If your employer is not listed above, they may not be a partner of the Northeast Georgia Employee Assistance Program (NEGEAP). 

Please call our office @ 706-549-7755 to speak with our Intake Coordinator to inquire about availability.

Welcome to Family Counseling Service of Athens, Inc. Please complete this intake packet for the person identified as the primary person receiving services. Example: for you - your name; for couples* or families** - the name of an adult; for children - the name of the child.

*Notice to couples: The record will be established in the name of the caller. Any records released will require this individual's signature.

**Notice to families: To initiate family counseling services, we first require an intake session between the individual and the counselor to assess family needs and determine how to proceed. Please complete this application as an individual and note your interest in family counseling under the section titled "Briefly describe why you are seeking help." 

Do you feel that any of your concerns are affecting your job? Please rate the following items on a scale from 1 - 5, with 1 = "not at all" and 5 = "very much."

Please complete the questions below with information about the employee with the EAP benefit. This information is utilized by our agency to identify trends in employees and dependents seeking services.

The Northeast Georgia Employee Assistance Program (NEGEAP) is designed to help you and your family members manage mental health and situational concerns. The NEGEAP offers assessment, short-term consultation, referral, and follow-up services.

Your NEGEAP counselor works with you to assess your problem and develop an appropriate action plan to help resolve that problem. This plan may include short-term counseling with your NEGEAP counselor and/or the NEGEAP counselor might facilitate a referral to another provider or organization with the expertise in your area of need.

All NEGEAP services are provided at no cost to you or your family members. However, if your action plan involves seeking services outside of the NEGEAP, the financial responsibility for payment to the referral source is yours. It is possible that the services may be coordinated through the benefit plan offered by your employer.

The information you share with your NEGEAP counselor is confidential. Limits of confidentiality do apply, however; according to federal regulations, licensed clinical providers are mandated to report information that professional judgment would determines constitutes threat or serious harm to self or others, or of information regarding child or elder abuse or neglect.

DISCLOSURE OF INFORMATION: Under certain circumstances, disclosures of information may be made:

1. When the client consents in writing.

2. When the disclosure is allowed by a valid court order.

3. When the disclosure is made to medical personnel in a medical emergency.

4. When the disclosure is made in a non-identifiable form for research, audit, or program evaluation.

MISSED APPOINTMENT POLICY: We require 24-hours' notice to cancel appointments. We understand that there may be isolated, unforeseen emergencies where it is difficult or impossible to give adequate notice. Barring such rare circumstances, an appointment is considered "missed" when it is cancelled within 24 hours of the starting time of the appointment. There is no charge for a missed EAP session; however, you will have one less session available to you.

COUPLES AGREEMENT: It is understood that the medical record is opened in the name of the person requesting service. Typically this is the caller who initially scheduled the first appointment. It is understood that, unless otherwise agreed, both parties have access to the record even though the record is filed under the name of the caller. If you wish to change the name in which the record has been opened, please discuss this with your counselor.

CONSENT TO SERVICES: I hereby authorize the professional staff of Family Counseling Service, Inc. (FCS) to provide therapy, counseling, and other treatment as deemed necessary for me. I understand that information provided to FCS staff will not be shared with anyone without my written consent, except in situations mandated by state or federal law, i.e. threat to self or others, including child abuse or neglect. I (we) have read the above statement of procedure at Family Counseling Service, Inc., understand its purpose and potential benefit to me (us), and hereby consent to services. I (we) understand that this consent may be withdrawn at any time.

CONSENT TO SERVICES FOR MINORS (for all clients under 18 years of age): The initial visits at Family Counseling Service, Inc. are considered consultation and assessment to determine the appropriateness of our services for your child. In cases involving custody, we require that you provide proof of legal custody. By signing below, you attest that you have the legal right (legal custody) to seek mental health services for this child, and are not required to obtain permission from any other person. A copy of divorce documents reflecting the above shall be made available to the Agency upon request before final treatment I hearby certify that I have read and understand the content of the information stated above.

Family Counseling Service of Athens, Inc.

1435 Oglethorpe Avenue, Athens, GA 30606 (706) 549-7755

NOTICE TO OUR CLIENTS REGARDING NEW PRIVACY PRACTICES

As you are probably aware, federal law requires that you be notified of your rights regarding protection of information you share with us during treatment. The information on this form summarizes those rights as defined in federal law.

Signing this form only indicates you have been made aware of these rights. It does not authorize us to release any information regarding your services here. It is our policy to only release information after you have signed our consent form. The only exception to this is situations that are mandated by state or federal law; i.e. threat to self or others including child abuse or neglect as stated in our Consent to Services form which is also included for your signature.

In other words our protection policy is stricter than federal guidelines. If you have any questions, please discuss with your counselor.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your therapist, clinical nurse specialist, psychiatrist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the therapist's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a therapist, clinical nurse specialist, or psychiatrist to whom you have been referred to ensure that these individuals or organizations have the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in the course of normal business operations. These activities include, but are not limited to, case review, quality assessment activities, supervision of health care workers in training, licensing, and conducting or arranging for other business office activities. For example, we may disclose your protected health information to student interns that see clients at our office. We may also call you by name in the waiting room when your therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Sharing Your Information: There are situations when we are permitted, and in some instances, required to disclose information without your authorization. These situations are: when a state or federal lawhealth information be reported for a specific purpose; for public health purposes, such as contagious disease reporting, investigation or surveillance; for notices to and from the Federal Food and Drug Administration regarding drugs or medical devices; to protect victims of abuse, neglect, or domestic violence; for health oversight activities, if any, required of us such as complaint investigations, licensing, audits, and inspections; for lawsuits, legal proceedings, and when otherwise required by law; when requested by law enforcement as required by law or court order; to report criminal activity; to report to coroners, medical examiners, and funeral directors; for inmates; for organ and tissue donations; for research approved by our review process under strict federal guidelines; to reduce or prevent a serious threat to public health and safety; for workers' compensation or other similar programs if you are injured at work; for specialized government functions such as military activity, intelligence, and national security; for incidental disclosures that are an unavoidable by-product of providing treatment, obtaining payment or office operations. For example, front office staff responsible for records maintenance and billing.

Finally, under the law, we must make disclosures to you and, if required, by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Private Practices Law.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except the use or disclosure indicated in the authorization.

Your Rights:

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Fees may apply. Under limited circumstances, we may deny you access to a portion of your health information and you may request a review of the denial. Under federal law, however, you may not inspect or copy the information compiled in a reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; protected health information that is subject to law that prohibits access to protected health information, and in some instances psychotherapy notes taken by your therapist.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

However, your therapist, clinical nurse specialist, or psychiatrist is not required to agree to a restriction that you may request if the therapist, clinical nurse specialist or psychiatrist believes it is in your best your interest to permit use and disclosure of your protected health information. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your therapist, clinical nurse specialist or psychiatrist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complain. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer, Grace Edmonds, in person or by phone at (706) 549-7755.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

The following is important information about your services as related to telehealth (also known as "telemental health," "TMH"). Telehealth is defined as follows: "Telehealth means the mode of delivering services via technology-assisted media, such as but not limited to a telephone, video, or internet platform via smartphone, tablet, PC desktop system or other electronic means, using appropriate encryption technology for electronic health information. Telemental health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers." (Georgia Code 135-11-.01)

Personal Health Information (PHI) as it relates to technology requires additional security and protection compared to in-person services to ensure privacy and confidentiality. Georgia law requires all licensed mental health clinicians to have training in telemental health. We at Family Counseling Service of Athens, Inc. ("FCS") have developed several policies and procedures to ensure that your Protected Health Information (PHI) remains confidential. The following information will explain our use of, or interaction with, different delivery platforms and communication methods, so that you may make informed decisions about your participation in telehealth services with our agency.

Landline: It is important to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear you or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided us with that phone number, we may contact you on this line from a cell phone or our VOIP (voice over internet protocol) service. If this is not an acceptable way to contact you, please let us know. Telephone conversations lasting more than 15 minutes are generally billed at your clinician's hourly rate.

Cell phones: As with landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. We recognize that most people have and utilize a cell phone. We may also use a cell phone to contact you. Telephone conversations lasting more than 15 minutes are generally billed at your clinician's hourly rate. If this is a problem, please let us know, and we will discuss alternative options.

Video Conferencing (VC): Video conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but can also see each other on a screen. We utilize Zoom Professional for our meetings at this time. This VC platform is encrypted to the federal standard, is HIPAA-compliant, and has signed a HIPAA Business Associate Agreement (BAA) to assist in protecting your PHI. The BAA means that Zoom is willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential. If you and your therapist choose to utilize this technology for a session by video, your therapist will give you directions and a code to log-in securely. We strongly suggest that you only communicate through a computer or device that you know is safe (e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, is able to receive security updates from the software manufacturer, etc.).

Email: Email is not a reliably secure means of communication and may compromise your confidentiality. However, we recognize that many people prefer email as a method of communication because it is a quick way to convey information asynchronously. If we email you anything other than an appointment confirmation or information regarding a change in your appointment, we will use an encryption service to protect access to that information. Please do not discuss any therapeutic content via email; this will contribute to protection of your privacy and confidentiality. Please be aware that we are required to keep a copy or summary of all email correspondence as part of your clinical record. We strongly suggest that you only communicate via email through a device that you know is safe and technologically secure (e.g., has anti-virus software installed, is password protected, not accessing the internet through a public wireless network, is able to receive security updates from the software manufacturer, etc.). If in crisis, please do not communicate this to us via email or through other asynchronous means, as we cannot guarantee that emails will be responded to you within a timely manner. Instead, please see the information below under "Emergency Procedures," and follow the instructions outlined for receiving help in the event of a crisis situation.

Social Media (Facebook, Twitter, Linkedln, Instagram, etc.): It is our policy not to accept "friend" or "connection" requests from any current or former client on our personal social networking profiles (Facebook, Twitter, Instagram, etc.) because it may compromise your confidentiality and blur the boundaries of our relationship. Please note that FCS has a professional Facebook page; you are welcome to "follow" us on this professional account. However, please do so only if you are comfortable with the general public being aware of the fact that your name is associated with and attached to Family Counseling Service. Please refrain from making contact with us using social media messaging systems such as Facebook Messenger. These methods have insufficient security, and we do not watch them closely. We would not want to miss an important message from you.

Recommendations to Websites or Applications (Apps): During treatment, your clinician may recommend that you visit certain websites for pertinent information or self- help. Your clinician may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking software allowing automated software or other third-party entities to know that you've visited these sites or applications. They may even utilize your information to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps may be able to see that you have been to these sites by viewing the history on your device. As such, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that your clinician not make these recommendations. Please let them know by checking (or not checking) the appropriate box at the end of this document.

Faxing Medical Records: If you authorize us (in writing) via a "Release of Information" form to send your medical records or any form of PHI to another entity for any reason, we may need to fax that information to the authorized entity. We use a secure scanner/fax machine located in our office. Please be aware that information that has been faxed may remain in the hard drive of our scanner. This machine is kept behind two locks in our office and, when it needs to be replaced, the hard drive is destroyed in a manner making information on that device inaccessible.

Communication Response Time: We are required to make sure that you're aware that we are located in the Southeast and as such we use Eastern Standard Time. Our practice is considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. Your clinician is not available at all times. If at anytime this does not feel like enough support, please inform your clinician so that additional or alternative resources can be identified, or so that your case may be transferred to a therapist or clinic with 24-hour availability. We generally will return phone calls within 24 hours. However, your clinician may not return calls or emails on weekends or holidays. We do have an after-hours (outside of normal business hours) number that you can call for assistance. This number will contact the clinician on call for urgent but non-life-threatening calls. This number is (706) 549-7755. When you reach the voicemail on this line leave a name and number and the nature of your urgency and the call will be returned as soon as possible. Do not wait for this return call if this is a true life threatening emergency. In that instance, please follow the instructions below. Please ask your counselor if you have questions about this. Our After Hours service is only available to "current" clients. Your file will be placed in "closed" status if you have not been seen or do not have a scheduled appointment for 3 months following the previous service. When this happens you will must contact our office during normal business hours to resume services.

In Case of an Emergency: If you have a mental health emergency, we encourage you not to wait for communication back from your clinician, but do one or more of the following:

• Call the Georgia Crisis and Access Line ("GCAL")/Behavioral Health Link at 1 (800) 715-4225
• Call Lifeline National Crisis Line at 1 (800) 273-8255
• Call Summit Ridge Hospital at (678) 442-5858
• Call Ridgeview Institute at (770) 434-4567
• Call Peachford Hospital at (770) 454-5589
• Call 911. Go to the emergency room of your choice.

Your Responsibilities for Confidentiality & Telehealth: Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, coworkers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. You must remain stationary in a location disclosed to the therapist at the beginning of session, and must inform your therapist if you move to another location. Per Georgia state law, you must be physically located in the State of Georgia for the duration of your telehealth session. Additionally, you agree not to record any telehealth sessions.

Structure and Cost of Sessions: We may provide phone and/or video conferencing if you and therapist decide that telehealth services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, telehealth, or both. Your clinician will discuss what is best for you and make determinations based upon a standardized level of care assessment (LOCA) used by our agency. The structure and cost of telehealth sessions are exactly the same as face-to-face sessions listed on your clinician fee sheet. Your clinician will require a credit card ahead of time for ease of billing. Your credit card will be charged after your telehealth session has concluded. This authorizes any therapeutic interaction outside of setting up appointments. Insurance companies have many rules and requirements regarding telehealth that are specific to certain benefit plans. At the present time, many insurance companies may not cover telehealth services. It is your responsibility to find out about your insurance policies. We make attempts to verify benefits with your insurance company, but all final determinations are dependent upon the explanation of benefits (EOB) received after filing a claim. You will be responsible for payment of all fees for services not covered by your insurance policy. You are also responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, modem/routers, device chargers, software, headset, etc.

Emergency Procedures Specific to Telehealth Services: There are additional procedures that we need to have in place specific to telehealth services. These are for your safety in case of an emergency and are as follows:

• You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, your clinician may determine that you need a higher level of care and that telehealth services are not appropriate.
• We require an Emergency Contact Person (ECP) whom we may contact on your behalf in a life-threatening emergency only. You provided this information to us as part of the "Service Record" on page 2 of this online form. Either you or your clinician will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or your clinician determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand we will only contact this individual in the extreme circumstances stated above.
• You agree to inform your clinician of the address where you are at the beginning of every telehealth session. You agree to inform your clinician of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a telehealth session). Please list this hospital and contact number below.

In Case of Technology Failure: During a telehealth session, technological failures may occur. The most reliable backup plan is to contact you via telephone. Please make sure you have a phone with you, and that your clinician has the phone number associated with your device. If you get disconnected from a video conference, end and restart the session. If the connection cannot be reestablished within ten minutes, your clinician will call you by phone. If you are on a phone session and get disconnected, please call back or contact our office to schedule another session. If the issue is due to our phone service, and we are not able to reconnect, we will not charge you for that session.

Cancellation Policy: In the event that you are unable to keep either a face-to-face appointment or a telehealth appointment, you must notify your clinician at least 24 hours in advance. If such advance notice is not received, you will be financially responsible for the session you missed. Please note that insurance companies do not reimburse for missed sessions.

Limitations of Telehealth Services: Telehealth services should not be viewed as a complete substitute for therapy conducted in-office, unless there are extreme circumstances that prevent you from attending therapy in-person. It is an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, we might not see a tear in your eye. Or, if audio quality is lacking, we might not hear the crack in your voice that we could easily pick up if you were in the office. There may also be a disruption to the service (see "In Case of Technology Failure" above). This can be frustrating and interrupt the normal flow of interpersonal interaction. Your clinician may require at least one face-to-face meeting before performing telehealth sessions.

Consent to Telehealth Services: Please check the boxes below indicating what telehealth services you are authorizing us to utilize for your treatment or for administrative purposes. Together, we will ultimately determine which modes of communication are best for you. You may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying us in writing. If you do not see an item discussed previously in this document listed for your authorization below, this is because it is built-in to our practice, and we will be utilizing that technology unless otherwise negotiated by you.