Acknowledgment

The practice may utilize my payment methods on file for any balances, including late cancellation and no-show fees, without additional authorization.

Client Rights

You are assured protection in the areas of your fundamental human, civil, constitutional, and statutory rights. This page serves as written declaration of your rights as a client of Integrated Interventions LLC.

You have the right to:

• Impartial access to treatment and services, regardless of race, creed, color, religion, gender, national origin, age, disability, sexual identity or gender expression.
• Humane treatment environment that ensures protection from harm, privacy to as great a degree as possible with regard to personal needs and respect and dignity in regard to your person.
• Communication in the language and format understandable to you, the client.
• The right to be free from mental, physical, sexual, and verbal abuse, as well as neglect and exploitation.
• Receive services within the least restrictive environment possible.
• An individualized treatment plan, based on assessment of current needs.
• Actively participate in planning for treatment and recovery support services to include care being furnished, the plan of care, expected outcomes, barriers to treatment, and any changes to your treatment plan.
• Access to information contained in your record, except for when such disclosures would put you, the client, at risk.
• Confidentiality of records and the right to be informed of the conditions in which information can be disclosed without your individual consent (see privacy policy).
• Refuse to take mediation unless a court of law has determined you, the client, lack capacity to make decisions about medication and are in imminent danger of self or others.
• Be free from restraint and seclusion unless there is imminent risk of physical harm to self or others.
• Refuse to participate in any research project without compromising access to program services.
• Exercise any of your client rights without reprisal in any form, including the ability to continue services with uncompromised access.
• Consult with independent specialists or legal counsel, at you, the clients, own expense.
• Information in advance of the reason(s) for discontinuation of any service or part of service, and to be involved in planning for the consequences of that event.
• Be informed as to the reasons for denial of services.
• Refuse care and services at any time for any reason.
• Be informed of, to the extent to which payment may be expected from the client, any source of funding to the agency.
• Have your person and property treated with consideration, respect, and full recognition of you, the client, and your personal needs.
• Be free from abuse, neglect, and exploitation by and agency employee, volunteer, or contractor.
• Have someone designated to make treatment decisions on your behalf by a court of law.
• Not have any part of any session recorded without your explicit written consent.

Questions, concerns, or complaints regarding this document or the services provided?

Joshua Westby

Founder

(208) 261-1158

Joshua@westwindclinic.com

 

Idaho Division of Occupational and Professional Licenses

11341 W. Chinden Blvd.

Boise, ID 83714

(208) 334-3233

 

General Information

The therapeutic relationship is unique in that it is highly personal and simultaneously a contractual agreement. It is essential for us to have a clear understanding about how our relationship will work and what each of us can expect. This Consent for Services (the "Consent") aims to provide a clear framework for our work together. Please read and indicate your agreement by signing at the end of this document.

The Therapy Process

Therapy is a collaborative process where you and your Provider will work together to achieve goals that you define. The process is supported by scientific evidence and involves specific rights and responsibilities for both you and your Provider. Therapy generally shows positive outcomes for individuals who engage actively in the process. Therapy begins with the intake process, including reviewing policies and procedures, discussing fees, and forming a treatment plan. Participation in therapy is voluntary, and you can stop at any time. The outcome of your treatment depends largely on your willingness to engage in this process, which may at times be uncomfortable.

Your Therapist

Your therapist will be assigned by WestWind Wellness Clinic with input from you. All WestWind mental health providers hold a Master's degree and a license as a Marriage and Family Therapist (MFT), Licensed Social Worker (LMSW/LCSW), or Professional Counselor (LPC/LCPC Therapists at WestWind Wellness Clinic may be under clinical supervision in pursuit of their clinical license and may have an assigned supervisor. WestWind Wellness utilizes intern therapists on occasion for cost reduced services.

Confidentiality Policy

Therapeutic communications, records, and contracts with your provider will be treated with confidentiality. WestWind Wellness Clinic may release information, including your protected health information, if required by state or federal law or if necessary to provide treatment to you. PLEASE SEE THE PRIVACY POLICY. In addition, the therapists at WestWind Wellness Clinic may discuss your case for the purpose of professional consultation with other mental health professionals. All therapists or other mental health professionals will treat your protected health information as confidential. Confidential files will remain with WestWind Wellness Clinic for 7 years after the last day of enrollment. In the event of a providers death, illness, retirement, or relocation WestWind Wellness Clinic will have information to help you access your records. Clients with any concerns or questions about this policy agree to address them with their provider at the earliest possible time in order to resolve them in the client's best interest.

Cancellation Policy 

All clients of WestWind Wellness Clinic are encouraged to be at the office 5 minutes before their appointment for check-in. Appointments may be canceled 48 hours before a scheduled appointment with no penalty. The first missed appointment fee is waived as a courtesy. Missed appointments are not covered by insurance and will be billed to the card on file for the full amount of the session. Payment for a missed appointment is due before the next scheduled session. 

Work Agreement 

The first few sessions are a time of mutual evaluation. A joint determination will be made whether the therapy seems comfortable and appropriate. If, at any time, and for any reason, the relationship does not seem workable, other options will be discussed. You as the client may seek other options on your own, or the provider may present other options for consideration. These options may include referral to another provider or to a specialist for consultation or testing. You agree to inform the therapist of any conflict, disagreement, or hurt feelings pursuant to the therapist, that may arise, before such things become a major hindrance in the therapy relationship, and thus affect the desired counseling outcome. 

Contacting the Provider 

WestWind Wellness Clinic is not a emergency provider. Calls to the WestWind Wellness Clinic will be returned at the earliest convenience. Calls to your provider outside of scheduled telehealth appointments should be limited to brief consultations (no longer than 15 minutes If a longer consultation is required. an appointment may be scheduled. WestWind Wellness Clinic answers phone calls Monday-Friday 9AM-5PM PST. In an emergency contact 911. 

An emergency constitutes situations in which but are not limited to: 1. You are out of control 2. You have made plans or statements indicating intent to harm yourself or to harm others 3. You demonstrate potentially harmful behavior

Fees For Service

Fees for service depend on contracted rates with your insurance company. Fees for service depend on the contracted rates with your insurance company and will not exceed the posted cash rate unless contracted at a higher rate. WestWind Wellness Clinic has a posted fee schedule for cash payment that can be found at www.westwindclinic.com/fees.

Counseling Techniques 

Cognitive Behavioral Therapists use a wide variety of techniques to help patients change their cognitions, behavior, mood, and physiology. Techniques may be cognitive, behavioral, environmental, biological, supportive, interpersonal, experiential, or experimental. Therapists select techniques based on their ongoing conceptualization of the patient and his or her problems and their specific goals for the session. Homework in the form of, readings, journaling, and practicing situations will be used to strengthen concepts.

Telehealth Services

Telehealth requires an internet connection and a device with a camera. There are risks and benefits associated with telehealth, such as issues with technology, privacy concerns, and emergency management. Benefits include flexibility and ease of access. 

Complaints 

Reports of suspected unethical or illegal acts on the part of the agency or your provider may be reported to the state board that issued the therapist's license or licenses, i.e. LPC, LMFT. 

Idaho Division of Occupational and Professional Licenses 

11341 W Chinden Blvd. 

Boise, ID 83714 

(208)-334-3233

 

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

OUR PLEDGE REGARDING HEALTH INFORMATION

WestWind Wellness Clinic understands that health information about you and your healthcare is personal. That information is often called “protected health information” or“PHI.” WestWind Wellness Clinic is committed to protecting health information about you.WestWind Wellness Clinic will create records of the care and services you receive from us.We needs this record to provide you with quality care and to comply with certain legalrequirements. This notice applies to all of the records of your care generated by thispractice. This notice will tell you about the ways in which WestWind Wellness Clinic may useand disclose health information about you. We also describe your rights to the healthinformation we keep about you and describe certain obligations we have regarding the useand disclosure of your health information.

WestWind Wellness Clinic is required by law to:

• Make sure that PHI that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to healthinformation.
• Follow the terms of the notice that is currently in effect.
• WestWind Wellness Clinic can change the terms of this Notice, and such changes willapply to all information we have about you. The new Notice will be available uponrequest in our office.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose healthinformation. For each category of uses or disclosures, we will explain what we mean and tryto give some examples. Not every use or disclosure in a category will be listed. However, allof the ways we am permitted to use and disclose information will fall within one of thecategories.

For Treatment, Payment, or Health Care Operations:

Federal privacy rules (also knownas the HIPAA regulations) allow health care providers who have direct treatmentrelationship with the patient/client to use or disclose the patient/client’s personal healthinformation without the patient’s written authorization, to carry out the health careprovider’s own treatment, payment or health care operations. We may also disclose yourprotected health information for the treatment activities of any health care provider. This toocan be done without your written authorization. For example, if a clinician were to consultwith 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 orderto assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessarystandard: Because therapists and other health care providers need access to the full recordand/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 providerswith a third party, consultations between health care providers and referrals of a patient forhealth care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, We may disclose healthinformation in response to a court or administrative order. We may also disclose healthinformation about your child in response to a subpoena, discovery request, or other lawfulprocess by someone else involved in the dispute, but only if efforts have been made to tellyou about the request or to obtain an order protecting the information requested.

CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

1. Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in45 CFR § 164.501, and any use or disclosure of such notes requires your specificAuthorization unless the use or disclosure is:
   1. For our use in treating you.
   2. For our use in training or supervising mental health practitioners to help themimprove their skills in group, joint, family, or individual counseling or therapy.
   3. For our use in defending ourselves in legal proceedings instituted by you.
   4. For use by the Secretary of Health and Human Services to investigate ourcompliance with HIPAA.
   5. Required by law and the use or disclosure is limited to the requirements of such law.
   6. Required by law for certain health oversight activities pertaining to theoriginator of the psychotherapy notes.
   7. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As a mental health clinic, we will not use or disclose your PHI for marketing purposes without express written consent.
3. Sale of PHI. As a mental health clinic, we will not sell your PHI in the regularcourse of our 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 yourAuthorization for the following reasons:

1. 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.
2. For public health activities.
3. For reporting suspected child, elder, or dependent adult abuse, orpreventing or reducing a serious threat to anyone’s health or safety.
4. For health oversight activities, including audits and investigations.
5. For judicial and administrative proceedings, including responding to a court oradministrative order, although our preference is to obtain an Authorization from youbefore doing so.
6. For law enforcement purposes, including reporting crimes occurring on our premises.
7. To coroners or medical examiners, when such individuals are performing dutiesauthorized by law.
8. For research purposes, including studying and comparing the mental health ofpatients who received one form of therapy versus those who received another formof therapy for the same condition.
9. Specialized government functions, including, ensuring the proper execution ofmilitary missions; protecting the President of the United States; conductingintelligence or counter-intelligence operations; or, helping to ensure the safety ofthose working within or housed in correctional institutions.
10. For workers’ compensation purposes. Although our preference is to obtain anAuthorization from you, we may provide your PHI in order to comply with workers’compensation laws.
11. Appointment reminders and health related benefits or services. WestWindWellness Clinic may use and disclose your PHI to contact you to remind youthat you have an appointment with us. We may also use and disclose yourPHI to tell you about treatment alternatives, or other health care services orbenefits that we offer.

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

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

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the rightto ask us not to use or disclose certain PHI for treatment, payment, or health careoperations purposes. We are not required to agree to your request, and we may say“no” if we believe it would affect your health care.
2. 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 ahealth care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How we Send PHI to You. You have the right to ask us tocontact you in a specific way (for example, home or office phone) or to send mail toa different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” youhave the right to get an electronic or paper copy of your medical record and otherinformation 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 receivingyour written request, and we may charge a reasonable, cost-based fee for doing so.
5. The Right to Get a List of the Disclosures we Have Made. You have the right torequest a list of instances in which WestWind Wellness Clinic has disclosed your PHIfor purposes other than treatment, payment, or health care operations or for whichyou provided us with an Authorization. We will respond to your request for anaccounting of disclosures within 60 days of receiving your request. The list we willgive you will include disclosures made in the last six years unless you request ashorter time. We will provide the list to you at no charge, but if you make more thanone request in the same year, We will charge you a reasonable cost-based fee foreach additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake inyour PHI, or that a piece of important information is missing from your PHI, you havethe right to request that WestWind Wellness Clinic correct the existing information oradd the missing information. We may say “no” to your request, but we will tell youwhy in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get apaper copy of this Notice.

 

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you havecertain rights regarding the use and disclosure of your protected health information. Bysigning below, you acknowledge that you have received a copy of the HIPAA Notice ofPrivacy Practices.

I understand that this information may be protected by Title 45 (Code of Federal Rules of Privacy of IndividuallyIdentifiable Health Information, Parts 160 and 164) and Title 42 (Federal Rules of Confidentiality of Alcohol and DrugAbuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the informationdisclosed to the recipient may not be protected under these guidelines if they are not a health care provider coveredby state or federal rules.

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing writtennotice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed whatinformation will be given, its purpose, and who will receive the information. I understand that I have a right to receivea copy of this authorization. I understand that I have a right to refuse to sign this authorization.