GROUP APPLICATION

The following is to inform you of your rights as a consumer of counseling services and to outline your responsibilities as a client. Please read the following carefully so that you may be as informed as possible in giving consent to treatment.

Treatment Engagement 
You have the right and the responsibility to participate in treatment decisions, and in the development and review of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw consent to treatment, and to be advised of the consequences of such refusal or withdrawal. Clients are often given homework assignments between sessions in order to facilitate growth and progress. You have the right to refuse these assignments at any time with the understanding that this could prolong your time in therapy. As your group therapists we will remain dedicated to your treatment and will provide quality care to the best of our abilities. We ask that you, as the client, also take responsibility for your progress in counseling by remaining engaged and committed to your goals.

Treatment Frequency and Attendance 
The Mind, Body, Soul Group is scheduled to meet for a total of eight consecutive sessions. We intend for each member to make the best effort to attend all group sessions in order to encourage growth and cohesiveness. The group sessions will also build upon one another, thus missing too many sessions may hinder the effectiveness of group treatment. If three sessions, are missed we will discuss with you whether or not the group is convenient for you at this time. We understand that absences do happen. If you need to miss a group session we ask that you let us know with at least 24 hours notice in order to avoid charge of the session. 

Our Relationship 
The client/counselor relationship is unique in that it is exclusively therapeutic. In other words, it is inappropriate for a client and a counselor to spend time together socially, to bestow gifts to one another, or to attend family or religious functions. The purpose of these boundaries is to ensure that we are clear in our roles for your treatment and we can remain unbiased participants in your treatment. If there is ever a time when you believe that you have been treated unfairly or disrespectfully, please talk with us about it. It is never the intention to cause this to happen to clients, but sometimes misunderstandings can inadvertently result in hurt feelings. We want to address any issues that might get in the way of the therapy as soon as possible.  

Contact Between Sessions 
Brief telephone calls or email exchanges regarding a schedule change or asking for a specific piece of information are encouraged. Please allow 24 hours for non-emergency phone calls to be returned. Established clients with an urgent need may call, but an immediate response is not guaranteed. If the concern is regarding something significant, you may want to schedule an appointment. More extensive phone conversations (over 15 minutes in duration) may be charged accordingly as a regular office visit. 
 
We do not have the capability to respond immediately to a menatl health emergency, and so if you experience a crisis in between counseling sessions, please call 911 or one of the crisis lines listed below: 
 
Empact Suicide Prevention Center/24 Hour Crisis Hotline: 480-784-1500 
Teen Lifeline: 1-800-631-1314  
Maricopa 24 Hour Crisis Hotline: 602-222-9444 
Across Arizona: 1-800-252-6465

Payment Policy 

Payment is due at the beginning of each counseling session. You may pay with credit card, cash, check or through Paypal. An extra 3.5% + $0.15 charge will be added to a credit card transaction for processing fees, and an extra 2.9% + $0.30 will be added for Paypal fees. The payment scale is as follows: $85/each group session. You may be charged the full rate of a session for any late cancellations or no shows.

Termination Policy and Procedure 

Clients may terminate treatment at any time. Mind, Body, Soul therapists may also terminate treatment for the following reasons:  
a. The therapist determines that she does not have the expertise to treat the client’s presenting symptoms.  
b. The therapist determines that the client needs a higher level of care and she doesn’t provide the scope of services needed for the client. 
d. The client is failing to adhere to the treatment plan (e.g. failure to notify the provider of significant changes in condition, lacking follow through with recommendations for treatment to the detriment of client’s progress). 
e. Excessive cancellations or after three absences within the course of the group therapy. 
f. Failure to pay outstanding charges on client account or failure to pay for services to include no show fees.  
g. Inappropriate behavior (e.g. threats, violence, damage to property, or illegal behavior).  

If care is terminated, the client will be provided written notice including the reasons for the termination and referrals for alternative sources of treatment (if, in the opinion of the provider, the client would benefit from furthered or alternative treatment).  

 

Privacy Notice 
  
I acknowledge that I have reviewed a copy of the HIPPA Privacy Notice and understand its content. If requested a copy will be provided to me.  

I have read the above information, and I voluntarily consent to participate as a client in Mind, Body, Soul group counseling. My signature on this document indicates that I exercised my option to ask questions about any aspect of my treatment and that my questions were answered to my satisfaction. I understand that I have the right to revoke this authorization. Until then this document remains in full effect.

The Mind, Body, Soul therapists regard confidentiality with the utmost importance, therefore it is essential that clients understand the limits and boundaries of confidentiality. In general, all information disclosed within a psychotherapy session, whether written or spoken, is confidential and legally privileged. Your therapists are the only individuals who have access to your file, unless you direct your therapists, in writing, to disclose information to specific entities. However, there are circumstances under which a therapist is legally and ethically bound to disclose information, which are detailed below.

Duty to Warn and Protect  
1. Harm to others. When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the intended victim and report this information to legal authorities.  
2. Harm to self. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client, which may include a listed emergency contact.  
3. Abuse of children and vulnerable adults. If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. 
4. Prenatal exposure to controlled substances. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. 

Legal Proceedings 
A court may require disclosure of confidential information in a legal proceeding in which your condition or treatment is a relevant concern. This may include, but is not limited to, legal proceedings such as a child custody hearing, board complaint, or criminal action.  
 
Clinical Supervision and Consultation

As independently licensed therapists Leslie and Sheana are not required to receive clinical supervision. However, in an effort to provide services that reflect best practices Leslie belongs to a group of therapists that meets regularly to discuss client care and Sheana engages in regular case consultation. When a client is discussed, identifying information is kept confidential to the extent necessary.  

Confidentiality in Group Counseling 
Members of a counseling group are not bound to the same ethical and legal mandates that therapists are, however, as an integral piece of preserving the safe space of Mind, Body, Soul, all members are asked to respect and maintain the confidentiality of what is disclosed during the course of treatment. 

Treatment Records 
The therapist is required to maintain treatment notes, which include but are not limited to: dates of treatment, diagnosis, treatment interventions, and goals. The client has a right to request records; however if examination of any part of these records would have an adverse effect on the client (or parent/guardian), the therapist is permitted to withhold that information and will provide justification for doing so.  

Use of Electronic and Phone Communication 
Although we utilize firewall and password protection for computer use, e-mail is not an encrypted form of professional exchange, therefore confidentiality cannot be guaranteed in this form of communication. When a client chooses to communicate using e-mail the client assumes the risk that the exchange may be intercepted. We also employ the use of a password to protect any voicemail or text messages. If a client chooses to text the therapist and/or gives permission for the therapist to leave voicemails, the client again assumes responsibility that these messages could be viewed by another party. 

 

I have read the information on the Confidentiality Policy of Mind Body Soul group therapy, and my signature indicates that I understand and comply with this policy.

I hereby authorize the Mind Body Soul therapists to bill the below-referenced credit card for routine group services. 
 
I understand that I can rescind this authorization at any time and arrange for alternative fee payment methods (i.e. cash, check, or alternate credit card).  
 
I acknowledge that in the event of missed or late canceled appointments (canceled with fewer than 24 hours’ notice), my card may be charged a full session fee ($85.00 per session) for the missed appointment.   
 
I have been made aware that a record of all fees associated with my treatment can be made available to me within seven (7) business days of my request.  

You are entitled to receive this Good Faith Estimate of what charges could be for psychotherapy services provided to you. While it is not possible to know in advance how many psychotherapy sessions are necessary for any given person, this form provides an estimate of cost services provided. Your total cost will depend on the number of sessions you attend, your unique circumstances, and the type and amount of services provided to you. 

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care need for an item or service. 

This estimate is not a contract and does not obligate you to obtain any services from either therapist, nor does it include any services rendered to you that are identified here.  

This estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. There may be additional items or services we may recommend as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens federal law allows you to dispute the bill.  

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit: http://www.cms.gov/nosurprised/consumers or call 1-800-985-3059. 

Based on a fee of $85 per visit at eight total group sessions: $680 

If you attend psychotherapy for a longer period, your total estimate charges will increase according to the number of sessions and length of treatment.  

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case and the estimated cost for those services depend on your needs and what you agree to in consultation with your therapists. You are entitled to disagree with any recommendation made to you concerning your treatment, and you may discontinue treatment at any time.