Consent for Treatment and Care
I voluntarily consent to behavioral health treatment and care provided by Blue Kite Wellness, either for myself or on behalf of my child or legal dependent. This includes services delivered by licensed clinicians, provisional clinicians, supervised interns, clinical support staff, and other providers. Services may be provided on site (in-office), via secure telehealth platforms, or offsite (in-home or community-based) settings as appropriate. I understand that by signing this form, I am either agreeing to receive care for myself as an adult client or, if I am a parent or legal guardian, I am authorizing services for the minor or dependent named in this form. This consent remains valid throughout the course of treatment and extends for up to three (3) years after the final treatment date, in order to allow for audits or post-payment reviews. I acknowledge that no guarantees have been made about treatment outcomes.

Scope of Treatment
Treatment may include any of the following services as determined appropriate by the clinical team:
• Individual, family, or group counseling, or therapy
• In-home or community-based support
• Psychiatric evaluation and management, and medication management
• Other services such as yoga, nutrition support, meditation, or art therapy—these are optional services provided by Blue Kite Wellness
• Psychological evaluation and management
Session timing will be agreed upon and may vary depending on service type and clinical need.

Community-Based and Exposure Therapy Services
I understand that offsite services (such as walk-and-talk therapy or community-based exposure therapy) may involve reduced privacy and physical activity. I affirm that I am physically able to participate and that these services are voluntary. I release Blue Kite Wellness from liability associated with participation. If I engage in Exposure and Response Prevention (ERP), I will not be asked to participate in exposures without informed consent and will receive a clear rationale for each step.

Right to Refuse Treatment
I understand that I have the right to refuse or withdraw consent to any treatment at any time. If I am signing on behalf of a child or dependent, I may withdraw authorization on their behalf. Withdrawal does not impact eligibility for future services at Blue Kite Wellness.

Confidentiality & HIPAA
I understand that personal health information (PHI) is protected under HIPAA and will only be used or disclosed as permitted by law. This includes circumstances involving danger to self or others, suspected abuse or neglect, or court orders. I acknowledge that I have received or have access to the Notice of Privacy Practices, and that all confidentiality protections apply across all treatment settings, including telehealth and offsite.

Limits of Data Security and Redisclosure
Blue Kite Wellness clinicians have a legal and ethical obligation to protect your Protected Health Information (PHI) using secure, HIPAA-compliant systems and reasonable safeguards. While we make every effort to protect your confidentiality through best practices and staff training, we cannot guarantee that all communications or data will remain completely secure. By receiving services, you acknowledge that unauthorized access or accidental disclosures may occur despite our best efforts, and you agree not to hold Blue Kite Wellness liable for any unintentional breaches that occur beyond our control. Additionally, once your PHI is shared with third parties (such as insurance companies, managed care organizations, or other providers with your consent), those parties may not be bound by the same confidentiality obligations, and re-disclosure may occur. Blue Kite Wellness is not responsible for any further use or release of information by entities that lawfully receive your records.

Sensitive Health Information
I consent to the use and limited disclosure of sensitive health information—including mental health history, substance use, sexual or domestic violence history, reproductive health, and HIV/AIDS status—for treatment, payment, and healthcare operations. If I am a guardian, I authorize disclosure on behalf of the client.

Information Sharing & Coordination of Care
I authorize Blue Kite Wellness to share necessary health information with my insurer, care providers, and collaborating agencies. I understand secure systems may be used for coordination of care.

Telehealth Consent
I consent to receive therapy via secure, HIPAA-compliant telehealth platforms. I understand that technical issues may occur, and either my clinician or I may end a session if the connection is inadequate. I am responsible for creating a private, confidential space during sessions and agree not to record sessions without permission. I will provide an emergency contact. If my session is interrupted and I am in crisis, I will call 911 or 988.

Communication Consent
I authorize Blue Kite Wellness to contact me by phone, voicemail, text, or email for appointment reminders, billing, or treatment coordination. I may revoke this at any time. If I am a guardian, I agree to be the primary point of contact for the minor or dependent.

Financial and Insurance Responsibility
I am responsible for all costs related to care, including co-pays, deductibles, non-covered or denied services, and any balance not paid by insurance. I authorize Blue Kite Wellness to bill my insurance and assign payment directly. If payment is not received within twelve (12) weeks, I may be billed directly. I agree to notify Blue Kite Wellness of insurance changes before sessions; failure to do so may result in a $25 resubmission fee. If my balance reaches $250 or more, services may be paused until payment is made or a plan is arranged. I am responsible for checking with my insurer in advance and agree to pay for any services not reimbursed.

Cancellation Policy
I must provide more than 24 hours notice to cancel or reschedule my appointment. If cancellation is made within 24 hours, you may be subject to charges for late cancellation. Missing three (3) consecutive appointments or four (4) in six months may lead to discontinuation of services. If I miss an appointment and do not contact Blue Kite Wellness within three (3) weeks, it will be assumed that I have chosen to terminate services.

Minor Clients
If I am consenting on behalf of a minor or dependent, I confirm that I have the legal authority to do so. Clients age 12 and older may have confidentiality rights under Illinois law.

Client Rights & Concerns
I have the right to respectful, non-discriminatory care, to request a new provider, to access records as allowed by law, and to voice concerns without retaliation. Concerns may be shared directly with our office at 630-635-0577.

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.

Our pledge regarding health information:

Blue Kite Wellness understands that health information about you and your health care is personal. We are committed to protecting this information. We create a record of the care and services you receive in order to provide quality care and comply with legal requirements.

This notice applies to all records of your care generated by Blue Kite Wellness. It explains how we may use and disclose your health information, your rights, and our legal duties.

We are required by law to:

• Make sure that your protected health information (PHI) is kept private
• Provide this notice of our legal duties and privacy practices
• Follow the terms of the current version of this notice
• Update this notice as necessary; the revised version will be available upon request, in our office, and on our website

Use and Disclosure of Your Health Information
We may use or share your Protected Health Information (PHI) for the following purposes:

• For Treatment: We may use and share your health information with doctors, nurses, or other healthcare providers who are involved in your care.
  Example: Your therapist may consult with your prescribing psychiatrist about your treatment plan.
• For Payment: We may use and disclose your PHI to bill for services, collect payments, or provide information about your treatment to your health insurance plan.
  Example: We may disclose your information to your insurance company to receive payment for services rendered.
• For Healthcare Operations: We may use or share your PHI for administrative purposes, such as improving the quality of care we provide or performing audits.
  Example: We may use your information to evaluate the performance of our clinicians or to improve our clinic’s services.

Other Uses and Disclosures
We may also use or disclose your PHI in the following situations:

• Public Health: To report certain conditions to public health authorities.
• Law Enforcement and Legal Requirements: If required by law or for law enforcement purposes, we may disclose your PHI.
• Medical Emergencies: If you are in an emergency situation and we need to use your information for your immediate care.

Uses and disclosures requiring your authorization:

1. We require your written authorization to use or disclose PHI unless:
   • It's for your treatment
   • For training or supervision of mental health staff
   • To defend against legal action initiated by you
   • Required for a regulatory or legal investigation
   • Required by law or health oversight activities
   • Disclosed to a coroner for lawful duties
   • Necessary to prevent a serious threat
2. Marketing purposes
   • We do not use or disclose your PHI for marketing.
3. Sale of PHI
   • We do not sell your PHI.

Uses and disclosures not requiring your authorization:

We may use or disclose your PHI without authorization for the following:

• When required by federal or state law
• Public health reporting (e.g., suspected abuse, threats to safety)
• Health oversight activities (e.g., audits, investigations)
• Judicial or administrative proceedings
• Law enforcement purposes
• Coroner or medical examiner duties
• Government functions (e.g., military, national security)
• Workers’ compensation compliance

 

Your rights regarding PHI

1. Right to request limits
   You can ask us not to use or share your PHI for treatment, payment, or healthcare operations. We are not required to agree to all requested restrictions but will consider your request.
2. Right to restrict disclosures for self-paid services
   You may request restrictions on disclosures to your health plan if you paid for the care in full, out-of-pocket.
3. Right to request confidential communication
   You may ask to be contacted in a specific way (e.g., at a different phone number or address), and we will honor reasonable requests.
4. Right to see and get copies of your PHI
   You may request an electronic or paper copy of your medical record. We will respond within 30 days and may charge a reasonable fee.
5. Right to a list of disclosures
   You may request a list of PHI disclosures made in the last 6 years (excluding disclosures for treatment, payment, or operations). The first list is free; additional requests may be subject to a fee.
6. Right to correct your record
   If your PHI is incorrect or incomplete, you may request a correction. We may deny the request but we will provide an explanation within 60 days.
7. Right to a copy of this notice
   You may request a paper or electronic copy of this notice at any time.

Under HIPAA, you have rights regarding the use and disclosure of your protected health information. 

I confirm that I have read, understood, and agree to all sections of above forms, including but not limited to the Consent for Treatment, HIPAA Notice of Privacy Practices, and my rights and responsibilities as a client.

I affirm that I am either the individual receiving services or the parent/legal guardian of the minor or dependent named in this form. In consideration of receiving services from Blue Kite Wellness, I voluntarily agree to participate in or authorize participation in services and hereby release Blue Kite Wellness from any claims, demands, or causes of action arising from participation or enrollment in care.