School Based Intake Form

You must verify your email address before proceeding.
Your email address will not be sold or distributed.

Brief Description of the problem

 Verification of Consumer Choice

I have received information regarding services which I am eligible to receive.  I have been informed of providers from whom I am eligible to receive such services.  Based on this information, I have made an informed choice of the services and providers.

 

I am  in completing his/her form is selecting She’s Counseling Trichology & Consulting Inc, as my provider of choice for one of the following Services:

  Comprehensive Clinical Assessments

  Outpatient Therapy: Individual/ Family/ Groups

It has been explained that I may continue to receive services through my current provider or I may select another provider to deliver these same services.

 Please note:  It is the policy of  She’s Counseling Trichology & Consulting Inc to uphold the integrity of the issue of choice for consumers.

Consent for Services/Emergency Care Consent

Consent For Services: I authorize She’s Counseling & Consulting Inc, to provide care and
treatment of services to me. This may include screening/assessment/evaluation, psycho education, mentoring, adaptive skill training, therapeutic interventions, community integration, support counseling behavior management, crisis intervention, etc. Emergency Care Consent: I give She’s Counseling & Consulting Inc, permission to obtain emergency care. Every effort will be made to honor the individual/parent/guardian choice of physician/hospital/dentist. However, should an emergency arise that requires immediate assistance, She’s Counseling & Consulting Inc will notify the principal of the school, then they will contact emergency assistance through 911.
I release She’s Counseling & Consulting Inc and individuals from liability in case of accident during
activities related to She’s Counseling & Consulting Inc.
I understand the consent may be withdrawn at anytime.
My signature below indicates that I have read and understand this release.

 

 

Consent for Communcation

I consent to be communicated with via mail, email and/or phone. I will IMMEDIATELY advise She’s Counseling Trichology and Consulting Inc in the event of change.

I give permission to allow referring person or agency to be thanked for referring me to She’s Counseling Trichology and Consulting Inc, I further give permission to She’s Counseling Trichology and Consulting Inc to place my name on the She’s Counseling Trichology and Consulting Inc mailing list will not be given or sold to any other individual or agency.

I acknowledge that I have received and read the She’s Counseling Trichology and Consulting Inc Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights. I further acknowledge that I seek and consent to treatment. My signature below confirms that I understand and accept all the information contained in the She’s Counseling Trichology and Consulting Inc Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights.

 

The Health Insurance Portability and Accountability Act of 1996
(HIPAA)
Notice of Privacy Practices and Client Rights
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 document may be updated without notice, so please review it each time you visit us. A copy of this statement is always available upon request.
Protected Health Information (PHI) and Your Privacy All information revealed by you in a counseling or therapy session and most information placed in your file (all clinical records or other individually identifiable health information held or
disclosed in any form [electronic, paper, oral]) is considered Protected Health Information (PHI)under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your PHI cannot be distributed to anyone else without your express informed and voluntary written consent or authorization. Exceptions to this are defined immediately below. Additional information regarding your rights as a client can be found in your therapist’s Professional

Disclosure Statement and Consent for Treatment.
Use or Disclosure of PHI Without Consent or Authorization
1. Uses and disclosures required by law – like files subpoenaed by a judge 2. Uses and disclosures about victims of abuse, neglect, or domestic violence – like the duties to warn explained in your counselor’s
Disclosure Statement 3. Uses and disclosures for health and oversight activities – like correcting records already disclosed 4. Uses and disclosures for judicial and administrative proceedings – as in a case where you are claiming malpractice or breech of ethics 5. Uses and disclosures for law enforcement purposes –
like when you claim mental health issues as a defense in a civil or criminal case. 6. Uses and disclosures for research purposes – like using client information in a research project; always maintaining confidentiality
7. Uses and disclosures to avert a serious threat to health or safety – like calling Probate Court for a commitment hearing 8. Uses and disclosures for Worker’s Compensation (WC) – like the basic information obtained in therapy as a result of your WC claim.
Your Rights as a Client under HIPAA
 Right to Access: You have the right to see your counseling file. Psychotherapy notes are excluded from this right.
 Right to Review: You have the right to review a copy of your counseling file, excluding psychotherapy notes.
 Right to Amend: You have the right to request amendments to your file.
 Right to Disclosure History: You have the right to request a history of all disclosures of your PHI.
 Right to Restrict Use and Disclosure: You have the right to restrict the use and
disclosure of your PHI for treatment, payment, or operations. If you choose to release any PHI, you must sign an Authorization for Release of PHI form detailing exactly who and what information you wish disclosed.
She’s Counseling & Consulting School Based Intake
 Right to File a Complaint: You have the right to register a complaint with the Secretary of Health and Human Services if you feel your rights have been violated.
Prior to Your Counseling or Therapy
You will receive:
1. An exact duplicate of these two pages.
2. She’s Counseling Professional Disclosure Statement and Consent for Treatment.
It is necessary for you to sign indicating that you have received, read, and understand both documents. This certificate will be placed in your counseling/therapy file. Please do not sign if you do not understand any part of the HIPAA Client Rights or Professional Disclosure Statement and Consent for Treatment. Your counselor or therapist will be happy to explain these documents further.
Compliance with H. 4624 – Gender Reassignment Procedures Law
On May 21, Governor McMaster signed into law H. 4624, which includes requirements for education professionals regarding the biological sex and gender identity of minor students. The law defines "sex" and "gender" and sets forth requirements for notifying parents or legal guardians.
Definitions:
1. Sex: Biological indication of male and female in the context of reproductive potential or capacity.
2. Gender: Psychological, behavioral, social, and cultural aspects of being male or female.
Notification Requirements: A school’s principal, vice principal, or counselor must immediately notify a minor’s parent or legal guardian if:
1. The minor student asserts that their gender is inconsistent with their sex.
2. The minor student requests to be addressed using a pronoun or title that does not align with their sex.
Prohibited Actions: School nurses, counselors, teachers, principals, or other officials or staff are prohibited from:
1. Encouraging or coercing a minor to withhold from their parent or legal guardian the fact that the minor’s perception of their gender is inconsistent with their sex.
2. Withholding information from a minor’s parent or legal guardian about the minor’s perception that their gender is inconsistent with their sex.
Purpose of Notification: Notification is intended to ensure parents have a full understanding of all concerns related to their child's gender identity. It does not constitute the commencement of She’s Counseling & Consulting School Based Intake any disciplinary action. This communication and partnership between parents and education professionals are vital for the benefit of all South Carolina students.
Parental Involvement: The SCDE and local districts are required by federal and South Carolina law to seek ways to increase parental involvement and communication. This new law enhances these efforts by ensuring parents are fully informed about their children's educational, medical, and psychological well-being.
Contact Information: If you have any questions about this notice or our privacy practices, please contact:
She’s Counseling & Consulting
Phone: 803-546-3896
Email: shescounseling.com
Address: 2638 Two Notch Rd suite 210 Columbia SC 29204.

 NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
As part of providing services to you, we will collect information about your care. We need this information to provide you with quality services and to comply with certain legal requirements. This notice applies to all of the records of your care generated at She’s Counseling & Consulting.
We are required by law to:
 Make sure that information that identifies you is kept private;
 Give you this notice of our legal duties and privacy practices with respect to information about you; and
 Follow the terms of the notice that is currently in effect.
If you have any questions about this notice, please contact the person who coordinates your services, or She’s Counseling & Consulting Corporate office at (803)936-1550.
The terms of this notice apply to all records containing your identifiable health information that are created or retained by She’s Counseling & Consulting
We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records.
She’s Counseling & Consulting, has created or maintained in the past and for any of your records that we may create or maintain in the future. We will post a copy of our current notice in each of our facilities in a prominent location. You may
request a copy of our most current notice during any visit or by phone. The effective date of our notice will be posted in the upper left-hand corner of the notice.
WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices of the entities that are part of She’s Counseling & Consulting including:
 Any professional authorized to enter information into your medical records;
 Any member of a volunteer group that assists you while you receive services from She’s Counseling & Consulting and
 All employees, staff and other personnel of She’s Counseling & Consulting.
Please realize that other professionals not associated with She’s Counseling & Consulting, may use different notices or policies regarding health information created in their offices.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be
listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories listed below.
 For Your Care and Services. We may use health information about you to provide, coordinate or manage the services, supports, and healthcare you receive from us and other providers.
 We may disclose health information about you to your medical care providers, your funding agency case manager, She’s Counseling & Consulting, other agency staff, or other persons who are involved in supporting you or providing care. For example, your direct care staff may need to share information about your medications with your psychiatrist or with your case manager.
 For Health Care/Service Operations. We may use and disclose information about you to run our program and to make sure you receive quality services, or to decide if we should change or modify our services. For example, we may disclose health information about you to train our staff. We may also use information for accreditation or licensing activities.
 Release of Information to Family/Advocates. We may release your health information to an advocate or family member who assists in taking care of you. In addition, we may disclose health information about you to an entity that is assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have specific objections or instructions regarding these communications, you may discuss them with us by contacting your service coordinator.
She’s Counseling & Consulting School Based Intake
 As Required By Law. We will disclose information about you when required to do so by federal, state or local law.
For example, we may reveal information about you to the proper authorities to report suspected abuse or neglect.
 To Avert a Serious Threat to Health or Safety. We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or of another person.
Any disclosure, however, would only be to someone able to help prevent the threat.
 Public Health Activities. We may disclose information about you for public health activities. These activities
generally include:
1. The prevention or control of disease, injury or disability;
2. Reports of child abuse or neglect;
3. Notification that a person may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
4. Notifications to the appropriate authorities if we believe that you have been the victim of abuse, neglect or domestic violence.
 Health Oversight Activities. We may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for appropriate oversight of the health care system, government programs and compliance with civil rights laws.
 Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, or if there is a lawsuit or dispute concerning your services, we may disclose information about you in response to a court or administrative order.
 We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
 Law Enforcement. If asked to do so by a local, state or federal law enforcement official we may release health information:
1. In response to a court order, subpoena, warrant, summons or similar process;
2. To identify or locate a suspect, fugitive, material witness, or missing person;
3. About the victim of a crime in certain limited circumstances, if we are unable to obtain the person's agreement;
4. About a death we believe may be the result of criminal conduct;
5. About criminal conduct at any facility where you are receiving treatment; and
6. In emergency circumstances to report a crime (including the location or victim(s) of the crime, the description, identity or location of the perpetrator).
 National Security and Intelligence, Protective Services for the President and Others. We may release information about you to authorized Federal officials for intelligence, counterintelligence and other national security activities authorized by law.
 RIGHTS REGARDING YOUR PROTECTED PERSONAL INFORMATION
You have the following rights regarding protected personal information we maintain about you:
 Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records. The right to inspect and copy health information does not include psychotherapy notes. To inspect and copy information that may be used to make decisions about you, you must submit your request in writing to your Lead therapist. If you need assistance, it will be provided to you. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
 Right to Amend. If you feel that the information we have about you is incorrect or incomplete, you may ask us to amend the information. You must make your request for an amendment in writing and submit it to your Lead therapist. In addition, you must provide a reason that supports your request. If you need assistance to put your request in writing, it will be provided to you. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend
information that:
1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
She’s Counseling & Consulting School Based Intake
2. Is not part of the information kept in your file;
 “Psychotherapy notes” means: notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.
Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. See 45
C.F.R. § 164.501. Please note, if material that otherwise meets the definition of psychotherapy notes is combined with (in other words, not kept separate from) the medical records, then those materials will not be subject to the special disclosure rules for psychotherapy notes under HIPAA.
 Is not part of the information, which you would be permitted to inspect and copy; or we believe is accurate and complete. If you disagree with the denial, you may submit a statement of disagreement. If you request an amendment to your record, we will include your request in the record whether the amendment is accepted or not.
 Right to an Accounting of Disclosures. We will keep a log record of disclosures made on or after January 2011, other than disclosures for treatment, billing, services or health care operations. You have the right to request an "accounting of disclosures". To request this list or accounting of disclosures, you must submit your request in writing to the Program Manager or State Director. If you need assistance, it will be provided to you. Your request must state a time period not longer than six years.
 Right to Request Restrictions. You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or a friend.
 We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
 To request restrictions, we encourage you to make your request in writing to your Program Manager. If you need assistance, it will be provided to you. In your request, you must tell us:
1. What information you want to limit;
2. Whether you want to limit our use, disclosure, or both; and
3. To whom you want the limits to apply.
 Right to Request Confidential Communications. You have the right to request that we communicate with you about your services in a certain way or at a certain location. For example you can ask us to contact you only at work or only by mail.
 You must make your request to obtain confidential communications in writing to the Lead therapist. You must specify how or where you wish to be contacted. If you need assistance, it will be provided to you. We will not ask you the reason for your request. We will accommodate all reasonable requests.
 Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
 To obtain a paper copy of this notice, contact a member of your service planning team or She’s Counseling & Consulting.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for information we already have about you as well as any information we receive in the future. The effective date will appear
on the lower left-hand corner of the first page.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the CEO or Partners of She’s Counseling & Consulting. You may also file a complaint with the Secretary of the Department of Health and Human
Services C/O Office for Civil Rights, US Department of Health and Human Services, 200 Independence Ave SW,
Washington, DC 20201.
She’s Counseling & Consulting School Based Intake
All complaints must be submitted in writing. If you need assistance, it will be provided to you. You will not be penalized or be retaliated against for filing a complaint.
You may also contact the Joint Commission at 1-800-994-6610.
OTHER USES OF PROTECTED PERSONAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose information about you, you may revoke that
permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we
have already made with your permission and that we are required to retain our records of the care that we provided to you.

 

                                       CONSENT FOR TELEMENTAL HEALTH SERVICES

This form is to be used as a supplement to the signed Service Agreement and Treatment Consent Form that is required for all clients receiving services from She’s Counseling, Inc.    

WHAT IS TELEMENTAL HEALTHCARE?

Telemental health is a subset of telehealth services that uses online, interactive videoconferencing software to provide mental health services from a distance. Telemental health includes terms such as telepsychology, tele behavioral health, online counseling and distance counseling. Private insurance companies in South Carolina and many other states are required by law to cover telemental health services. Telehealth does not include the use of fax, audio only (telephone), email or videotelephony products such as FaceTime and Skype.  

WHAT ARE THE POTENTIAL RISKS OF TELEMENTAL HEALTH? • Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection. • Nonverbal cues might be more difficult to observe and interpret during therapist and client interactions.  • May electronically share and sign practice and consent forms and accept risks that come with transmitting information and documents over the internet.  

WHAT ARE THE BENEFITS OF TELEMENTAL HEALTH? 

 Less limited by geographical location and transportation concerns.  Decrease in travel time and ability to meet virtually during inclement weather conditions. • Ability to participate in treatment from your own home or other environment where you feel safe, secure and comfortable. • Ability to participate in treatment from your home or other environment when physical needs/disabilities may prevent you from coming to the office. 

ELIGIBILITY 

She’s Counseling, Inc., and its clinical staff are only able to provide telemental health services to clients located in South Carolina where we hold valid licenses as mental health professionals. Clients must provide a valid ID or other proof of residency before telemental health treatment sessions can begin. A copy of this proof of residency will be kept in a client’s electronic file.    

Telemental heath may not be the most effective form of treatment for certain individuals or presenting problems. If it is believed the client would benefit from another form of service (e.g. face-to-face sessions) or another provider, an appropriate recommendation will be made. 

PRIVACY AND CONFIDENTIALITY 

The current laws that protect privacy and confidentiality also apply to telemental health services. Exceptions to confidentiality are described in the Notice of Privacy Practices. All existing laws regarding client access to mental health information and copies of mental health records apply.  Telemental health services are provided through the HIPAA compliant, secure software Vsee. No permanent video or voice recordings are kept from telemental health sessions. Clients may not record or store videoconference sessions.      

CLIENT EXPECTATIONS DURING TELEMENTAL HEALTH SESSIONS

   You’ll need the following to join a telemental health session with your clinician:

  A computer, tablet, or phone (no applications or software to download). • An external or integrated webcam. • An external or integrated microphone. • An internet connection with a bandwidth of at least 10 MBPS. We recommend an Ethernet cable over Wifi when possible to ensure you receive the best possible connection through your internet provider. • It may be helpful to shut down all background applications to ensure your telemental health session receives the majority of your internat’s bandwisth, especially applications that use your camera. • Access to Google Chrome, Mozilla Firefox or Safari (latest release versions) web browsers. • Proper lighting and seating to ensure a clear image or each participant’s face. • Dress and environment appropriate to an in-office visit. • Engage in sessions in a private location where you cannot be heard by others. • Only agreed upon participants will be present and the presence of individuals unapproved by both parties will be cause for termination of the session. • Client must disclose the physical address of their location at the start of the session. Unknown locations will be cause for termination of the session. • Client shall provide a phone number where they can be reached in the event of service disruption.

 EMERGENCY PROTOCOL 

 Client is to provide the name and contact information for a local emergency contact. In the case of a mental health emergency during a telemental health session where a client is deemed at imminent risk of harming themselves or someone else, the therapist engaged in the session will contact the client’s local emergency services and/or 911.

 Release of information forms will be completed for necessary entities unless confidentiality must be breached to protect the safety of the client or other identified individual.     

INSURANCE, SELF-PAY RATES AND PAYMENT PROCEDURES 

 Telemental health is not covered by all insurance companies, plans and policies. Currently, Anthem BC/BS, Tricare, Medicaid, Cigna is the only insurance company that She’s Counseling, Inc.     participates with that covers telemental health. Not all Anthem BC/BS plans/policies, however, cover telemental health for their customers. She’s Counseling, Inc. will verify a client’s coverage prior to the first telemental health session and an email will be sent back to the client outlining these benefits and any out-of-pocket responsibility the client may have. Ultimately, it is the client’s responsibility to be aware of and understand their specific plan and benefits. 

 

Our self-pay rate for telemental health is the same as the in-session (face-to-face) rate. These sessions are 45-60 minutes in length. We have, however, added an additional service that includes a shorter 20-30 minute session (telemental health only). The length of your specific session is set up between client and therapist prior to each session.

 All clients must pay for telemental health services using a valid credit card. This credit card is placed on file in our electronic health record for security purposes. It is up to the client to notify She’s Counseling, Inc.  of any changes to their credit card information before a new telemental health session begins.

    CONSENT FOR TELEMENTAL HEALTH TREATMENT 

 I hereby consent to engage in telemental health services with She’s Counseling, Inc. and any member of its clinical staff. I understand that telemental health includes mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communication of my medical and mental health information. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.