PAYMENT INFORMATION

I have read and understand the following. If the billing party is not the client, both parties must provide initials.

Private Pay: I understand that the fee for the BOLD Living Weekly Skills Group at The Anxiety Center at Renew Counseling Center is $50.00 per session. Payment is due for each week’s sessions before the group begins unless I have agreed to a payment plan. If my child attends a session I have not yet paid for or registered for, I will receive a monthly invoice for all outstanding sessions. I understand that if I purchase a session(s) and choose not to attend that session(s), I am responsible for this nonrefundable payment. If payment is being made via invoice, please make checks payable to Renew Counseling Center. We accept Visa or MasterCard.

Attendance and Absence Policy: I understand that I am required to give a minimum 24 hour notice to reschedule if I am not able to attend a scheduled session in order to allow group clinicians to prepare accordingly. If I do not provide the minimum twenty-four hour notice, I will be considered unexcused and my registration fee will be forfeit. 

Notice – If the billing party is not the patient and the patient is age 18 or over, the patient needs to complete an “Authorization to Use and Disclose Health Information” to allow Renew’s accounting department to communicate with the billing party.

CREDIT CARD AUTHORIZATION

Renew requires that all clients maintain a credit card authorization on file to ensure timely payment of all bills. This credit card will only be used in the event that your balance falls beyond 60 days of full payment and the client will have received two invoices prior to invoking the use of this authorization.

I authorize Renew to charge defaulted balances as described above to the credit card listed below. This authorization is valid until I provide you with written cancellation. (This authorization will be kept in a secure and locked location and shredded once the balance is paid in full.)

Account balances over 60 days past due will incur finance charges at the rate of 18% per year. Account balances over 90 days past due will be turned over to a collection agency or to an attorney and I will be responsible for any attorney fees for The Anxiety Center at Renew to collect payment.

Treatment Components

DNA-V
DNA-V is an evidence-based model that promotes psychological strength, and that values consistent living, vitality, and success. It is designed to help people cope with challenges, stress, and change. DNA-V can be thought of as a combination of Acceptance and Commitment Therapy (ACT) and positive psychology, and is underpinned by contextual behavioral science.
(DNA-V from The Thriving Adolescent © 2015 Louise Hayes and Joseph Ciarrochi / New Harbinger Publications.)

The BOLD Process
BOLD is a process for making Wise Mind decisions. Utilizing experiential learning, in-group practice, artful expression and daily goal setting we hope to support young people confront their defense mechanisms, cope with negative thinking; notice, understand and express their emotions while discovering new ways to interact with the world toward what matters to them.
(BOLD from Get Out of your Mind & into your life for teens © 2012 Joseph Ciarrochi, Louise Hayes and Ann Bailey / New Harbinger Publications.)

DBT Skills
DBT Skills Training groups are for clients who would like to cope more effectively with intense
emotions, addictive behaviors, and/or relationship struggles. DBT Skills are taught to reduce self-destructive behaviors and learn more adaptive ways to manage painful emotions.
(DBT Skills Training Manual © 2015 Marsha M. Linehan / The Guildford Press & DBT® Skills in Schools: Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A) by James J. Mazza, Elizabeth T. Dexter-Mazza, Alec L. Miller, Jill H. Rathus, and Heather E. Murphy. Copyright © 2016 The Guilford Press.)

CLIENT EXPECTATIONS & AGREEMENT

1. I agree to be respectful of staff and peers, use Wise Mind and refrain from cursing or discussing unhealthy coping skills in detail to avoid triggering peers (cutting, substance use, illegal activity).
2. I agree to participate in the group and practice skills at home.
3. I will utilize the distress tolerance bar to help engagement.
4. Group members may become friends, but I agree to NOT contact them in a crisis.
5. I will notify group leaders if I will be late or absent.
6. I agree to allow group leaders to check in with me and parents (if applicable) regarding
   treatment to determine ideal therapy dosage.
7. I agree to keep confidential what clients share and will not disclose that information with family, friends, visitors or the public.
8. I agree to accept personal responsibility for my actions, commit myself to change, openness and honesty and accept that I can learn much through the skills group process.
9. I agree to NOT use cell phones during group sessions. This enables one to be fully present and work on issues during these 3 hours.
10. I am entitled to a safe environment. I agree to behavior that is respectful and free of violence.

CONFIDENTIALITY

Renew maintains a strict policy of confidentiality. The staff protects the privacy of our patients by not disclosing their names, diagnosis or personal business outside of the treatment setting. We ask that our clients do the same. Who attends treatment sessions, and what is said in treatment sessions must never be discussed outside of the group. There are several additional issues related to confidentiality.

1. The staff will discuss patients and matters relating to their care outside of treatment sessions, but only in private staff meetings devoted to planning and/or supervising treatment, and only among themselves.
2. Information relating to patients’ diagnosis and treatment will be released to appropriate persons or institutions (such as physicians, insurance companies, etc.) only if patients sign consent forms authorizing us to do so.
3. All inquiries about our patients, whether by mail, telephone, or in person, will be responded to with a statement such as: “We cannot release that information, unless we have the patient’s consent to talk with the person inquiring”. In addition, we are unable to acknowledge a patient is in the program without a release of information.
4. There are rare occasions when we are required by law to suspend our policy of confidentiality if we have reasonable suspicion that the following may be happening:
   • We become aware that you might harm yourself.
   • We become aware that you might harm someone else.
   • We find out about child abuse.
   • We find out about elder abuse.
   • We find out about abuse of a physically or developmentally challenged individual.
   • If you are here for counseling under a court order.
   • In the event of a client’s death, the spouse or parents of a deceased client have the right to access their child’s or spouse’s records.
   • In cases in which a legal disciplinary meeting is being held regarding a report of unprofessional conduct and a health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

COMMUNICATION WITH STAFF:

Renew cannot ensure the confidentiality of any form of communication through electronic media, including email. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

I have read, understand, and agree to the above statement of confidentiality. I have been given a Renew HIPAA form (at the end of this contract the HIPAA is attached)

PATIENT RIGHTS: The Renew team has adopted the following list of patient rights:

1. Exercise these rights without regard to race, color, national origin, disability, age, cultural, economical, educational, or religious background or the source or payment for care. Pursuant to Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, and their implementing regulations, the program does not discriminate in the provision of services. For further information regarding services or to file a complaint, contact 913-768-6606.
2. To be provided safe, healthful, and comfortable accommodations, furnishings, and equipment.
3. To be treated with respect and dignity in your interactions with all staff of this program
4. Knowledge of the name of the therapist who has primary responsibility for coordinating your care 
5. and the names and professional relationships of other staff members who will see you.
6. Receive information about the disorder, the course of treatment and prospects for recovery in terms that you can understand.
7. Receive as much information about any proposed treatment as the patient may need in order to give informed consent or to refuse this course of treatment including alternate course of treatment or no treatment, the risks involved and to know the staff names conducting treatment.
8. Participate actively in decisions regarding therapy including the right to refuse treatment. 8. Full consideration of privacy concerning your medical care program. Case discussion, consultation, and treatment are confidential and should be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual.
9. Confidential treatment of all communications and records pertaining to the care at the program. Written permission shall be obtained before the medical records can be made available to anyone not directly concerned with care.
10. Reasonable responses to any reasonable requests made for service.
11. Leave the program even against the advice of a therapist or physician.
12. Reasonable continuity of care, to know in advance the time/location of appointment as well as the identity of the persons providing care.
13. Be advised of program/staff proposals to engage in or perform research affecting treatment. The patient has the
    right to refuse to participate in such research projects.
14. Be informed of continuing care requirements following discharge from the program. 15. Examine and
    receive an explained bill regardless of payment source.
15. Know which program rules/policies apply to a patient’s conduct.
16. Have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding mental
    health or medical care on behalf of the patient.
17. Forward patient complaints to staff members for appropriate response.
18. Expect that all program personnel shall observe these patients’ rights.

Notice of Privacy Practices Pursuant to HIPAA

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

If you have any questions about this notice, please contact Renew, Inc. (“Renew”) at 913-768-6606, press 0. Privacy is a very important concern for all those who come to this office. Federal and state laws and the codes of our profession make the issue of privacy very complicated. Some parts of this notice are quite detailed, and you may have to read the notice several times. If you have any questions, your therapist (Privacy Officer) will be happy to help you.

I. Introduction
This notice will tell you how this office handles information about you. It tells how information is used, shared with other professionals and organizations, and how you can see your information. This notice is required under the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

II. What is meant by “your health information”
Each time you visit this office or any other “health care provider”, information is collected about you and your physical and/or mental health. It may be information about your past, present, or future health or conditions, or about the treatment or other services you have received or about payment for health services. The information collected from you is called Protected Health Information (PHI). This information goes into your file. In this office, your PHI is likely to include these kinds of information:

• Your history as child, in school, and at work, and marital and personal history
  Reasons you came for treatment/counseling. This includes your problems, complaints, symptoms, needs, and goals · Diagnoses
• Treatment plan
  
  • Progress notes. Each time you come in, your therapist will write down how you are doing, observations, and what you tell him or her
• Records received from others who have treated you or evaluated you
• Information about medications you took or are taking
• Legal matters
• Billing and insurance information
• PHI is used for many purposes. For example, it may be used:
  • To plan your care and treatment
  • To decide how well treatment is working for you
  • When speaking with other health care professionals who are also treating you, such as your family doctor or someone who referred you
• To show what services you have actually received
• For teaching and training other health care professionals
• For psychological research
• For public health officials trying to improve health care in this county
• To measure the results of the work you’ve done and to improve the way Renew and I are doing our jobs When you understand what is in your record and what it is used for, you can make better decisions about how, when, and why others should have this information.

Although your health record is the physical property of the practitioner or facility (i.e.: Renew and your therapist) that collected it, the information in your health record is available for you to see, and you are entitled to copies of the PHI file. Psychotherapy notes are working notes and belong to the therapist and are not part of your health record. You can inspect, read, or review the health record. A copy of your PHI can be made but a charge for the costs of copying and mailing may apply. In some very unusual situations, you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or something important is missing you can ask us to amend (add information to) your record, although in some rare situations the therapist does not have to agree to comply. Your therapist can explain more about this to you.

III. Privacy and the laws about privacy
HIPAA requires therapists to keep your PHI private and to give you this notice of legal duties and privacy practices, which is called the Notice of Privacy Practices, or NPP. Your therapist will obey the rules of this notice as long as it is in effect, but if
the NPP is changed, the rules of the new NPP will apply. If the NPP is changed, the new Notice will be posted in the office where everyone can see it. You or anyone else may obtain a copy of the NPP at any time.

IV. How your PHI can be used and shared
When your therapist or others under the direction of the therapist read, share, utilize and analyze your information in the office that is called “use.” Conversely, “disclosure” is when the information is shared with or transmitted to others outside the office. Except in some special circumstances, when your PHI is used or disclosed, only the minimum necessary PHI is shared. The law gives you rights to know about your PHI, how it is used and to have a say in how it is disclosed.

Your PHI is used and disclosed for several reasons. Mainly, your PHI will be used and disclosed for routine purposes explained more fully below. For other uses, you must be told about them, and your therapist must have a written Authorization for release of information from you, unless the law allows or requires use or disclosure of PHI without your authorization. You may revoke your authorization for release of information at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that your therapist has relied on the authorization, or if the authorization was obtained on the condition of obtaining insurance coverage where the law provides the insurer the right to contest the claim under the policy. The law also says that therapists are allowed to make some uses and disclosures without your consent or authorization, and those situations are discussed below.

USES AND DISCLOSURES OF PHI WITHOUT YOUR CONSENT

For treatment, payment, or healthcare operations (TPO)
In almost all cases, your PHI will be used to provide treatment to you, arrange for payment for services, or some other business functions called healthcare operations. These routine purposes are called TPO (Treatment, Payment, and Healthcare Operations). An authorization form signed by you is not required in order for your PHI to be used for TPO. However, in order to provide therapy services, you will be asked to sign an Informed Consent for treatment form.

• Treatment. Your healthcare information will be used to provide you with psychological treatment or services. These services might include individual, couple, family, or group therapy, psychological testing, treatment planning,
  or measuring the effects of services. Your PHI may be used or disclosed to others who provide treatment to you. Your information may be shared with your personal physician. If a team of providers is treating you, we can share
  some of your PHI with them so that the services you receive will be coordinated. Others may enter their findings, the actions taken, and treatment plans into your record. Then, a decision can be made on what treatments work best for you. A treatment plan will be developed. You may be referred to other professionals or consultants for services this office cannot offer, such as special testing or treatments. When referral occurs, the referring clinician will need to be told about you and your conditions. Information received will go into your record. If you receive treatment in the future from other professionals, your PHI, from the records at this office, may be requested with your authorization and shared. These are only some examples of how your PHI may be used and disclosed.
• Payment. Your PHI may be used to bill you, your insurance carrier or others as you request or authorize. Your insurance company may be called in order to determine your insurance coverage. Your insurance carrier may have to be told about your diagnoses, what treatments you have received and is expected throughout treatment. The insurance carrier will need to be told when treatment began, your progress, and other similar information. In addition, if you fail to pay your account, your identity and the amounts that you owe, along with dates of services, may be transmitted to a collection agency or attorney who will assist us in taking action to collect payment.
• Healthcare operations. There are some other ways your PHI may be used or disclosed. Your PHI may be used to determine where improvements need to be made in the way the healthcare provider gives services. It is possible that the office could be required to supply information to some government health agencies studying disorders and treatment services. If so, your name and identity will be removed from what is provided.

For other uses in healthcare

• Appointment reminders. Your PHI may be used and disclosed in order to reschedule or remind you of appointments. You may be asked to complete a form if special arrangements are requested. If you want to be called or written to only at your home or your work, or if you prefer some other way to be contacted Renew can assist you.
• Treatment alternatives. Your PHI may be used to tell you about or recommend possible treatments or alternatives that may be of interest to you.
• Other benefits and services. Your PHI may be used and disclosed in order to tell you about health-related benefits or services that may be of interest to you.
• Research. Your PHI may be used or disclosed in order to research treatments. In all cases your name, address, and other identifying information that reveals who you are will be removed from the information given to researchers. If there is a need for your identity to be disclosed, the research project will be discussed with you and, if you wish, you may agree to sign a special Authorization form before identifying information is shared.
• Business associates. There are some tasks that may be outsourced to other businesses. Examples would include a copy service used to make copies of your health care record, and billing services that complete and mail billing statements. These business associates may receive some of your PHI to conduct their jobs properly. To protect your privacy, the business associates have contracted to safeguard your information.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

If your therapist wishes to use your information for any purpose besides the TPO described above, your permission is needed on an Authorization Form. You may revoke your authorization for release of information at any time, provided each
revocation is in writing. You may not revoke an authorization to the extent that your therapist has relied on the authorization, or if the authorization was obtained on the condition of obtaining insurance coverage where the law provides the insurer the right to contest the claim under the policy.

 

USES AND DISCLOSURES OF PHI NOT REQUIRING AUTHORIZATION OR CONSENT

 

• Child Abuse. If your therapist has reason to suspect that a child has been injured as a result of physical, mental or emotional abuse or neglect or sexual abuse, your therapist MUST report the matter to the appropriate authorities as required by law.
• Adult and Domestic Abuse. If your therapist has reasonable cause to believe that a dependent adult is being or has been abused, neglected or exploited or is in need of protective services, your therapist must report this belief to the appropriate authorities as required by law.
• Health Oversight Activities. Your therapist may disclose PHI to the Kansas Behavioral Sciences Regulatory Board if necessary for a proceeding before the Board.
• Judicial and Administrative Proceedings. If you are involved in a court proceeding and a request is made for information about the professional services provided to you and/or the record thereof, such information is privileged under state law, and your therapist will not release information without a court order or the written authorization of you or your legally appointed representative. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety. If your therapist believes that there is a substantial likelihood that you have threatened an identifiable third person or the public at large and that you are likely to act on that threat in the foreseeable future, your therapist may disclose information in order to protect that individual. If your therapist believes that you present an imminent risk of serious physical harm or death to yourself, s/he may disclose information in order to initiate hospitalization or to family members or others who might be able to protect you.
• For law enforcement purposes. Your PHI may be released under certain
  circumstances to law enforcement officials investigating a crime.
• For specific government functions. Your PHI may be disclosed to military personnel and veterans, to government benefit programs relating to eligibility and enrollment, to Workers’ Compensation programs, to correctional facilities if you are an inmate, and for national security reasons.

USES AND DISCLOSURES REQUIRING AN OPPORTUNITY TO OBJECT

Information can be shared with your family or close others, but only those involved with your care and those you choose, such as close friends or clergy. You will be asked what information can be shared about your condition and treatment. Your therapist will honor your wishes as long as it is not against the law. If there is an emergency – and in that case you may not be asked if you agree – personal information may be shared if your therapist believes that it is in your best interests.

An accounting of disclosures

You are entitled to an accounting (a list) of disclosures of your PHI. The accounting includes what was disclosed, when it was disseminated, and the person/agency that received the information.

If you have questions or problems

If you need more information or have questions about the privacy practices described above, please speak to your therapist (Privacy Officer), whose telephone number and address are listed on the top page of this Notice. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact your therapist. You have the right to file a complaint with your therapist, with the Kansas Behavioral Sciences Regulatory Board (KSRB) at 785-296-3240, and with the Secretary of the Federal Department of Health and Human Services. Filing a complaint will not result in a limitation of care.