Adult Client Intake Packet

I understand that my consent can be revoked orally or in writing prior to, or during the treatment period. I understand that claims will be processed on my behalf. I understand that unless this service(s) is fully covered by my insurance plan, fees for services and application to deductible may apply. I have read and had this information fully explained to me. I have had the opportunity to ask questions and receive answers about my treatment. The Emotional Wellness Department of Community Health Partners, does on occasion and where appropriate provide disability letters, letters regarding your ability to work, or letters that would inform providers of your mental health history. You must discuss these needs with your therapist in advance. If a letter is required attesting the client’s needs the therapist will need a minimum of 72 hours’ notice for completion. Letters are only provided to clients who have been seen for 3 sessions or longer. The Emotional Wellness Department does not provide companion/emotional support animal letters. Clients are discouraged from having the therapist subpoenaed. Though the client’s attorney, who initiates the subpoena request is responsible for the court appearance and testimony fees, it does not mean that the therapist's testimony will be solely in in the client's favor. The therapist will only testify their professional opinion and to the facts of the case. Additional fees and costs may apply that are not covered by insurance for legal preparation, appearance and testimony.

You are in partnership with Community Health Partners when receiving services.

Your rights are as follows:

• To be treated with dignity, courtesy and respect
• To ask for, consent for and receive quality treatment and services
• To receive services regardless of your place of residence, sex, race, age, sexual preference, national origin, ancestry, immigration status, veteran status, disability, or religion
• To maintain your legal and civil rights unless in Baker Act status
• To participate in the development, understanding and maintenance of your treatment
• To have reasonable access to records

Your responsibilities are:

• To supply, whenever possible, accurate information about illnesses, hospitalizations, medications, and other pertinent matters related to your physical and emotional health
• To respect the rights of all others and be considerate of them, including their privacy and confidentiality
• To report physical or mental abuse
• To keep your scheduled appointments, keeping missed appointments to a minimum and contacting within 24 hours if you need to cancel or reschedule your appointment
• To fully participate in your treatment

Community Health Partners rights are:

• To refuse service provision after you continually disregard your treatment, including no-showing three (3) times. 
• To refuse service provision to those clients/cases/situations that cause a professional conflict or threat to the clinician, the agency or the mission and vision of the practice.
• To report all suspected, disclosed, witnessed and/or confirmed abuse of a child or vulnerable adult to the Department of Children and Families and other necessary agencies.
• To give notice of your involuntary admission to your emergency contact person

I, with respect to any services provided or that are planned to be provided to myself as the patient or, as an authorized legal representative, for the below listed individual as the patient, fully consent to and authorize Naples Physician Hospital Organization dba Community Health Partners, ("Healthcare Provider") or any of its automated systems to contact me via phone (including to my cellular phone by way of phone call or text message) and/or email in relation to any services received from Healthcare Provider or any services planned to be received from Healthcare Provider (including any billing items and/or appointment reminders).

I consent to be contacted via the following method(s):(PLEASE DO NOT PROVIDE WORK EMAILS OR WORK PHONE NUMBERS)

The automated system will try to contact you, if you consented as follows: text first, email second and voicemail last. Once it is successful with one of the methods you consented to the other methods will not be executed.

If you do not consent to one of the above contact methods you understand you will not receive notification(s) of upcoming appointments and will be subject to the No Show/Late Cancellation Policy as listed below. If you do not consent to email notifications, you will not receive any administrative announcements (ie. notification of office closings or changes), from Healthcare Provider and any amounts not covered under the insurance (if applicable) will be your responsibility and billings will be sent to the mailing address on file for the above-mentioned patient.

Each client is forgiven for one missed/no show appointment. If the client misses a subsequent appointment, or does not cancel an appointment within twenty-four (24) hours of their scheduled appointment time they will be charged a fee of $30 for each subsequent appointment missed. The individual client will receive a bill in the mail from Community Health Partners. Services cannot continue with our clinicians until the balance owed has been paid in full.

I consent to engaging in telehealth with the Emotional Wellness Department of Community Health Partners (CHP) as a part of the therapy process and my treatment goals. I understand that telehealth psychotherapy may include mental health evaluation, assessment, consultation, treatment planning, and therapy. Telehealth will occur primarily through interactive audio, video, telephone and/or other audio/video communications. I understand that my first initial visit with the assigned therapist must take place in person at one of their offices. I understand that telehealth services are only available to those persons that the therapist determines are appropriate for virtual services and is limited to those clients who are over the age of 16 at time of enrollment. I understand and consent to providing a safe, confidential, private/personal and working email and phone number to the Emotional Wellness Department in order to access telehealth services. I understand I have the following rights with respect to telehealth:

1) I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

2) The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my sessions is generally confidential. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent,

3) I understand that there are risks and consequences from telehealth including but not limited to, the possibility, despite reasonable efforts on the part of Emotional Wellness Department of Community Health Partners (CHP) that: the transmission of my personal information could be disrupted or distorted by technical failures and/or the transmission of my personal information could be interrupted by unauthorized persons. In addition, I understand that telehealth-based services and care may not be as complete and in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to a mental health professional who can provide those services in my area. I also understand that there are potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and efforts of my therapist, my condition may not improve, or may have the potential to get worse.

 

4) I understand that I may benefit from telehealth services, but that results cannot be guaranteed or assured. I understand that the use of Advanced MD Telehealth platform audio/video systems are not 100% secure and may have issues with Wi-Fi connectivity. All attempts to keep information confidential while using these systems will be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. Signing this form shows an awareness of these issues and a decision by this client to use these systems for telehealth services. I will not hold Emotional Wellness Department of Community Health Partners (CHP) or its staff liable for gathering or use of client information by these service providers.

5) I understand I have the right to access my personal information and copies of case notes. I have read and understand the information provided above. I have discussed these points with my therapist, and all of my questions regarding the above matters have been answered to my approval.

6) By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situation may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threating or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. In accordance with the Health Insurance Portability and Accountability Act (HIPPA) and Florida Statute 394, this Notice applies to all sites owned and/or leased by Community Health Partners (CHP) where protected health information is created and maintained.

Definition: Protected Health Information (PHI) refers to all the information created and maintained (whether oral, written, electronic, magnetic or recorded in any form) by CHP when a member receives treatment or services.

General Rule: In certain circumstances we may use and disclose your PHI without your written consent.

Examples of disclosures include:

• For Treatment- CHP may disclose information to past and future providers within CHP and to your CHP team for the purpose of coordinating the service you receive. CHP may also provide information to contracted providers who provide services you receive during your treatment. CHP will share information with your current healthcare providers outside of CHP if you offer the name and address of these providers and sign a release of information.
• For Payment- CHP will use and disclose your PHI to send bills and collect payment from you, your insurance company, and other payers for the care, treatment, and other related services you receive. Your PHI may also be submitted to business associate collection agencies as needed to secure payment for your service.
• For Health Care Operations- PHI may be disclosed to Florida and Federal regulatory agencies and licensing authorities.

Your PHI may also be used or disclosed without your authorization or written consent as follows:

• When required by Federal law and Florida Statutes
• When a serious and imminent threat to the health and safety of a person or the public has been made
• When threats concerning the well-being of the President of the United States have been made
• When research and development for educational purposes is being conducted
• When a court order has been issued
• When there is abuse, neglect, exploitation, domestic violence or criminal activity
• To contact you with an appointment reminder or to communicate information about your appointment Other uses and disclosures of your PHI, including psychotherapy notes, will occur only with your written authorization. You may revoke authorization in writing at any time. CHP will make reasonable efforts to use or disclose the minimum amount of PHI necessary to accomplish the intended purpose.

 

RELEASE OF INFORMATION

I hereby authorize the disclosure of information from Emotional Wellness Department at Community Health Partners to:

I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization and do not need to sign this form in order to receive treatment. I acknowledge that I give consent to this disclosure as described above. I understand that I have the right to revoke this authorization at any time in writing. I understand that revoking this authorization will not affect any
actions already taken on it. I understand that I am entitled to receive a copy of this authorization upon request. Each disclosure requires an additional signed authorization. This consent will expire 180 days after the date of my signing. I hereby agree to hold Community Health Partners and its clinicians harmless for any liability that may result directly or indirectly from the disclosure released in accordance with this consent.

NO SHOW AND LATE CANCELLATION POLICY

Each client is forgiven for one missed/no show on an appointment. If the client misses a second appointment, or does not cancel an appointment within twenty-four (24) hours of their scheduled appointment they will be charged a fee of $50. The individual client will receive a bill in the mail from Community Health Partners. Services cannot continue to be provided until the balance owed has been paid in full. Clients with three or more no-shows will be discharged from the practice for one year. Please be aware that clients can leave a confidential voicemail on 239-659-7751 or a confidential email to ew@chealthpartners.com and this will be sufficient notification.

 

Provider/Requester: I hereby authorize my therapist in the Emotional Wellness Department of Community Health Partners to release information to the following person(s) in the event of a medical or mental health emergency:

For the purpose of: CARE DURING A MEDICAL OR MENTAL HEALTH (SUICIDAL/HOMICIDAL/DEATH) EMERGENCY

The information authorized to be released (please initial below):

I have been told that, in order to protect the limited confidentiality of records, my agreement to obtain or release information is necessary and that this permission is limited for the purposes and to the person listed above, and will be effective from the date of my signature to a maximum of two years. I may change the contact in this consent at any time. A photocopy or facsimile of this form may be accepted in lieu of the original signed form. I also understand that this consent is revocable except to the extent that action has been taken on it already.

I further understand that the Emotional Wellness Department and its practitioners at Community Health Partners will not condition my treatment on whether I give authorization for the requested disclosure.

Clients are discouraged from having us subpoenaed or having us provide records for the purpose of litigation. Even though you are responsible for the testimony fee, it does not mean that our testimony will be solely in your favor. We can only testify to the facts of the case and to our professional opinion. Furthermore, we need to assess to ensure there are no conflict of interest that could arise from our  testimony. We would rather not damage the trust we have built in the counseling relationship with each client, especially if we are still seeing that person(s) for therapy.

If we are to receive a subpoena, the attorney or office staff will need to call our office and setup a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice of any court appearance so that schedule changes for our clients can be made within a reasonable time frame.

Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 hour notice, there will be an additional $250 express charge, which must be paid prior to my appearance in the courtroom.

When it comes to court action, the following fees are in effect (please note that the fee schedule listed below is NOT covered by insurance:

1. Preparation Time (including submission of records): $200/hr (billable in 15 minute increments)
2. Phone calls: $200/hr (billable in 15 minute increments)
3. Depositions: $250/hour
4. Time required in Giving Testimony: $250/hour
5. Mileage: .50/mile
6. All attorney fees and costs that are incurred by me as a result of the legal action.
7. Filing documents with the court: $100 flat fee
8. The minimum charge for a court appearance: $1000

A retainer of $1000 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If we am subpoenaed, and the case is continued with less than 48 business hours notice prior to the beginning of the day of the scheduled court appearance and/or the testimony is not given, then the
client will be charged $500 (in addition to original retainer of $1000 for having to appear in court). All fees listed above are doubled if the therapist is scheduled to be going out of town. Bills are presented to clients on a weekly basis and payment is expected upon receipt.

I understand the above fee schedule and agree to these terms:

Please complete the information below. Information provided on this form is protected as confidential information.

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family members relationship to you in the space provided (e.g. father, grand mother, uncle, etc.)