Developing Wellness Solutions

Please list the person I should contact in case of an emergency:

Current Concerns/History of Mental Health Concerns

Have you ever served in the military?

If yes what is the most recent war served? _Afghanistan _Iraq_Other

List a family member who lives in your home. Use the next page and/or back of sheet if needed. Name Age Relationship Occupation

 

Have you had any involvement with the legal system? (history of any aggressive behavior or sexually inappropriate, fire setting, active gang involvement children/adolescents DSS involvement) in the past or present? 

Have you been hospitalized recently for mental health concerns? Yes/No Please explain:

 

 

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

Developing Wellness Solutions (DWS) is committed to protecting your health information. DWS is required by law to maintain the privacy of Protected Health Information (PHI PHI includes any identifiable information that we obtain from you or others that relate to your physical or mental health, the health care you have received, or payment for health care. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. In order to provide treatment or to pay for your healthcare, DWS will ask for certain health information and that health information will be put into your record. The record usually contains your symptoms, examination and test results, diagnoses, and treatment. That information, referred to as your health or medical record, and legally regulated as health information, may be used for a variety of purposes. DWS and Business its Associates are required to follow the privacy practices described in this Notice, although DSW reserves the right to change our privacy practices and the terms of this Notice at any time.

DWS employees will only use your health information when doing their jobs. For uses beyond what DWS normally does, DWS must have your written authorization unless the law permits or requires it, and you may revoke such authorization with limited exceptions. The following are some examples of our possible uses and disclosures of your Uses and Disclosures without Consent Relating to Treatment, Payment, or Health Care Operations:For treatment: DWS may use or share your health information to approve, deny treatment, and to determine if your medical treatment is appropriate. For example, DWS health care providers may need to review your treatment with your healthcare provider for medical necessity or for coordination of care. To obtain payment: DWS may use and share your health information in order to bill and collect payment for your health care services and to determine your eligibility to participate in our services. DWS maintains adequate financial records and confirms arrangements for financial reimbursement with the client. For example, your health care provider may send claims for payment of medical services provided to you. For health care operations: DWS may use and share your health information to evaluate the quality of services provided, or to our state or federal auditors. Other Uses and Disclosures of Health Information Required or Permitted by Law: Information purposes: Unless you provide us with alternative instructions, DWS may send appointment reminders and other materials about the program to your home.

Required by law: DWS may disclose health information when a law requires us to do so. Avert threat to the health or safety: In order to avoid a serious threat to health or safety, DWS may disclose health information as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. Abuse and neglect: DSW will disclose your health information to appropriate authorities if we reasonably victim of believe that abuse, domestic violence, some other DWS crime. may a possible neglect or may disclose disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

Family, friends, or others involved in your care: DWS may share your health information with people as it is directly related to their involvement in your care or payment of your care. DWS may also share your health information with people to notify them about your location, general condition, or death. Worker's compensation: DWS may disclose health information to worker's compensation programs that provide benefits for work-related injuries or illnesses without regard to fault. Lawsuits, disputes and claims: If you are involved in a lawsuit, a dispute, or a claim, DWS may disclose your health information in response to a court or administrative order, subpoena, discovery request, the investigation of a complaint filed on your behalf, or other lawful process. Law enforcement: DWS may disclose your health information to a law enforcement official for purposes that are required by law or in response to a subpoena. Other parties for conducting permitted activities: DWS may conduct the above-described activities ourselves, or we may use non-DWS entities (known as Business Associates) to perform those operations. In those instances where we disclose your PHI to a third party acting on our behalf, we will protect your PHI through an appropriate privacy agreement

Your Rights You Have a Right to: Limit the information shared: You have the right to request a restriction or limitation on the health information DWS uses or discloses about you. DWS will accommodate your request if possible, but is not legally required to agree to the requested restriction. Except as otherwise required by law, DWS must accommodate your request if the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. Request confidential communication: You have the right to ask that DWS send you information at an alternative address or by alternative means. DWS must agree to your request as long as it is reasonably easy for us to do so

Inspect and copy: With certain exceptions (such as psychotherapy notes, information collected for certain legal proceedings, and health information restricted by law), you have a right to see your health information upon your written request. If you want copies of your health information, you may be charged a reasonable and cost based fee for copying, postage, and preparing an explanation or summary of the protected health information. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying. If DWS maintains your health information using electronic health records, we will provide access in electronic format and transmit copies of the health information to an entity or person designated by you, provided that any such choice is clear, conspicuous, and specific. Get a copy of this privacy notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by mail upon request. Receive breach notification: You have the right to receive notification whenever a breach of your unsecured PHI occurs. 

Receive protection of mental health records: If a medical record that is developed in connection with you receiving mental health services is disclosed without your authorization, DWS will only release the information in your record that is relevant to the purpose for which the disclosure is sought.

To Report a Problem about our Privacy Practices: If you believe that your privacy rights have been violated, you may file a complaint. You can file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights 877-696-6775.

DWS will take no retaliatory action against you if you make such complaints. Adapted from the Maryland Department ofHealth and Mental Hygiene http://dhmh.maryland.gov/eshc/Documents/NOTICE%200F%20PRIVACY%2OPRACTICES%204617.pdf

Health Insurance Portability and Accountability Act (HIPAA) Receipt Form

I certify that I have received from Developing Wellness Solutions (DSW) the Notice of Privacy Practices (NPP) describing how DWS can use and disclose my Protected Health Information (PHI) to carry out health treatment, payment or health care operations for other purposes that are permitted by law. I understand that the NPP describes my rights to access and control my protected health information. In addition, I hereby authorize the release of information to personal acquaintances named below (and relationship if possible):

If unable to get acknowledgement, specify why:

Welcome to Developing Wellness Solutions (DWS Our goal at DWS is to provide you with quality mental health care services. Our mission is to improve wellness from the inside out.

Please carefully read the following consent.

Consent to Mental Health Therapy Treatment

As a client in mental health therapy you have has rights and responsibilities. As a patient in mental health therapy you have the right to be informed of the risks and benefits of mental health therapy. Several risks associated with mental health therapy are discomfort, sadness, frustrations, anger and discussing unpleasant parts of your life. Although, therapy comes with risks it has been shown to provide many benefits such as a reduction in stress, improvements in functioning, greater personal awareness and learning to better manage stressors. Mental health therapy requires a very active effort on your part. In order for mental health therapy to be effective it will require you to work on things

The first sessions will be working to build rapport with you and assess your needs. By the end of the second session we will work to develop goals. At this point you should evaluate to see if you feel comfortable working with me. If at any point you feel that I am not a fit for you I will be hapy to refer you to another mental health professional. It important that you feel comfortable with the therapeutic process with me.

Mental health therapy sessions are 45-50 minutes in length at a frequency that we both agree is needed (two weekly, once weekly, biweekly If you need to cancel or reschedule please provide me with at least 24 hours' notice. If a commercial insurance recipient misses a session without honoring this policy they will be charged the copayment unless it is for emergency circumstances. Medicaid and Medicare recipients will not be charged a cancellation fee. Patients who No-Show three (3) or more times in a 12-month period, may be discharged from the practice thus they may be denied any future appointments.

In providing treatment to minors parental involvement is essential to the therapeutic process. I will not provide treatment to any child under the age of 13 unless she/he/they givs consent that I can share whatever information I consider neccessary to the parent. For children 14 and older, I will request an agreement between the client and parent that allows me to share general treatment information and progress. All other information shared in therapy will remain confidential unless consent is provided from the minor. The right to confidently will be waived in emergency circumstances such as child abuse, threats to harm themselves or someone else.

In instances of consumers under the care and custody of another individual (i.e. extended family member, DSS), legal documentation in the form of court orders or custody agreements will be requested and included as part of the medical record. Agency efforts to secure documentation of legal guardianship will be noted in the record.

If I am not available by phone leave a message in my confidential voicemail and I will return your call within 48 hours. If it is an emergency please contact the Baltimore Crisis Response hotline (410) 433-5175 or 911.

You will be notified promptly and in there is a need for the transfer, referral, or continuation of service in relation to your needs or preference or in the event of the termination or interruption of services.

You have the right to superior serviesc and if you are unhappy with the treatment process, I encourage you to talk with me so that I can respond to your concerns. You have the right to ask questions regarding your treatment, my specific training and experience. You have the right to mental health services without discrimination to race, ethnicity, gender, sexual orientation, age, or religion.

I voluntarily consent to receive mental health therapy services from Developing Wellness Solutions.

 

Telehealth is a way to visit with healthcare providers.

You can talk to your provider from any place, including your home. You don't go to a clinic or hospital.

You talk to your provider by phone, computer, or tablet. Sometimes, you use video so you and your provider can see each other.

You don't have to go to a clinic or hospital to see your provider. You won't risk getting sick from other people.

Will my telehealth visit be private?

We will not record visits with your provider. If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you. Your provider will tell you if someone else from their office can hear or see you. We use a HIPAA compliant telehealth technology that is designed to protect your privacy. If you use the Internet for telehealth, use a network that is private and secure. There is a very small chance that someone could use technology to hear or see your telehealth visit. If you choose to use a non HIPAA compliant platform (Apple Facetime, Google Hangouts, Skype, and Zoom (free and regular versions) there is a higher risk for exposure and your data being exposed.

How much does a telehealth visit cost?

We offer self pay and accept various health benefits. .A telehealth visit will not cost any more than an office visit.

 

What does it mean if I sign this document? If you sign this document, you agree that:

The same mandatory and permissive exceptions to confidentiality outlined in the General Consent Form and Notice of Privacy Practices apply to Telehealth services. There is a risk 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. We will make reasonable efforts to provide me with emergency resources. I understand that my therapist will not be able to assist me in an emergency situation. If I require emergency care, I understand that I will call 911, the crisis hotline 988 or proceed to the nearest hospital emergency room for immediate assistance.

We talked about the information in this document.

We answered all your questions.

If you sign this document, we will give you a copy.

adapted from https://www.ahrq.gov/