ADULT CONSENT FOR TREATMENT

I/We hereby give consent for mental health treatment (which may include services, supports) for the above-named Consumer. Services may include one or more of the following:

1. Diagnostic Evaluation (with or w/out medical) and Diagnostic Evaluation Update
2. Community Psychiatric Service Treatment (CPST)
3. Psychotherapy (Individual, Family, Group, Crisis)
4. Psychoeducation Support Services (Therapeutic Behavioral Services, Psychosocial Rehabilitation)
5. Substance Use Disorder Assessment and ASAM Level of Care
6. Substance Use Disorder Services (Case Management; Individual Counseling; Group)
7. Intensive Outpatient Treatment
8. Pharmacologic Management Services
9. Laboratory Analysis

I understand that all information shared with service providers at The Table Core Services is confidential and no information will be released without my consent. During the course of treatment at The Table Core Services, it may be necessary for my service provider to communicate with providers at The Table Core Services. While written authorization will not be requested, prior to any discussion with The Table Core Services providers, I understand that only provider will discuss all communications with me. In all other circumstances, consent to release information is given through written authorization. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:

A. When there is risk of imminent danger to myself or to another person, the service provider is ethically bound to take necessary steps to prevent such danger.
B. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the provider is legally required to take steps to protect the child and to inform the proper authorities.
C. When a valid court order is issued for medical records, the provider and the agency are bound by law to comply with such requests.

If I have any questions regarding this consent form or about the services offered at The Table Core Services I may discuss them with my provider or the Clinical Manager. I have read and understand the above. I consent to receive the treatment offered to me by The Table Core Services. I understand that I may stop treatment at any time.

The consent/or treatment process has been thoroughly explained to me and I understand that I may stop treatment at any time.

Thank you for choosing The Table Core Services Agency for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our Client Financial policies.

● The Client (or Client’s guardian, if a minor) is ultimately responsible for the payment for treatment and care.

● We will bill your insurance for you. However, the Client is required to provide the most correct and updated information regarding insurance. If we are unable to process payment through your insurance for any reason we will bill you for the services provided at the following rates:

1. Individual Psychotherapy 1-hour Session $ 55.00

2. Group Psychotherapy 1-hour Session $ 75.00

3. Family Psychotherapy 1-hour Session $ 75.00

4. Diagnostic Evaluation Flat fee $ 50.00

5. Diagnostic Evaluation with Medical Flat fee $250.00

6. Community Psychiatric Supportive Treatment 1-hour Session $ 35.00

7. Therapeutic Behavioral Services 1-hour Session $ 35.00

8. Psychosocial Rehabilitation 1-hour Session $ 35.00

9. Substance Use Disorder Assessment & ASAM Flat fee $ 50.00

10. Substance Use Disorder Services 1-hour Session $ 35.00

11. Intensive Outpatient Treatment Hourly Rate $ 75.00

● Clients are responsible for payment of copays, coinsurance, deductibles and all         other procedures or treatment not covered by their insurance plan
● Copays are due at the time of service
● Coinsurance deductibles and non-covered items are due 30 days from receipt of       billing
● Clients may incur, and are responsible for payment of additional charges, if           applicable. These charges may include: Charge for returned checks - $30.00

 

 

By my signature below, I hereby authorize assignment of financial benefits directly to The Table Core Services Agency and any associated healthcare entities for service rendered as allowed under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment.

Client Acknowledgement and Authorization

We respect Client confidentiality and only release personal health information about you in accordance with the State and Federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully.

By my signature below, I acknowledge that I have received and read the privacy notice provided by The Table Core Services to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, and or other physicians or healthcare entities to participate in my care. 

I attest that I have been provided with the information necessary to make an informed choice about service, informed about the range of other services in a way that in non-coercive and protects my right to self-determination. My selection of a service provider was based solely upon my identified needs, diagnosis, preference, and provider availability.

By signing this Statement of Provider Choice, I acknowledge that I was given choice of provider and that the screening discussed location, available times, specialty, culture and linguistic preferences with me.

Introduction
Tele-mental health (Tele-therapy) means the use of, real-time audiovisual communications of such quality as to permit accurate and meaningful interaction between a provider of the service and the person(s) service is being to.

Tele-mental health allows clients to access mental health care using audio-video interface such as videoconferencing. Asynchronous modalities that do not have both audio and video elements are considered telehealth. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
Improved access to mental health care by enabling a client to remain in his/her home or office. Improved convenience for the client.

● More efficient management of mental health care within the community setting.
● Obtaining expertise of a distant specialist.

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of tele-mental health. These risks include, but may not be limited to:

● In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for the effective communication between the client and the mental health professional. Effective communication is vital to the provision of mental health services by the mental health professional;
● Cultural and/or language differences between the client and the mental health
professional may affect communication and service delivery.
● Delays in mental health assessment and treatment could occur due to deficiencies or failures of the equipment;
● In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
● In rare cases, a lack of access to complete medical records may result in judgmental errors by the mental health professional;

 

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to tele-mental health and that no information obtained in the use of tele-therapy which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of tele-mental health in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained in the course of a tele-mental health interaction and may receive copies of this information for a reasonable fee.
4. I understand that no video and/or audio recordings of tele-mental health sessions will be made.
5. I understand that a variety of alternative methods for the provision of mental health services may be available to me, and that I may choose one or more of these at any time.
6. I understand that an alternative method for the provision of mental health services may be used by my mental health professional when deemed necessary.

7. I understand that it is my duty to inform my mental health professional of any other healthcare providers involved in my medical/ mental health care.
8. I understand that I may expect the anticipated benefits from the use of tele-mental health in my care, but that no results can be guaranteed or assured.
9. I understand that The Table Core Services cannot ensure confidentiality at the site where the client is located and when unapproved equipment software is used by the client, when tele-mental health procedures are not followed by the client.
10. I understand that The Table Core Services is not responsible for overages on client data usage plans, when Wi-Fi is not used by the client.
11. I understand that my mental health professional providing tele-mental health is a qualified mental health professional with specialized training in the provision of distance mental health.
12. I understand that The Table Core Services Agency is located at 1507 Saint Clair NE, Cleveland, OH 44114-2003; phone number: 216-451-5020
13. I understand that in times of crisis, or as desired during business hours, I may reach my mental health professional by business cell or desk phone.
14. I understand that in times of crisis outside of normal work hours of my mental health professional I may call the Mobile Crisis Hotline at 234-334-1880 or call 911.

Client Consent to the Use of Tele-Mental Health

I, (printed name below) hereby consent to engaging in teletherapy with The Table
Core Services Agency. I understand that “teletherapy” includes the practice of mental health care, delivery, diagnosis, consultation, treatment and education using interactive audio, video, or data communications of my medical/mental health information, both orally and visually, to The Table Core Services Agency via a teletherapy service such as Doxy.Me, Zoom, etc. (a HIPPA compliant video platform service).

I have read and understand the information provided above regarding tele-mental health, have discussed it with my mental health professional as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of tele-therapy in my medical care. I hereby authorize The Table Core Services to use tele- mental health in the course of my mental health diagnosis and treatment.

 

This permission slip must be signed by the parent or guardian of the client (if applicable). If you do not give permission, please indicate in the appropriate space of the form.

Permission to Use Photograph

I, the client or (Parent/Legal Guardian, if minor/conservator) grant The Table Core Services, its representatives and employees the right to take photographs of me in connection with any activities I may participate in connected with services offered by The Table Core Services. I authorize The Table Core Services, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

Permission to Transport

I, the undersigned, hereby authorize The Table Core Services Agency to use or disclose my personal health information and/or confidential information as described below to:

Type of Information to be Released/Exchanged:

I understand and acknowledge that the requested information may contain information regarding physical and mental illness, HIV test results or diagnosis, AIDS or AIDS related conditions, alcohol and/or drug dependence/abuse*. I also understand that information used or disclosed according to this authorization may
be subject to re-disclosure by the recipient and may no longer be protected.

I understand that I may see and copy the information described on this form if requested in writing.

I also understand that the provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. The health care providers listed above will not receive financial or in-kind compensation in exchange for using or disclosing my health care information.

 

I understand I have a right to revoke this authorization (in writing) at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization. If not revoked, this authorization will expire one year from the date written below or on the following date, event or condition (if earlier): ________________________.

I understand there may be charges for the copying and release of information and accept financial responsibility for those charges. I understand and agree that a copy of this authorization shall have the same force and effect as the original.