have been made to tell you about the request and you have been provided an opportunity to object or to obtain an appropriate court order protecting the information requested.

       3. Public Health Risks: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.

       4. Food and Drug Administration (FDA): Uniquely Centered Therapeutic Service, LLC may disclose to the FDA, or persons under the jurisdiction of the FDA. PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

       5. Serious Threat to Health or Safety: Uniquely Centered Therapeutic Service, LLC may disclose your PHI if you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if Uniquely Centered Therapeutic Service, LLC, determines in good faith that disclosure is necessary to prevent the threatened danger. Under these circumstances, Uniquely Centered Therapeutic Service, LLC may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public.

      6. Minors: If you are a minor (under 18 years of age), Uniquely Centered Therapeutic Service, LLC may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.

      7. Abuse and Neglect: Uniquely Centered Therapeutic Service, LLC may disclose PHI if mandated by Georgia child, elder, or dependent adult abuse and neglect reporting laws. Example: If Uniquely Centered Therapeutic Service, LLC has a reasonable suspicion of child abuse or neglect, Uniquely Centered Therapeutic Service, LLC will report this to the Georgia Department of Child and Family Services.

      8. Coroners, Medical Examiners, and Funeral Directors: Uniquely Centered Therapeutic Service, LLC may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death or other duties as authorized by law. Uniquely Centered Therapeutic Service, LLC may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.

      9. Communications with Family, Friends, or Others: Uniquely Centered Therapeutic Service, LLC may release your PHI to the person you named in your Durable Power of Attomey (if you have one), to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you), or any other person you identify, relevant to that person’s involvement in your care or payment related to your care. In addition, Uniquely Centered Therapeutic Service, LLC may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition. 

      10. Military and Veterans: If you are a member of the armed forces, Uniquely Centered Therapeutic Service, LLC may release PHI about you as required by military command authorities. Uniquely Centered Therapeutic Service, LLC may also release PHI about foreign military personnel to the appropriate military authority.

      11. National Security, Protective Services for the President and Intelligence Activities: Uniquely Centered Therapeutic Service, LLC may release PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.

      12. Correctional Institutions: If you are or become an inmate of a correctional institution, Uniquely Centered Therapeutic Service, LLC may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.

      13. For Research Purposes: In certain limited circumstances, Uniquely Centered Therapeutic Service, LLC may use information you have provided for medical/psychological research, but only with your written authorization. The only circumstance where written authorization would not be required would be if the information you have provided could be completely disguised in such a manner that you could not be identified, directly or through any identifiers linked to you. The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of your information.

      14. For Workers' Compensation Purposes: Uniquely Centered Therapeutic Service, LLC may provide PHI in order to comply with Workers' Compensation or similar programs established by law.

      15. Appointment Reminders: Uniquely Centered Therapeutic Service, LLC is permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that you may need or that may be of interest to you.

      16. Health Oversight Activities: Uniquely Centered Therapeutic Service, LLC may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs and compliance with laws, Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess Uniquely Centered Therapeutic Service, LLC's compliance with HIPAA regulations.

       17. If Disclosure is Otherwise Specifically Required by Law. VI. OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION: In any other situation not covered by this notice, Uniquely Centered Therapeutic Service, LLC will ask for your written authorization before using or disclosing medical information about you If you chose to authorize use or disclosure, you can later revoke that authorization by notifying Uniquely Centered Therapeutic Service, LLC in writing of your decision. You understand that Uniquely Centered Therapeutic Service, LLC is unable to take back any disclosures it has already made with your permission, Uniquely Centered Therapeutic Service, LLC will continue to comply with laws that require certain disclosures, and Uniquely Centered Therapeutic Service, LLC is required to retain records of the care that it's therapists have provided to you.

 

VII. RIGHTS YOU HAVE REGARDING YOUR PHI:

      1.The Right to See and Get Copies of Your PHI: In general, you have the right to see your PHI that is in Uniquely Centered Therapeutic Service, LLC's possession, or to get copies of it; however, you must request it in writing. If Uniquely Centered Therapeutic Service, LLC does not have your PHI, but knows who does, you will be advised how you can get your PHI. You will receive a response from Uniquely Centered Therapeutic Service, LLC within 30 days of receiving your written request. Under certain circumstances, Uniquely Centered Therapeutic Service, LLC may feel it must deny your request, but if it does, Uniquely Centered Therapeutic Service, LLC will give you, in writing, the reasons for the denial. Uniquely Centered Therapeutic Service, LLC will also explain your right to have its denial reviewed. If you ask for copies of your PHI, you will be charged not more than $.25 per page and the fees associated with supplies and postage. Uniquely Centered Therapeutic Service, LLC may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance 

      2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that Uniquely Centered Therapeutic Service, LLC limit how it uses and discloses your PHI. While Uniquely Centered Therapeutic Service, LLC will consider your request, it is not legally bound to agree. If Uniquely Centered Therapeutic Service, LLC does agree to your request, it will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that Uniquely Centered Therapeutic Service, LLC is legally required or permitted to make.

      3. The Right to Choose How Uniquely Centered Therapeutic Service, LLC Sends Your PHI to You: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternative method (for example, via email instead of by regular mail Uniquely Centered Therapeutic Service, LLC is obliged to agree to your request providing that can give you the PHI, in the format you requested, without undue inconvenience

      4. The Right to Get a List of the Disclosures: You are entitled to a list of disclosures of your PHI that Uniquely Centered Therapeutic Service, LLC had made. The list will not include uses or disclosures to which you have specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family); neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel. The request must be in writing and state the time period desired for the accounting, which must be less than a 6 year period and starting after April 14, 2003. Uniquely Centered Therapeutic Service, LLC will respond to your request within 60 days of receiving your request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known),a description of the information disclosed, and the reason for the disclosure. Uniquely Centered Therapeutic Service, LLC will provide the list to you at no cost, unless you make more than one request in the same year, in which case it will charge you a reasonable sum based on a set fee for each additional request.

      5. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that Uniquely Centered Therapeutic Service, LLC correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receivea response within 60 days of Uniquely Centered Therapeutic Service, LLC's receipt of your request. Uniquely Centered Therapeutic Service, LLC may deny your request, in writing, if it finds that the PHI is: (a) correct and complete, (b) forbidden to disclose, (c) not part of its records, or (d) written by someone other than Uniquely Centered Therapeutic Service, LLC. Denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and Uniquely Centered Therapeutic Service, LLC's denial will be attached to any future disclosures of your PHI. If Uniquely Centered Therapeutic Service, LLC approves your request, it will make the change(s) to your PHI. Additionally, Uniquely Centered Therapeutic Service, LLC will tell you that the changes have been made and will advise all others who need to know about the change(s) to your PHI.

      6. The Right to Get This Notice by Email: You have the right to get this notice by email. You have the right to request a paper copy of it as well. VII: COMPLAINTS: If you are concerned, your privacy rights may have been violated, or if you object to a decision Uniquely Centered Therapeutic Service, LLC made about access to your PHI, you are entitled to file a complaint. You may also send a written complaint to the Secretary of the Department of Health and Human Services Office of Civil Rights. Uniquely Centered Therapeutic Service, LLC will provide you with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.

By signing below I agree that I have received a copy of my HIPAA Privacy Rights and understand how my private information will be utilized and stored:

Mental Health Client Rights, Responsibilities, and Grievance Procedure

 

I. The right to be treated with consideration and respect for personal dignity, autonomy. and privacy.

2. The right to service in a humane setting which is the least restrictive, feasible environment as defined in the treatment plan.

3. The right to be informed of one's own condition, of proposed or current services, treatment or therapies and of alternatives.

4. The right to consent to or refuse a service, treatment or therapy upon full explanation of the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service, treatment or therapy on behalf of a minor child.

In accordance with Section 5122.04 of the Ohio Revised Code, Mental Health Services, except for the use of medication may be provided to minors 14 years of age or older for not more than 6 sessions or 30 days, whichever occurs first, without knowledge or consent of a parent or guardian.

5. The right to have and receive a copy of a current, written. individualized service plan that addresses one's own mental health, physical health, social and economic needs and that specifies the provision of appropriate adequate services, as available, either directly or by referral.

6. The right to active and informed participation in the establishment, periodic review and reassessment of the service plan.

7. The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others.

8. The right to be informed and the right to refuse any unusual or hazardous treatment procedures.

9. The right to participate in any appropriate and available service, regardless of refusal of one or more other services, treatments or therapies. or regardless of relapse from earlier treatment in that or another service, unless there is a valid and specific necessity which precludes and/or requires the client's participation in another service. This necessity shall be explained to the client and written in the client's current service plan.

10. The right to be informed of and refuse any unusual or hazardous treatment procedures.

11. The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, television. movies or photographs.

12. The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one's own expense.

13. The right to confidentiality of communications and of all personally identifying information within the limitations and requirements of disclosure of various funding and /or certifying sources, state or federal statutes, unless release of information is specifically authorized by the client or parent or legal guardian of a minor or court-appointed guardian of the person of an adult client in accordance with rule 5122;2-3-11 of the Administrative Code and 42 CFR.

14. The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction. a goal to remove the restriction, and the treatment being offered to remove the restriction.

15. The right to be informed a reasonable amount of time in advance of the reason for terminating participation planning for the in a service. and to be provided a referral, unless the service is unavailable or not necessary.

16. The right to receive an explanation of the reasons for denial of service.

17. The right not to be discriminated against in the provision of service on the basis of religion. race, color, creed, sex, national origin, age, sexual orientation, lifestyle, physical or mental handicap or developmental disability, or the inability to pay.

18. The right/freedom to express and practice religious and spiritual beliefs.

19. The right to know the cost of services.

20. The right to fair treatment and consistent enforcement of program rules and expectations.

21. The right to receive hands off non-violent crisis intervention/de-escalation strategies

22. The right to be fully informed of all rights and to receive a written copy upon request.

23. The right to exercise any and all rights without reprisal in any form including continued and uncompromised access to service, except that no right extends so far as to supersede health and safety considerations.

24. The right to file a grievance.

25. The right to have oral and written instructions for filing a grievance, and to assistance in filing a grievance if requested

26. The right not to be discriminated against for receiving services on the basis of ethnicity.

27. The right not to be discriminated against for receiving services on the basis of genetic information.

28. The right not to be discriminated against for receiving services on the basis of human immunodeficiency virus status.

29. The right to reasonable protection from physical, sexual or emotional abuse and inhumane treatment.

30. The right not to be discriminated against for receiving services in any manner prohibited by local, state or federal laws

 

Client Responsibilities

1. Set and attend scheduled appointments with your therapist.

2. Provide a copy of legal custody or guardianship papers at the first appointment and report if custody or guardianship changes.

3. Pay all fees that are due.

4. Provide accurate and thorough information about your physical and mental health.

5. Help plan, revise, and follow through with your goals.

6. Keep your therapist informed about changes in your condition and your progress towards meeting your goals.

7. Report if you are dissatisfied with services or if the treatment is ineffective for you. 

8. Participate in sessions unimpaired by alcohol or other drugs (Your therapist may refuse to see you if you are under the influence of alcohol or other drugs at the time of the appointment

9. Participate in updates of records/documentation as indicated by your therapist.

10. Honor confidentiality and privacy of other clients.

11. Terminate your counseling relationship before beginning with another therapist.

 

Client Grievance Procedure

The following administrative procedure is based on the principle that clients must have a way to filea grievance within the practice structure. This procedure is available to all clients. The griever/client may contact our Client Rights Officers (CRO) LaDrina Eves or co owner Joseph Eves Jr., @ 513-223-3068; located at 1329 East Kemper Road, Suite# 4100G; Available hours: Monday - Friday, 9:00 a.m. - 6:00 p.m.

 

Step I:

If you are dissatisfied with your therapist or have any concerns, a grievance may be made verbally and the therapist will be responsible for making a written statement of the grievance. The written grievance must be signed and dated by the client, or have an attestation by the client advocate that the written grievance is a true and accurate representation of the client's grievance. The grievance should include, if available, the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved.

 

Step II:

A grievance of any procedure or policy is to be brought to the attention of the identified CRO (who is not your primary therapist) in writing. Poppy' Therapeutic Corner, LLC will make a resolution decision on the grievance within twenty-one calendar days of receipt of the grievance. If, for any reason. Uniquely Centered Therapeutic Service, LLC is not able to make a resolution decision within twenty-one calendar days, any extenuating circumstances indicating that this time period will need to be extended must be documented in the grievance file and written notification given to the client. A written acknowledgment of receipt of the grievance be provided to each grievant. Such acknowledgment shall be provided within three business days from receipt of the grievance. The written acknowledgment shall include, but not be limited to, the following: (a) Date grievance was received; (b) Summary of grievance; (c) Overview of grievance investigation process; (d) Timetable for completion of investigation and notification of resolution; and, (e) Treatment provider contact name, address and telephone number.

 

Step III:

If the situation or concern is resolved or not resolved, you may terminate the counseling relationship and/or file a grievance with the following organizations at any time:

Ohio Department of Mental Health & Addiction Services

30 East Board St

Columbus, OH 43215

(614) 466-2596

 

Ohio Counselor, Social Worker and Marriage and Family Therapist Board 50 West Broad Street, Suite 1075 Columbus, Ohio 43215 (614)466-0912

Uniquely Centered Therapeutic Service, LLC

200 S. Civic Center Dr Suite 300

Columbus, OH 43215 (614) 466-7264

U.S. Department of Health and Human services (civil rights regional office)

233 N. Michigan Ave Suite 1300

Chicago, IL 60601

Hamilton County Mental Health B Recovery Services Board

2350 Auburn Avenue

Cincinnati, Ohio 45219

(513)946-8600

 

Mental Health Client Rights, Responsibilities, and Grievance Procedure

By signing below I agree that I have read of my Client Rights, Responsibilities and Grievance Procedure.

Limited Authorization for Release of Information

I understand that Uniquely Centered Therapeutic Service, LLC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow Uniquely Centered Therapeutic Service, LLC to release some of my personal information to certain individuals or agencies.

Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by Uniquely Centered Therapeutic Service, LLC.

 

I understand I do not have to sign a release form. I do not have to allow Uniquely Centered Therapeutic Service, LLC to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If would like Uniquely Centered Therapeutic Service, LLC to release information about me in the future, I will need to sign another written, time-limited release. Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Uniquely Centered Therapeutic Service, LLC. Uniquely Centered Therapeutic Service, LLC and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

This release expires on:

*Expiration should meet the needs of the victim, which is typically no more than 15-30 days, but may be shorter or longer

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

*No copay or out of pocket costs for clients with Medicaid plans.*

Missed Appointment/Late Cancellation: Equal to your session fee

Client Responsibilities and Fee Information

• Each person is expected to pay his/her fee at the time of service.
• Notify your therapist if there are any changes to your insurance benefits or if your insurance is discontinued.
• No shows or cancellations without a 24 hour notice will be charged the self-pay cost of the session, which is not reimbursable by insurance. No show fees do not apply to school-based clients.
• All inquiries into pre-certification, benefits, treatment plans (if necessary coverage, etc. are the client's responsibility.
• Payment is expected at the time of service and the client has the ultimate responsibility for their account and making sure insurance payment is received if using insurance.
• If a claim is denied it is the client's responsibility to pay their account upon notification of denial at the insurance reimbursement rate. If payment is not received for services rendered in a timely manner I understand that Uniquely Centered Therapeutic Service, LLC will release my information to a third party Credit agency to attempt to collect my debt. The information provided to the Credit agency will only be demographic information in order to collect this debt.
• Uniquely Centered Therapeutic Service, LLC has your permission to release your protected health information to your insurance company.
• In order to receive services from Uniquely Centered Therapeutic Service, LLC you are agreeing to the conditions outlined above.

                      Telehealth Informed Consent

 

I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the [Informed Consent Form or Statement of Disclosures] I received from my therapist also apply to my
Telehealth services.

2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.

3. I understand that miscommunication between myself and my therapist may occur via Telehealth.

4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.

5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.

6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and refer me to in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who
can provide such services.

7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.

9. I have discussed the fees charged for Telehealth with my therapist and agree to them [or for insurance patients: I have discussed with my therapist and agree that my therapist will bill my insurance plan for Telehealth and that I will be billed for any portion that is the patient’s responsibility (e.g. co-payments)], and I have been provided with this information in the [Informed Consent Form or Name of Payment Agreement Form].

10. I understand that my therapist will make reasonable efforts to ascertain and provide me withemergency resources in my geographic area. I further understand that my therapist may not be able toassist me in an emergency situation. If I require emergency care, I understand that I may call 911 orproceed to the nearest hospital emergency room for immediate assistance. I have read and understand the information provided above, have discussed it with my therapist, and understand that I have the right to have all my questions regarding this information answered to my satisfaction. [For conjoint or family therapy, patients may sign individual consent forms or sign the same form.]

Uniquely Centered Therapeutic Service, LLC