1. Clicking the NEXT button below goes to the next page.

2. Before leaving this page, click the SAVE button below. In the box that pops up, add your email and make up a password.

3. Every few pages, click the SAVE button. A popup box will appear (see image below). Close the box by clicking the "X" in the right corner. You may have to scroll up the page to find the popup. Then click NEXT to go to the next page.

4. If your internet crashes or you accidentally close the browser, you can restore your responses from the last time you clicked SAVE. Find an email and click the link.

5. At the end of the form, click SUBMIT and you are done.

We are required by insurance and credit card companies to verify your identity. Please take a photo of an ID such as a driver's license, passport, work ID, or another form of photo ID. If you do not have a photo ID, please let us know.

Please note that we need to confirm the other parent's agreement to your child receiving therapy in our clinic, whether you are married, divorced, or separated. If you have a custody arrangement we ask that you provide us this before your first session.

By signing this agreement, you confirm that you have the legal right to enroll your child in psychotherapy services, that you give us permission to contact your child's other parent, and that you will provide us with a custody arrangement if you have one.

DEDUCTIBLES AND COPAYS: Please call the number on the back of your  insurance card to be certain therapy services are covered. If you have a deductible, you have to pay all your medical costs until your deductible is reached. After that, you then only pay the copay. Psychotherapy out of pocket in our clinic can range from $130 to $235 for the intake appointment (the first appointment), $130 to $206 for appointments after that (depending on the degree of the person you see). If you can’t afford the cost of therapy, please talk to us about a payment plan. Services provided outside of scheduled appointments such as completing forms for you, treatment summaries, telephone therapy, etc. is prorated at $40 per 15-minute increment. Sessions need to be paid before you can reschedule. We keep a credit/debit card on file for billing.

HOW DOES THERAPY WORK? In the first 2 to 3 sessions, we  will meet with you and your child to identify the main problems, set goals for change, and develop a treatment plan. Therapy typically lasts around 20 sessions (but sometimes goes longer) and always works toward goals. Therapy is a medical intervention and more than just a place to vent about problems or receive social support. We only want your child to come to therapy when it is helpful. If your child is not benefiting from therapy, we can discuss what to do and come up with a plan, e.g., try a different treatment strategy, end therapy, refer you to another provider, seek medication, or other options.

MISSED OR CANCELED APPOINTMENTS: Please notify us as soon as possible if you need to cancel or reschedule your appointment. Unless you give me 48-hour notice, and without exception, missed or canceled appointments will incur a $50 fee for the first appointment and the full fee for any appointments after that. Sessions will not be rescheduled until all balances are paid.

HOW CAN WE DO THERAPY? If you are paying out-of-pocket for therapy (not using insurance), we can do therapy by telephone, by video, or in-person. If you are using insurance, you can do therapy by video or in-person. Insurance often does not reimburse telephone therapy appointments. You will be responsible for any out-of-pocket expenses not covered by insurance for Teletherapy.

TELETHERAPY: If engaging in Teletherapy, the laws that protect the confidentiality of your medical information also apply to Teletherapy. Please be aware there are risks affiliated with Teletherapy. Some (but not all) include the possibility that, despite responsible efforts, the transmission of your medical information could be disrupted or distorted by technical failures and the storage of your medical information could be accessed by unauthorized persons.

EMERGENCIES: We will try our  best to help your child during a crisis but we do not provide emergency services. The services you are receiving are outpatient therapy and not emergency services. If your child has a crisis that requires immediate attention or thoughts of suicide, please reach out for help using one of the following: dial 988 or go to your local hospital ER.

 

Confidentiality for Adolescents (Age 11 and Older)
Before beginning treatment, you need to understand our approach to working with your child and agree to some rules about your child’s confidentiality during the course of his/her treatment.

Therapy is most effective when a trusting relationship exists between the therapist and a child. Privacy is especially important in securing and maintaining that trust. Children must establish a “zone of privacy” with their therapist that allows them to feel free to discuss personal matters. Therefore, it is our policy to provide you with general information about the treatment of your child, but we will not share with you what your child has disclosed without your child’s consent. However, if we ever believe that your child has been abused or is at serious risk of harming him/herself or another, we will inform you. This “zone of privacy” extends to the information contained in treatment records as well.

Adolescence is a time when children need to develop a greater sense of independence and autonomy. If your child is an adolescent, he/she may reveal sensitive information during therapy sessions regarding sexual contact, alcohol and/or drug use, or other potentially problematic behaviors. For us to effectively work with your child, we must maintain confidentiality about these behaviors unless they involve imminent risk of harm to self or others, such as driving while under the influence of alcohol or drugs. We will also inform you if your child does not attend sessions or if it is necessary to refer your child to another mental health professional.

We ask that you not start therapy in our clinic if you plan on requesting your child's records or requiring that each session your therapist provide you with all the details of your child's therapy sessions.

 

Confidentiality for Children (10 Years and Younger)
Unlike therapy with adolescents, when meeting with children under the age of 10 years, it may be beneficial to meet with parents and discuss in more detail what happened in therapy. We will use our clinical judgment to keep you involved in the therapy process in a way that is helpful as well as respects your child’s privacy.

 

Confidentiality will NOT be maintained when a client who is a minor does any of the following:

• discloses plans to cause serious harm or death to themselves, and we believe they have the intent and ability to carry out this threat very soon. We must take steps to inform a parent or guardian or others of what the child has told me and how serious we believe this threat to be and to try to prevent the occurrence of such harm. 
• discloses plans to cause serious harm or death to someone else, and we believe they have the intent and ability to carry out this threat. In this situation, we must inform a parent, guardian, or others, and we may be required to inform the police and the person who is the target of the threat. 
• are doing things that could cause serious harm to themselves or someone else, even if they do not intend to harm themselves or another person. In these situations, we will need to use our professional judgment to decide whether a parent or guardian should be informed. 
• disclose or it appears that a child is being neglected or abused--physically, sexually, or emotionally--or that it appears that they have been neglected or abused in the past. In this situation, we are required by law to report the alleged abuse to the Iowa Department of Human Services.
• We are ordered by a court to disclose information. 
  

Risks and Benefits
Counseling for adolescents/children can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Working through difficult emotions can sometimes lead to an increase in difficult behaviors before the adolescent/child can utilize new skills or fully integrate their experiences. On the other hand, counseling has been shown to have benefits, such as better relationships, improved problem-solving skills, significant reductions in feelings of distress, and improved self-esteem. But there are no guarantees of how an adolescent/child will respond. Adolescents/children are unique beings that sometimes require assistance and support to grow and develop to their fullest potential. Counseling can often be beneficial for many adolescents/children and their families but there is no guarantee of this.

Divorce
Both parents have the right to be made aware of the child’s progress in treatment. Confidentiality can be maintained while still allowing for both parents to understand treatment goals, intervention strategies, and successes. We cannot withhold your child's appointment information or treatment records from the other parent, as long as they have legal rights. Both parents can contact the therapist to discuss the child's treatment, goals, and progress.

Ending Therapy
One risk of child therapy involves disagreement among parents and/or disagreement between parents and a therapist regarding the best interests of the child. If such disagreements occur, we will strive to listen carefully and try to understand your perspectives, while fully explaining our position. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. If either parent decides that therapy should end, we ask that you allow your therapist the option of having one or more closing sessions with your child to appropriately end the treatment relationship.

If conflicts arise between parents, you understand and agree that your therapist's role is strictly limited to providing psychotherapy for the benefit of your child. This means, among other things, that you will treat anything said in session as confidential and you will not attempt to gain an advantage in any legal proceeding from your therapist's involvement with your child. You agree that you will not involve your therapist in any legal dispute, especially a dispute concerning custody or visitation arrangements. You will not ask your therapist to testify in court, either in person or by affidavit. You also agree that you and/or your legal counsel will not subpoena your therapist or anyone in this clinic.

Legal Involvement
If a court appoints an evaluator, mediator, or guardian ad litem, we will provide information as needed, if appropriate releases are signed or a court order is provided. We are ethically bound not to give my opinion about either parent’s custody or visitation suitability. If for any reason, We are required to participate in a legal dispute, the party responsible for our participation agrees to reimburse their child's therapist at the rate of $350/hour for time spent testifying, being in attendance at hearings, or any case-related costs. Additional fees will be incurred for preparing reports, telephoning, and travel time.

Payment
The parent who brings the child to therapy will be responsible for paying for services. If another parent agrees to pay, please notify us. If costs are split between parents, it is the responsibility of the parent bringing the child to therapy to request reimbursement from the child's other parent.

Your Understanding
Thank you for your understanding and cooperation. Your signature indicates a legally-binding agreement with the terms set forth in this contract. 

This consent will be valid until the minor reaches the age of 18, but can be revoked at any time by written notification.

By signing this agreement, you state that you have read this contract for outpatient psychotherapy services and are voluntarily enrolling your child in psychotherapy.

We understand that emergencies come up, here is our cancellations policy:

• There is no charge for the first missed appointment.
• There is a $50 charge to the card on file for the second missed appointment.
• The full session fee is charged to the card on file for the third and subsequent missed appointments.
• If you miss 3 or more appointments, Evergreen Therapy Center may discontinue treatment due to lack of engagement.

Here are things you can do:

• Problem-solve in advance with your therapist any challenges that could prevent you from attending. We’re here to support you.
• Please do not schedule when you have other commitments that may force you to cancel, for example, being called into work at your appointment time.
• Let us know as soon as you miss an appointment and tell us why you missed. You may email, text, or call our office.

Sign below to indicate your understanding and acceptance of our cancellation policy.

Over the past 2 weeks, rate how often these problems have happened to your child?

Notice of Privacy Policies and Practices to Protect the Privacy of Your Health Information 

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND 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 Privacy Practices is provided to you by law as a requirement of the Health Insurance  Portability and Accountability Act (HIPAA). Please retain the entirety of this form for your records.  Privacy is a very important concern for all those who come to this office. It is also complicated, because  of the many federal and state laws and our professional ethics. If you have any questions, please contact Evergreen Therapy Center to discuss further. 

I. DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS 

We may disclose your protected health information (PHI), for treatment, payment, and health care  operations purposes with your consent. 

II. USES AND DISCLOSURES REQUIRING AUTHORIZATION 

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations  when your appropriate authorization is obtained. An “authorization” is written permission above and  beyond the general consent that permits only specific disclosures. In those instances when we are asked  for information for purposes outside of treatment, payment and health care operations, we will obtain  an authorization from you before releasing this information. We will also need to obtain an  authorization before releasing your psychotherapy notes. “Psychotherapy Notes” are notes we have  made about our conversation during a private, group, joint, or family counseling session, which we have  kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. 

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not  revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the  authorization was obtained as a condition of obtaining insurance coverage, and the law provides the  insurer the right to contest the claim under the policy. 

III. LIMITS OF CONFIDENTIALITY 

We may use your PHI without your consent or authorization in the following circumstances: 

Child Abuse: If we know, or have reasonable cause to suspect, that a child is abused, abandoned, or  neglected by a parent, legal custodian, caregiver or other person responsible for the child's welfare, the  law requires that we report such knowledge or suspicion to the Iowa Department of Human Services. 

 

Abuse of Elderly or Disabled Adult: If we know, or have reasonable cause to suspect, that a vulnerable  adult (disabled or elderly) has been or is being abused, neglected, or exploited, we are required by law  to immediately report such knowledge or suspicion to the Iowa Department of Human Services.

 

Health Oversight: If a complaint is filed against me with the Iowa Department of Health on behalf of the  Board of Psychology, the Department has the authority to subpoena confidential mental health  information from me relevant to that complaint. 

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is  made for information about your diagnosis or treatment and the records thereof, such information is  privileged under state law, and we will not release information without the written authorization of you  or your legal representative, or a subpoena of which you have been properly notified and you have  failed to inform us that you are opposing the subpoena or a court order. The privilege does not apply  when you are being evaluated for a third party or where the evaluation is court ordered. You will be  informed in advance if this is the case. 

Serious Threat to Health or Safety: When you present a clear and immediate probability of physical  harm to yourself, to other individuals, or to society, we are required by law to communicate relevant  information concerning this to the potential victim, appropriate family member, or law enforcement or  other appropriate authorities. 

Worker’s Compensation: If you file a worker's compensation claim, we must, upon request of your  employer, the insurance carrier, an authorized qualified rehabilitation provider, or the attorney for the  employer or insurance carrier, furnish your relevant records to those persons. 

IV. CLIENT’S RIGHTS AND PSYCHOLOGIST’S DUTIES 

Patient’s Rights: 

Right to Request Restrictions - You have the right to request restrictions on certain uses and  disclosures of protected health information about you. You also have the right to request a limit on the  medical information I disclose about you to someone who is involved in your care or the payment for  your care. If you ask me to disclose information to another party, you may request that I limit the  information I disclose. However, I am not required to agree to a restriction you request. To request  restrictions, you must make your request in writing, and tell me: 1) what information you want to limit;  2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply. 

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means  and at alternative locations. (For example, you may not want a family member to know that you are  seeing me. Upon your request, I will send your bills to another address. You may also request that I  contact you only at work, or that I do not leave voicemail messages.) To request alternative  communication, you must make your request in writing, specifying how or where you wish to be  contacted. 

Right to an Accounting of Disclosures - You generally have the right to receive an accounting of  disclosures of PHI for which you have neither provided consent nor authorization (as described in  section III of this Notice). On your written request, I will discuss with you the details of the accounting  process. 

Right to Inspect and Copy - In most cases, you have the right to inspect and copy your medical and  billing records. To do this, you must submit your request in writing. If you request a copy of the  information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to  information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative  proceeding. 

Right to Amend - If you feel that protected health information I have about you is incorrect or  incomplete, you may ask me to amend the information. To request an amendment, your request must be  made in writing, and submitted to me. In addition, you must provide a reason that supports your  request. I may deny your request if you ask me to amend information that: 1) was not created by me; I  will add your request to the information record; 2) is not part of the medical information kept by me; 3)  is not part of the information which you would be permitted to inspect and copy; 4) is accurate and  complete. 

Right to a Copy of this Notice - You have the right to a paper copy of this notice. You may ask me to  give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my  policies and/or to change this notice, and to make the changed notice effective for medical information I  already have about you as well as any information I receive in the future. The notice will contain the  effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the  current notice available on request. 

Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this,  you must submit your request in writing to my office. You may also send a written complaint to the U.S.  Department of Health and Human Services. 

Psychologist’s/Clinician's Duties: 

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal  duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and  practices described in this notice. Unless we notify you of such changes, however, we are required to  abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with  the revised policy in person or by mail at the address you provide. 

V. EFFECTIVE DATE, RESTRICTIONS, AND CHANGES TO PRIVACY POLICY 

This notice will go into effect on March 1, 2018. We reserve the right to change the privacy policies and  practices described in this notice. Unless we notify you of such changes, however, we are required to  abide by the terms currently in effect. If we revise our policies and procedures, you will be notified  about those changes in your next office visit, by telephone communication, or by mail. 

Patient’s Acknowledgment of Receipt of Notice of Privacy Practices  

Please sign, print your name, and date this acknowledgment form. 

I have been provided a copy of Evergreen Therapy Center’s “Notice of Privacy Practices.”  We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services. 

This form gives Evergreen Therapy Center permission to text or email you about appointments and information regarding your care. If you do not wish to communicate by text or email, leave this form unsigned.

Please note that email and texting is a convenient form of communication, but it is not a secure form of communication and confidentiality cannot be absolutely guaranteed. If this is a concern, please call 319-853-8762.

I consent and give permission for my provider and other staff at Evergreen Therapy Center to communicate with me by email or text regarding various aspects of my care, which may include, but shall not be limited to, diagnoses, treatment plans, recommended interventions, appointments, and billing.

I understand that email and text messaging are not confidential methods of communication. I further understand that, because of this, there is a chance that email and text messages regarding my care might be read by someone else.