Please read and fill out the forms carefully and thoroughly regarding your upcoming appointment.

PRIOR TO YOUR APPOINTMENT, if the following items are not taken care of, we reserve the right to cancel or re-schedule your appointment.

1. Fill out this electronic packet of forms in its entirety.

2. Take a picture of the front and back of your insurance card and upload it where  prompted.

Notice of Privacy Practices

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

Our PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of our legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.

We can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available, upon request, in our office and on our website.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health 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.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow healthcare providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the healthcare provider’s own treatment, payment, or health care operations. We may also disclose your protected health information for the treatment activities of any healthcare provider. This, too, can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful processes 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.

CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. We may keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: 

For our use in treating you.
For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
For my use in defending myself in legal proceedings instituted by you.
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
Required by law and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required by a coroner who is performing duties authorized by law.
Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

 

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.

For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an authorization from you before doing so. For law enforcement purposes, including reporting crimes occurring on my premises.

To coroners or medical examiners, when such individuals are performing duties authorized by law.

For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

For workers' compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers' compensation laws.

Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other healthcare services or benefits that we offer.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose how we send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so.

The Right to Get a List of the Disclosures I Have Made.

You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

 

I do hereby seek and consent to take part in treatment through the offices of Kalamazoo Child and Family Counseling, PLLC (“KCFC”).

I understand that the assigned therapist will develop a treatment plan, based upon my individual circumstances and objectives. I also understand that the therapist and I will periodically review the progress made toward achieving those treatment goals.

I understand that my therapist will not be immediately available after business hours and on weekends. If I am in need of emergency assistance when my therapist is not available, I can call the Gryphon Helpline, a 24 hour service, at (269) 381-4357, or 211. I can also call 911 or visit my local emergency room to request emergency assistance.

I understand that I am responsible for the payment of all co-pays and other fees not reimbursed by insurance. If a Court order exists which allocates payment of KCFC fees for the client/child between two or more individuals, I understand that as the signatory below, I am responsible for payment directly to KCFC for 100 percent of the fees charged -- after which it is my sole responsibility to collect reimbursement from the other individual or individuals who have been Court-ordered to pay a portion of the counseling fees.

By signing below, I acknowledge that Kalamazoo Child and Family Counseling, PLLC has provided me with a document which sets forth the rates for all professional services.

I understand that by signing this form, I hereby consent to my therapist releasing necessary information to a third-party payer (e.g. an insurance company or HMO) for billing purposes, as necessary.

 

I understand that Kalamazoo Child and Family Counseling, PLLC will submit claims to insurance companies that are in network with Kalamazoo Child and Family counseling.  I understand that if my insurance company is not in network then I am responsible for all costs of service at the time of treatment.  I can request documentation in order to submit out of network claims myself to my insurance company, however, the transaction between my out of network insurance company and myself has no bearing on my responsibility to pay Kalamazoo Child and Family Counseling upon receipt of services.  

I understand that no promises have been made regarding the result of treatment or of any procedures provided by my assigned therapist, and that the results are directly related to my commitment and time spent attempting to achieve my treatment goals.

I am aware that I may terminate treatment with my assigned therapist at any time, upon written notice to Kalamazoo Child and Family Counseling, PLLC. If I terminate treatment, I understand that it is my responsibility to pay for services already rendered -- unless my insurance provider has already paid in full for those services.

If I have been ordered to attend counseling by a caseworker, probation officer, or court order, I understand that it is my sole responsibility to schedule and attend said counseling/therapy sessions.

I understand I must call to cancel an appointment at least 24 hours before the time of my scheduled appointment. I understand that failure to contact the office 24 hours prior to my scheduled appointment will result in a $75 fee being assessed.  I understand that this is not billed to insurance and is my personal responsibility. 

Three cancellations in a three-month period or two consecutive no-shows may result in the cancellations of all future appointments and/or result in discharge from care at Kalamazoo Child and Family Counseling.

I understand that therapy is confidential and that I must sign a release of information in order for any information to be shared with any agency or individual, with the following exceptions: (1) In cases involving the Department of Health and Human Services, Child Protective Services, and/or a Foster Care agency, a release may not be required; (2) Confidential information may be released to a third party (insurance company or HMO) for the purpose of attempting to collect payment for professional services rendered; and (3) If my therapist’s records are subpoenaed by a Judge, Attorney, or other officer of the District, Circuit, Probate, or Federal Court, my therapist may be ordered to submit the subpoenaed documents, and may be ordered to testify in Court.

I understand that my therapist and the office of Kalamazoo Child and Family Counseling, PLLC cannot guarantee that electronic communications (such as e-mails or text messages) will remain confidential, pursuant to federal HIPAA laws. I understand that if I choose to communicate with my therapist via electronic communications, I am assuming the risk that those communications may not remain confidential, through no fault of my therapist or Kalamazoo Child and Family Counseling, PLLC.

I understand that Kalamazoo Child and Family Counseling, PLLC does not perform evaluations regarding custody and/or parenting time issues. I understand that I must inform Kalamazoo Child and Family Counseling, PLLC if I am seeking a custody and/or parenting time evaluation. In those instances, Kalamazoo Child and Family Counseling will cease the client’s (child’s) therapy appointments and will refer the client to another provider. I also understand that I must provide Kalamazoo Child and Family Counseling, PLLC with a copy of any existing Court order regarding the issues of custody and parenting time, within 10 days after I sign this Consent for Treatment Form. If any Court orders are modified in the future, I must provide a copy of the revised order(s) to Kalamazoo Child and Family Counseling, PLLC.

In the event that a KCFC Therapist is served with a Subpoena or Court Order to produce documents, appear as a witness in a Court proceeding, provide a letter to the Court, and/or any other action involving a Court proceeding, KCFC reserves the right to bill the client's responsible party for any and all time spent by the therapist in order to comply with the Subpoena and/or other Court Order. The fee charged will be the same as the Therapist's billing rate for counseling services, rounded upward to the nearest quarter-hour. These services are not covered by insurance; accordingly, the responsible party shall be responsible for payment of 100% of these fees.

I understand that Kalamazoo Child and Family Counseling, PLLC has developed policies and has implemented procedures for the thorough cleaning and sanitizing of its offices (including all therapists offices, the reception area, the front desk, the conference room, the kitchen, the bathrooms, and all other areas which may be open to the public and/or staff members). I also understand that all therapists and staff members are required to follow the procedures implemented by Kalamazoo Child and Family Counseling,

I also understand that Kalamazoo Child and Family Counseling, PLLC, having taken all necessary precautions, cannot guarantee that an illness or disease (such as COVID-19) will not be transmitted to a client (or any individual in the client’s family or circle of guardians/friends) who appears on the premises of Kalamazoo Child and Family Counseling, PLLC for a therapy appointment, to make a payment, to schedule an appointment, or for any other reason. In the event that an illness or disease is inadvertently transmitted to a client or his or her family, friends, or guardians, I will hold Kalamazoo Child and Family Counseling, PLLC harmless from any alleged damages thereby incurred (including, but not limited to, financial damages, damages for pain or suffering, damages for injuries suffered, and/or damages for wrongful death).

I understand that client-therapist  or clinician confidentiality does not exist in certain circumstances and that my therapist is mandated by existing law to act upon the information I may disclose (verbally or in writing) whether the disclosure occurs in a counseling session, between sessions, on the phone, or through a written communication such as an e-m  ail, text message, letter, etc., regarding any of the following:

Any suspected child abuse or neglect

Someone is in imminent danger of harming themself

Someone is in imminent danger of harming someone else

My electronic signature confirms that I understand and agree to the above statements and terms. I am signing this Consent For Treatment Form freely and voluntarily. I acknowledge that Kalamazoo Child and Family Counseling, PLLC, has provided me with a copy of its fee structure for professional services, contemporaneously with this Consent For Treatment Form.

 

This Consent is for patients or the parent/guardian/managing conservator of minor child patients of Kalamazoo Child and Family Counseling (“KCFC”) who would like the patient to be evaluated and treated at KCFC's Pediatric Mental Health Clinic (“PMHC”). 

PMHC is currently staffed by Melissa Reffitt (“Reffitt”), DNP, APRN, PMHS, as the sole mental healthcare provider. Reffit is a Pediatric Mental Health Specialist.

A Pediatric Mental Health Specialist is not a physician. An PMHS is an advanced practice registered nurse (APRN) who has received advanced education and training in providing a wide range of mental healthcare services to pediatric patients and families in a variety of settings. PMHS’s diagnose and prescribe medications for patients who have mental health and developmental disorders.  They are licensed to provide the evaluation and management of mental health conditions and conduct physical assessment of their pediatric patients, create treatment plans, and manage patient care. Prescribed medications are written in collaboration with a Psychiatrist.  

Informed Consent.

I understand I have the right to make an informed decision about treatment.  I understand that I have the right to revoke consent or discontinue treatment with the PMHC.

Patient’s Rights. I understand Reffitt will provide healthcare within her scope of practice and is able to consult with a physician, as required by law, regarding the best treatment plan. Voluntary, Informed Consent to Treatment. My signature below indicates voluntary consent for the treatment plan for myself or the minor child. If for a minor child, I hereby attest I am the legal guardian of the minor child and have the right to consent to treatment for this child. 

This consent applies to all providers at the KCFC who may provide services and permits the sharing of information amongst KCFC staff.  

Furthermore, I understand that this consent is an addendum to KCFC’s primary consent document.  This document specifically consents for treatment rendered by PMHC.

Fees and Insurance. 

The fees for an initial diagnosis and evaluation, and ongoing treatment are listed in our fee schedule.

A patient who does not have insurance coverage will be charged the amount on the fee schedule for the procedure that matches the service provided. Some insurance companies may partially cover these costs. In the event your insurance carrier declines benefits, you acknowledge and agree that you are fully responsible for the charges and expect them to be applied to your account. If you have coverage you can assign the benefit and pay only your copay or coinsurance at the time of each visit. If your deductible has not been met, you are responsible for payment at the time of visit. Law does not allow for the waiver of deductibles or copayment. If you choose to use your insurance, you understand that certain information about your case will be shared with your insurance company and or an intermediary for purposes of filing the claim. By consenting to treatment, you acknowledge that you are responsible for the cost of services provided to you or your minor child and agree to pay them when billed or at time of service. 

Medication Refill/Prior Authorization Policy. Medication requests are only addressed during business hours.

Emergency Care. In case of an emergency, I understand KCFC reserves the right to administer medical treatment on the premises or to contact and advise emergency personnel on the premises or at an emergency room regarding my needs at that time.  Reffitt and/or KCFC staff are not “on call,” in the event of an emergency I understand I need to call 911, or go to the nearest emergency room.  

Danger. In the event your provider in her clinical judgment believes you to be a danger to yourself or others, by signing this consent, you authorize her to contact your listed emergency contact or someone else to help provide assistance through this crisis situation.

Indemnification. I will indemnify and hold harmless from any expense or claim of any nature any person or entity that provides or causes to be provided examination, treatment, or hospital care under this authorization (except to the extent such person or entity is negligent therein) and conditionally agree to make or cause to be made, by assignment of third-party benefits or otherwise, full and complete payment for such examination, treatment, or hospital care. Limits to Termination of Services. I understand and agree that I am entering into a therapeutic relationship with my provider. The success of the treatment is contingent upon active participation and constant attendance. More than three no shows will result in termination of services. Your file may be closed after sixty days of zero communication and no appointment. 

I have read the above, and hereby consent to the services of the  PMHS for mine or my minor child’s mental healthcare needs.  

I undestand that Kalamazoo Child and Family Counseling (KCFC) will not be billing my or my child's secondary or tertiary Medicaid insurance for professional services rendered on my behalf or the behalf of my child. I agree that I am responsible for payment of what my primary insurance does not pay and that amount will not be billed to Medicaid. I also agree not to attempt to collect payment from Medicaid for my secondary or tertiary Medicaid insurance that KCFC did not bill.

I agree that Kalamazoo Child and Family Counseling (KCFC) will not be billing my secondary or tertiary insurance that is not in network with KCFC. I understand that I am responsible for immediate payment of what my primary insurance does not pay and that amount, that is not paid by my primary insurance, will not be billed to my secondary or tertiary insurance. I further understand that if I desire to collect reimbursement from my secondary or tertiary insurance that I may request a bill from KCFC, and I will be responsible for submitting that to my secondary or tertiary insurance company, but that the reimbursement, or lack of it, from either my secondary or tertiary insurance will have no bearing on my responsibility to pay for services rendered to me.  

I am entering into this Agreement freely and voluntarily, without any undue influence or coercion.

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

Disclaimers:
This Good Faith Estimate outlines the expected costs of services based on information available at the time it was created. It is not a contract and does not obligate you to obtain any services from the provider(s) listed. Additionally, it does not include any services that are not identified here. The estimate does not account for unknown or unexpected costs that may arise during treatment. Additional services may be recommended as part of your care that must be scheduled separately and are not reflected in this estimate. If complications or special circumstances arise, additional charges may apply.

If you receive a bill that is at least $400 more than the estimated charges in this Good Faith Estimate, you have the right to dispute the bill under federal law. You may contact the provider or facility listed to discuss the discrepancy, request an updated bill, negotiate payment, or inquire about financial assistance. You may also initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (approximately 4 months) of receiving the bill. There is a $25 fee to initiate the dispute process. If the reviewing agency determines that the billed charges should be reduced to match this Good Faith Estimate, you will pay the estimated amount. If the agency rules in favor of the provider or facility, you will be responsible for the higher charge.

For more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

The initiation of a dispute process will not impact the quality of services provided to you.

For ongoing services , a single Good Faith Estimate may be provided for the entire year, as long as it includes the expected scope of services, frequency, session fee, and anticipated duration of treatment. The estimate can only include recurring services expected within 12 months. A new estimate must be provided for services beyond 12 months or if any significant changes occur.

If you have any questions about this estimate, please feel free to discuss them with your provider.

Primary CPT Codes:

Psychotherapy: new patient 90791, for established patients 90837.  Supplemental codes used could be 90785. Additional codes that could be used 90834, 90853.

Pediatric Mental Health Clinic (PMHC) Medication Management: new patient 99205, for established patients 99215, 99214.  Additional codes that could be used 96127, 90836, 90785, 90833, G2212

Psychology Testing: new patient 90791, testing codes used could be 96130, 96131, 96136, 96137

 

Psychotherapy Cost

Maximum out of pocket fees for private in the event your insurance covered nothing and/or was out of network with Kalamazoo Child and Family Counseling.

Number of Weeks	Cost per week
1 week of Service	$156.00
13 weeks of Service (approximately 3 months)	$2,028.00
26 weeks of Service (approx 6 months)	$4,056.00
39 weeks of Service (approx 9 months)	$6,084.00
52 weeks of Service  (approx 12 months)	$8,112.00

 

Pediatric Mental Health Costs

Maximum out of pocket fees for Private Pay and in the event your insurance covered nothing, and  / or was out of contract with Kalamazoo Child and Family Counseling.  The Pediatric Mental Health Clinic codes appointments primarily by medical complexity. Below is a usual sequence of appointments and their coding.  The medical complexity of your child's presenting issue will also impact how services are charged.

 

Initial Visit	99205 - $267.00 96127 - $30.00 G2212 or 99417- $75.00 per additional 15 min.
2nd Visit	99215 - $267.00 G2212 or 99417 $75.00 per additional 15 min.  96127 $30.00
3rd Visit	99214 $200.00 90836 $100.00 90785 - $31.50
4th and ongoing visits	99214  - $200 - 1 hr 90833 - $90.00 16-37 min 90785 - $31.50

Psychology Testing Fees

Maximum out of pocket fees for Private Pay and in the event your insurance covered nothing, and  / or was out of contract with Kalamazoo Child and Family Counseling.

Half Day of Testing

CPT Code     Units            Cost per unit     Billed to Insurance

90791            1                 $196.00               $196.00     

96130            1                 $300.00               $300.00

96131            2                $300.00                $600.00

96136            1                 $150.00               $300.00

96137            7                $150.00              $1,050.00

                  Total Billed to Insurance             $2,446

Full Day of Testing

CPT Code     Units            Cost per unit     Billed to Insurance

90791            1                 $196.00               $196.00     

96130            1                 $300.00               $300.00

96131            7                 $300.00               $2,100.00

96136            1                 $300.00               $300.00

96137           11                $150.00              $1,650.00

                  Total Billed to Insurance             $4,546.00

 

The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

This form is provided as an additional consent and will be added to your file along with your initial paperwork which includes informed consent and practice policies. This form is used when a counselor or dietitian and client have determined that online counseling is a necessary and supportive service for client’s treatment. A discussion about the contents of this form is conducted in a face-to-face meeting (via video or in-person).

Telehealth is the use of technology, like video conferencing software, to provide services at a distance. Your treatment maybe provided through interactive audio, video, and/or telephone communication using a secure, encrypted platform.

There are several benefits to using telehealth services. It increases accessibility to treatment, reduces travel time, and allows for participation in therapy from an environment of your choosing. Years of empirical research have established telehealth as a useful and effective mode of healthcare delivery.

When using technology, however, there is the risk of security and technical difficulty (e.g., disconnection of the internet, computer or software not working)

Additionally, technical issues can sometimes limit visual or auditory cues and contribute to miscommunication or misunderstanding. Please know that open, clear, and meaningful communication is one of my highest priorities. Please talk to your provider about any communication challenges or perceived misunderstandings during sessions. If issues persist and impact your treatment, alternatives to telehealth can be considered such as in-person counseling.

Telehealth is not appropriate for all clients. Kalamazoo Child and Family Counseling require an in-person Intake meeting in order to determine if telemental health meets your needs. You and your provider will regularly evaluate the appropriateness of this modality for your goals. If it becomes clear that telehealth is not ideal, your provider will assist you in finding alternative options (e.g., face-to-face therapy).

The laws that protect your privacy and the confidentiality of your health information also apply to telehealth services. For more information about exceptions to confidentiality, please refer to the NOTICE OF PRIVACY

No permanent video or voice recordings are kept from our telehealth sessions. To preserve your privacy and confidentiality, it is also advised that you do not record or store videoconferences or phone sessions.

You are required to provide contact information to an emergency person of your choice. This person would be contacted only in cases of an emergency. This person must be over the age of 18 and willing and able to physically go to your location in the event of an emergency.

For safety reasons, you will be asked to disclose your physical address at the start of each session. If you anticipate that you will be traveling or changing locations, please let me know in advance so that we can make the appropriate arrangements for privacy and format of our sessions. When scheduling or needing to contact your provider, please be aware that we are in Michigan and abide by the Eastern Standard Time Zone. Please refer to the INFORMED CONSENT for more about our availability and emergency resources.

If you would like to have a family member or another person join you in your session, please first discuss this with me to make arrangements. If you do not make prior arrangements, sessions that include unapproved individuals will be terminated.

If reception is bad, or if our session gets disconnected, we will try to reconnect by restarting the video platform. If we still experience technical difficulties, we will use phone to continue with our session. You also have the option to cancel or reschedule your session.

Telemental Health Checklist
Choose a “meeting” space or environment that allows you to focus on the discussions you want to have with your counselor. If you have technology options (phone, laptop, tablet, etc, choose the one that allows you to have the best telehealth experience. If your environment or your technology is creating distractions, you won’t get as much out of the sessions.

1. Situate yourself in a private space Think about the best way to make your privacy a priority so you feel comfortable talking freely. For example: Close the door

2. Put a Do Not Disturb sign out (if appropriate)

3. Go for a walk in a park or neighborhood with privacy4. Inform people in your house or office that you have an important meeting and ask that they not interrupt you unless absolutely necessary.

4. Consider who might enter the room/space during your meeting time and prepare your response to get back to the session quickly.

5. For video sessions: Your laptop with a microphone and speaker are ideal because it will feel most natural for talking to one another. Using headphones with your laptop might work even better for you.

6. Confirm that your internet speed and therefore your video quality allow us to see and hear each other.

7. Good lighting and a stabilized video camera (not walking with your phone or moving around often) will help both you and I get the most out of our video experience with each other.

8. For Phone/Voice sessions: Consider whether you need to be on wifi to get the best experience and choose your location accordingly. Using headphones when possible is the best way to have a clear and volume-regulated conversation. With a little attention to a comfortable environment and technology, telemental health offers a wonderful alternative to in-person meetings and can have many benefits to your personal counseling goals.

 

By signing this document, I acknowledge that I have been informed about the policies of Kalamazoo Child and Family Counseling as it relates to telehealth services. I affirm that I have been provided all necessary information about the policies of the practice in order to make a decision to engage in telemental health. My signature also shows my understanding of my rights related to confidentiality and that I know that I can ask questions at any time about the services I’m receiving and that I can terminate at any time.

 

In our best effort to protect your privacy, we will not accept requests, invitations, or emails from clients or their first degree relatives for any social media to include, but not limited to Facebook, Twitter, Linkedln, Pinterest, Instagram, TikTok or personal blogs. We have a monitored Facebook business page for Kalamazoo Child and Family Counseling and welcome 'likes,' but we will not respond to email or instant messaging through that site or any of the above mentioned. We are appreciative of word of mouth referrals, however we cannot confirm or deny past or current client's treatment to potential or new clients. If you choose to write a recommendation on a business review site for Kalamazoo Child and Family Counseling or its individual therapists, please keep in mind that you may be sharing personal information in a public forum and we encourage you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection.

At Kalamazoo Child and Family Counseling: If you have private insurance, we require that you provide KCFC with an HSA,  credit card or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable.  Your credit card information is kept confidential and secure. 

Payments to your card are processed for co-payments, co-insurance, and deductibles weekly on Friday mornings as per below: 

 ·        After the client has completed their appointment, the therapist will complete their notes and generate an invoice for submission.

·        The invoice is submitted.

·        The range for insurance to return with a payment or designation of deductible or coinsurance amount due from the client is anywhere from 2 days to 2 weeks.

·        The Friday after we receive notification from the insurance company designating a deductible or a coinsurance amount, the HSA card, debit card, or credit card on file is charged for that deductible or coinsurance amount.   (Co-pays are always charged the Friday directly after the appointment.)

·        An automatic message is generated to the responsible party that the card on file has been charged. 

 

I authorize Kalamazoo Child and Family Counseling to charge the portion of my bill that is my financial responsibility to the following credit or debit card.

I (we), the undersigned, authorize and request Kalamazoo Child and Family Counseling to charge my credit card for balances due for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by Kalamazoo Child and Family Counseling. This authorization will remain in effect until I (we) cancel this authorization. To cancel, you will need to call our office or send a request in writing.

 

 

Group counseling can be a powerful and valuable venue for healing and growth.  It is the desire of your group facilitator(s) that you reap all the benefits group has to offer.  To help this occur, groups are structured to include the following elements:  A safe environment in which you are able to feel respected and valued as you work.  An understanding of group goals and group norms.  Investment by both your facilitator(s) and members to produce a consistent group experience.

 A SAFE ENVIRONMENT:

A safe environment is created and maintained by both the facilitator(s) of a group and its members.  Primary ingredeients are mutual respect and a a chance to create trust.  Another primary ingredient for a safe environment has to do with confidentiality.  Your group facilitator(s) are bound by law to maintain confidentiality, as a group member you are bound by honor to keep what is said in the group in the group. 

LIMITS OF CONFIDENTIALITY

If you are a threat to yourself or others (showing suicidal or homicidal intent), your facilitator(s) may need to reporty your statements and/or behaviors to family, your therapist, or other appropriate mental health or law enforcement professionals in order to keep you and others safe.

All KCFC staff are mandated reporters.  There are a broad range of events that are reportable under child protection statues, this includes child abuse or neglect that has not previously been reported.

If a court of law orders a subpoena of case records or testimony, your facilitator(s) will first assert "privilege" which is your right to deny the release of your records although this is not available in all states for group discussions.  Your facilitator(s) will release records if a court denies the assertion of privilege and orders the release of records. 

 

OTHER SAFETY ISSUES

Members of a group may not use drugs or alcohol before or during group

Members of a group should not engage in discussionof group issues outside of group

Members of a group should remember that keeping confidentiality allows for an environment where trust can be built and all members may benefit from the group experience. 

ATTENDANCE

Your presence in group is highly important.  A group dynamic is formed that helps create an environment for growth and change.  If you are absent from the group this dynamic suffers and affects the experience of you and other members of the group.  Therefore, your facilitator(s) would ask that you make this commitment a top priority for the duration of the group. 

It is understood that occasionally an emergency may occur that will prevent you from attending group.  If you are faced with an emergency or sudden illness, please contact your facilitator(s) before group begins to let them know you will not be present.

We ask this because each member of a group is important - your presence and your absence impacts members and and facilitators and we want to allow time for membes to process when members choose to leave.

 

WHAT TO EXPECT

Group time consists of both teaching and processing time.  Processing may revolve around an issue one member of the group is working on with time for structured feedback and reactions by other members of the group.  The group dynamic offers a place where you can experience support, give support, understand more cleary how you relate to others, and examine your own beliefs about yourself, and the world around you. 

 

FEES

We will submit claims to isnurance for whom we are in network.  You are responsbile to pay for each session at the time of service.  The fees for group therapy and other psychotherapy services are listed in our Fees for professional services document. 

CONSENT

My signature at the end of the document confirms that I understand and agree to the above statements and terms.  I consent onbehalf of myself or a person for whom I have guardianship to participate in Group Therapy at Kalamazoo Child and Family Counseling. 

This consent expires one year from today’s date, or the termination of treatment, or the verbal or written revocation of this consent for release of confidential information.

Signature of Client's Parent or Guardian/Responsible Party: My signature below confirms that I understand and agree to all the above statements and terms within the previous pages.   I am signing this freely and voluntarily.