Consent to Treatment

The undersigned, client/client's legal guardian, voluntarily consent to outpatient treatment for mental health, co-occurring, and/or substance use disorder(s) and authorize Mindfully, LLC (MINDFULLY) to provide such outpatient treatment that is determined to be medically necessary or otherwise appropriate. These services may include individual or group counseling/therapy, Diagnostic Assessment, and Psychological Testing.

 

DESCRIPTION OF SERVICES 
Our Warmline clinicians typically see clients Monday through Friday.

We view the therapeutic relationship as a partnership that is principally dedicated to your growth and to finding solutions. Part of our job is to remind you of your own strengths and abilities while you go about the business of creating more of the type of life that you want. 

As with any type of treatment, there is the chance that it may not be helpful. The "fit" between client and clinician is important to an effective treatment outcomes. In the beginning of treatment, you may feel worse before you feel better. Therefore, we want to hear from you throughout our work together about how we are doing - so that we can make any adjustments needed to help you more effectively. it is your right to transfer clinicians if you feel your clinician is not a good fit. Please call and let us know, we are happy to assist in this process. 

If you believe your rights have been violated, you have a right to discuss your concerns with our clinical director by calling our office and requesting the call.

CONFIDENTIALITY 
Information discussed within the therapy setting is held confidential and will not be shared without written permission except under limited situations which under reasonable circumstances would be discussed with you before disclosure is made. These situations include revelations of unreported child or elder abuse, imminent suicide or harm to others, or reports of exploitation by a clinician. 

Our practice is only to release clinical notes generated from your contact with us. We do not release raw materials or records obtained from third parties. 
 

Possible Risks of Warmline Health Treatment

• There can be difficulty for both parties to pick up on visual, non-verbal, or gestural cues.
• Differences in connection speed can lead to disconnection or interruption.
• We will make every effort to eliminate disruptions and interruptions on our end, however we cannot predict whether you will feel completely secure in the privacy of the session.
• Feeling anxiety if symptoms increase during session.
• Loss of confidentiality if using a public computer, a computer on a shared network, or if others are present in your setting.

 

 Electronic Communication  

If you elect to communicate with me by e-mail  at some point of time in our work together, please be aware that e-mail is not completely confidential. There are risks associated with e-mail messaging as outlined below: 

All e-mails and text messages are retained in the logs of the e-mail/phone/internet service provider. 

Although under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. 

Copies of e-mails and texts may exist even after the sender and/or the recipient has deleted his or her copy. E-mail and text senders can easily misaddress an e-mail or text and send the information to an undesired recipient. 

E-mails and texts can be intercepted, altered, forwarded or used without authorization or detection. 

 

Conditions for the use of email : 

As your clinician, I cannot guarantee but will use reasonable means to maintain the security and confidentiality of e-mail information sent and received, including a passcode lock on my phone. 

E-mail is not appropriate for urgent or emergency situations. I cannot guarantee that any particular e-mail  will be read and responded to within any particular period of time. 

E-mail should be concise. Unless we have agreed to a specific exception, sensitive or complex situations should be discussed in a phone call or during a scheduled appointment, not on e-mail. 

If e-mails contain information relevant to your treatment, they may be retained in your medical record, or a summary of the content may be included in a clinical note in your record. 

If you choose to use e-mail, you agree that I may reply to your email and text messages, and that I may include any information that I deem appropriate, including information that would otherwise be considered confidential. 

You agree that if you do not receive a timely response from an e-mail message to me, that you will follow up with a phone call to me. 

If you choose to use e-mail, you agree not to hold me liable for improper disclosure of confidential information that is caused by you or any third party. 

By signing below, you agree that you have read and understand the risks associated with communication via e-mail, and that you consent to the conditions outlined above. 

 

Communication Plans and Policies:

In the event that there is a technical failure, both parties should re-launch the program and attempt to re-connect. If this is not successful, the clinician will call you at the phone number provided at intake.  

You will be able to join the virtual 'waiting room' prior to our appointment start time. Please plan on signing on for your session 5-10 minutes prior to be sure that your webcam, microphone and internet connection are all working as expected.  

Please note that in order for us to provide Tele-Mental Health services the clinician that you see must be licensed in the state in which you live. Please verify the time zone of your appointment times. 

I, the undersigned, understand that at any time I may elect to participate in other services or refuse any services, treatment or therapy upon full explanation of the expected consequences of such refusal

PROTECTED HEALTH INFORMATION (PHI) TO BE OBTAINED OR DISLCOSED TO:

I give permission for the following information to be shared:

I, the undersigned, hereby authorize a representative of Mindfully to use and/or disclose information from medical or financial record as specified above.

I understand and acknowledge that this authorization extends to all or any part of the records designated above, which may include documentation of treatment for mental health disorders, alcohol/drug abuse or dependence, and/or HIV/AIDs test results or diagnosis.  I explicitly consent to the release of information as designated about.  Furthermore, I consent to the release of the facsimile transmission of my protected health information as necessary.

This authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to your request for revocation.  In order to revoke the authorization the individual/parent/legal guardian must submit a revocation request in writing to the disclosure.  I also understand that Mindfully may charge a reasonable fee for the preparation, copying and postage as allowed by state law for copies of medical records.

I understand that Mindfully will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this authorization.  If the person/entity that received the above PHI is not a health care provider/health plan covered by federal privacy regulations, the PHI described above may be re-disclosed by such person/entity and will likely no longer be protected by the federal privacy regulations.

I understand that if I am requesting my physical records to be released to myself or another person/organization, I will need to complete an additional form titled Records Release Form.