Please be assured that all information you provide in this form is secure and will be treated with the utmost confidentiality. Your privacy is important to us, and we are committed to protecting your personal information.

By signing this form, I authorize my counselor at The Rest Initiative to contact the emergency contact(s) listed below, but only in the case of an emergency or when deemed necessary for my safety.

In order to initiate counseling and be fully informed about the counseling you will be receiving, please read and complete the following agreement. Your signature attests that you both understand and agree to the terms contained herein:

I. Description of Counseling

Our counseling philosophy is holistic in that three interrelated perspectives are explored: the Existential (the person), the Situational (his/her world), and the Normative (his/her God). Although our counseling is guided by a Christian worldview, your counselor will be sensitive to your religious/cultural differences and perspectives. Based on your counseling needs, you may be advised to take appropriate tests/inventories or seek medical treatment to facilitate the counseling process. We adhere to the Code of Ethics prescribed by the American Association of Marriage and Family Therapy and American Christian Counseling Association. To view our code of ethics, log on to www.aamft.org and to www.aacc.net.

II Referral Policy/Disclaimer 

Clients will be referred outside of of our organization when treatment required is beyond the scope of care available by our counselors. Though The Rest Initiative strives to be responsible and professional in the referral procedure, it is your full right and responsibility to select the professional of your choice. Furthermore, we are not liable for any services provided or not provided by the referred professional.

III Confidentiality
All information disclosed within sessions with TRI counselors, and the written records pertaining to those sessions, are confidential and may not be revealed to anyone without your written permission except where required by law or when specific exceptions have been agreed upon in writing. The participant agrees to the following exceptions to confidentiality:

 IV. Emergency Contact and Safety
In the event of a mental health crisis or emergency that poses a risk to your safety or the safety of others, your counselor may contact the emergency contact person you have provided. This will only be done when necessary to ensure appropriate care and support. Please ensure the emergency contact information you provide is current and that the individual is aware they may be contacted in such circumstances.

If a situation arises that requires immediate intervention and we are unable to ensure your safety through other means, we may also contact emergency services.”

V. Consultation and Disclosure

i. Consultation: In order to provide the highest quality care, TRI staff may consult with other professionals on the TRI treatment team regarding participants.

ii. Disclosure Required by Law: The circumstances where disclosure is required by law are when there is a reasonable suspicion of child, dependent, or elder abuse or neglect; or when a person presents a danger to self or others; or when court ordered to do so by a judge.

Release of Liability
In consideration of the benefits to be derived from the counseling, the receipt whereof is hereby acknowledged, I hereby release, remise and forever discharge and covenant not to sue or hold legally liable The Rest Initiative, its employees or supervisors for any and all claims, demands, actions or causes of action of whatsoever kind and nature related to the counseling process.



VI. Cancelation Policy

The Rest Initiative requests that you notify your counselor at least 24 hours before your scheduled appointment time if you need to cancel a session. Failure to do so will result in charges for the missed appointment. Exceptions are for sudden illnesses and emergencies only.

VII Contacting Your Counselor

For scheduling and canceling your appointments, you must contact your counselor directly via email. For emergencies after-hours, please contact 911, your local emergency room or your local emergency contact.

VIII Religious Counseling
I understand and acknowledge that I am receiving religious counsel from The Rest Initiative. I will be seeing a trained professional working for The Rest Initiative whose desire it is to see all people find wholeness in who they were created to be.

It is important that you understand the following limitations of video contact, as well as expectations for each other we make for video counseling:

I. Any Internet-based communication is not guaranteed to be secure/confidential.
II. There are precautions that you, as my client, can take to increase security, including:

i. Ensuring that you are online in a private room/area with the door closed, and if possible, using some type of sound blocking device.

ii. When possible, connect to the Internet directly (as opposed to using WiFi; this also helps with transmission).

iii. Make sure to turn video off, not just disconnect from the call when the session is over. III. Make the same commitment to your online session that you would to an in-office appointment.

i. Don’t be late.

ii. Limit distractions – turn off cell phones; avoid ‘split screens.’ Explain to others that you are unavailable for the next hour (perhaps hang a ‘Do Not Disturb’ sign on the door).

iii. Have your computer on a firm surface and sit on a sofa/chair or at a desk if possible.

iv. Check the audio/visual in the ‘preferences’ each time before a session so that you can see what I am seeing (and vice versa).

IV. An Online session is subject to our 24-hour cancellation policy.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (PROTECTED HEALTH INFORMATION) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment, andhealth care operations:

• Treatment means providing, coordinating, or managing health care and related
services by one or more health care providers. Examples of treatment would include psychotherapy, medication management, etc.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your insurance company for your services.
• Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.
NOTICE OF PRIVACY PRACTICES

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services. We will use and disclose your PROTECTED HEALTH INFORMATION when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. Your written authorization will be required for any other uses or disclosures. Should you choose to revoke your authorization, you may do so only in writing. We will abide by your written request with the exception of information we released upon obtaining the written authorization and releasing information as required by law.
You may contact our Privacy Officer in
writing to invoke your following rights:
• You may request in writing that we restrict using and disclosing your PROTECTED HEALTH INFORMATION to family members and relatives, friends, or others you identify. We reserve the right to deny this request.

• You may request an amendment to your PROTECTED HEALTH INFORMATION.
• You may request alternative means or locations in which you receive confidential communications.

• You may request an accounting of disclosures of PROTECTED HEALTH INFORMATION beyond treatment, payment, and health care operations. We are required by law to protect the privacy of your PROTECTED HEALTH INFORMATION and to abide by the terms of the Notice of Privacy Practices. We will make and post revisions to the Notice of Privacy Practices in accordance with the law.

You may obtain a written copy of these changes by written request.
You may file a formal, written complaint with us at the address below or with the Department of Health & Human Services, Office of Civil Rights, if you feel your privacy rights have been violated.

For more information regarding our Privacy Practices, please contact: • The Privacy Officer
Neal Salzman, L.M.H.C.

789 N. Highland Ave NE Suite A
Atlanta, GA 30306
(805) 973-7812
For more information about HIPPA or to file a complaint, please contact:

• The U.S. Department of
Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W. Washington, D.C. 20201

(877) 696-6775 (TOLLFREE)

As part of your intake process with The Rest Initiative (TRI), we want to clearly outline the nature of the services being provided. Please read the following agreement carefully and sign at the bottom to indicate your understanding and consent.

Nature of Counseling Services

The Rest Initiative provides faith-integrated pastoral counseling services through trained professionals who are either licensed therapists or master’s-level counselors pursuing licensure. Depending on your location and the licensure status of your counselor, services may be considered pastoral in nature, rather than clinical mental health care.

The term “counseling” used throughout your paperwork, conversations, and sessions refers to pastoral counseling, unless clinical counseling within your state is clearly established and permitted by law. Pastoral counseling may include emotional, relational, vocational, and spiritual support but does not necessarily include clinical diagnosis, treatment plans for medical mental health conditions, or medical record keeping.

Jurisdiction and Scope of Care

Your counselor will provide services within the scope of their licensure and/or training. If your counselor is not licensed in the state in which you reside, your care will be provided as pastoral counseling. Should your needs be determined to require clinical mental health care beyond the scope of pastoral counseling, your counselor will discuss appropriate next steps and may assist in referring you to a qualified provider licensed in your state.

Confidentiality

All sessions are held in strict confidence, in accordance with the ethical guidelines of The Rest Initiative and the professional standards of your counselor. There are rare exceptions required by law, such as situations involving harm to self or others, abuse, or court orders.

Spiritual Integration

Counseling at TRI includes the integration of spiritual and faith-based values when appropriate and desired by the client. You are always welcome to share your preferences regarding the role of faith in your sessions.

Consent to Receive Care

By signing below, you acknowledge that you understand and consent to receive pastoral counseling services through The Rest Initiative and that you are aware of the limitations related to licensure across state lines. You agree to communicate with your counselor about any concerns or preferences as care progresses.

 

*Your signature below indicates that the information you have provided above is truthful.