EMERGENCY CONTACT: I volunteer to provide the below contact information and authorize Counseling Associates of Central Iowa, PC to contact any listed individual on my behalf in the event of an emergency.

INFORMED CONSENT TO TREATMENT: This form documents that I give my consent to Counseling Associates of Central Iowa, PC, (the“therapist") to provide psychotherapeutic treatment to me. 

PATIENT RIGHTS & RESPONSIBILITIES: While I expect benefits from this treatment, I fully understand that no specific outcome can be guaranteed. I understand that I am free to discontinue treatment at any time, but it would be best to discuss it with the therapist before doing so. Our discussion about therapy has included the therapist's evaluation and diagnostic formulation of my problems, the method of treatment, goals, length of treatment, and information about my financial obligation. I have been informed about, and understand, the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. I understand that therapy can sometimes cause upsetting feelings to emerge and may feel temporarily worse before feeling better. I have the right to considerate, safe, and respectful care without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion,national origin, or source of payment. I understand that I have a right to ask the therapist about the therapist's training and qualifications and where to file complaints about the therapist's professional conduct if needed. I have fully discussed with the therapist what is involved in psychotherapy and understand and agree to the policies about scheduling, fees and missed appointments. I understand that I am fully, financially responsible for treatment which includes any portion of the therapist’s fees that are not reimbursed by my insurance. In the event of a medical, behavioral, or mental health emergency, or if I cannot keep myself safe, I will call 911, go to the nearest hospital emergency room, or call 988 Suicide Hotline. I understand that the therapist cannot provide immediate emergency services. It is my responsibility to take care of myself until such a time that I can talk to my therapist.

NOTICE OF PRIVACY: I have received a HIPAA Notice of Privacy Practices from the therapist, or I can obtain a copy from the office. I understand that information about psychotherapy is almost always kept confidential by the therapist and not revealed to others unless I give my consent. There are a few exceptions as noted in the HIPAA Notice of Privacy Practices. Some exceptions include, but are not limited to, the following:

1. Mandatory Reporting of child/dependent adult abuse or neglect to the proper authorities.

2. Emergency circumstances for the purposes of treating a medical or mental condition which poses a threat to the safety and health of myself, any individual, or the public that requires immediate intervention.

3. Judicial and Administrative Proceedings: If I am involved in certain court proceedings, the therapist may be required, by law or otherwise, to reveal information about my treatment.

4. Payment Purposes: My health insurance may require that I waive confidentiality so the therapist can give them information about my treatment.

5. Treatment Purposes: The therapist may consult with other therapists about my treatment but in doing so, they will not reveal my name or other information that would identify me unless specific consent to do so is obtained.

6. When the therapist is away or unavailable, another therapist might answer calls and will need to have access to information about my treatment. I understand that the covering therapist will discuss my situation with me or notify me before any confidential information is revealed and will reveal only the least amount of information that is necessary.

By signing below, I confirm I have read and consent to the above, and I give my consent to treatment.

• Private Pay: I agree to pay at every appointment.

• Private Insurance: I agree to pay my copay, coinsurance and/or deductible at the time of every appointment. I authorize my insurance benefits to be paid directly to Counseling Associates of Central Iowa, PC. I authorize the release of any medical or other information necessary to process claims. If my coverage is under a group contract held by an employer, an association, a trust fund, a union, or similar entity, this authorization also permits disclosure to them for the purposes of payment, utilization, review, or audit.

Insurance Benefits, Claims, Authorization: If you are using your health insurance for in-network and out-of-network benefits, please check with your insurance company for your mental health benefits and pre-approval requirements. It is your responsibility to know which services are covered, not covered, and considered reasonable or unreasonable by your insurance company. You will need to pay for out-of-network services before services are received. Any changes to your insurance policy or coverage must be reported before services are rendered. You may be required to call your insurance company if their payment is not received or if they deny payment. If for any reason your insurance company does not pay, you are responsible for paying Counseling Associates of Central Iowa, PC, for the services you received. It is your responsibility to contact your insurance company if you have questions regarding their payment, nonpayment, or need an explanation of benefits.

Payment: Payment is due at the time services are rendered. Cash, check, or credit card is expected at the time of service. Credit Card Agreement forms are available to keep your credit card on file to pay any balances due from you after insurance pays or for self-pay if you do not use insurance. For all returned checks, there will be a surcharge of $30.00. If you are more than 90-days delinquent on your balance owed to Counseling Associates of Central Iowa, PC, we will determine whether to provide services until appropriate referrals are made. If termination or withdrawal of service is due to your non-payment, your therapist will work with you and/or your family to identify other service options. Please let the office staff know if a problem arises regarding your ability to make timely payments.

Missed/Cancelled Appointments: Missed and cancelled appointments pose some issues for both you and your therapist. The work of psychotherapy is sometimes challenging, and you may find it easier to avoid coming in for treatment. It is always better to speak about this with your therapist. We hold your scheduled appointment specifically for you. Your therapist sees a limited number of patients so that you get the focus and attention you deserve. Counseling Associates of Central Iowa, PC may charge you a fee up to $150 for appointments that are missed and cancelled without 24-hour notice. If you are running late for your appointment, please phone the office as soon as you can to let us know. If you are late for your appointment, it will still end at the regularly scheduled time. We offer text reminders for appointments but sometimes they do not get sent due to various situations beyond our control. We suggest also keeping a written reminder of your appointments to avoid a late cancel or no-show fee.

Consent to Release Confidential Information: Communication between behavioral health providers and your primary care physicians is important to help ensure that you receive comprehensive and quality health care. This information will not be released without your consent. This information may include diagnosis, treatment plan, progress, and medication. You may revoke this consent at any time except to the extent that action has been taken in reliance upon it.

Consent to Release Confidential Information: Communication between behavioral health providers and your primary care physicians is important to help ensure that you receive comprehensive and quality health care. This information will not be released without your consent. This information may include diagnosis, treatment plan, progress, and medication. You may revoke this consent at any time except to the extent that action has been taken in reliance upon it.

Counseling Associates of Central Iowa, PC will communicate with you via texts, voicemail messages, and emails. Please let us know if you want to opt-out of receiving appointment reminder texts, leaving messages on your voicemail, and/or messaging through email.  Treatment may include telehealth for reasons such as client preference, illness, or weather. Telehealth connects Counseling Associates of Central Iowa, PC (CACI) clinicians with clients via secure, HIPAA-compliant video and audio for psychological care, including diagnosis, treatment, consultation, and referrals. Confidentiality laws apply as they do to in-person sessions. Risks include technical failures, unauthorized access, or data loss. CACI clinicians follow State of Iowa and board regulations and are trained in telehealth services.

It is your therapist’s duty, as a mandatory reporter, to immediately report any suspected child abuse and any suspected dependent adult abuse to the Department of Human Services (DHS). Your therapist will report suspected abuse orally to the DHS followed by a written report within 48 hours after such oral report. They will also make an oral report to an appropriate law enforcement agency if immediate protection of the child or adult is advisable.

• Physical Abuse
• Mental Injury
• Sexual Abuse
• Denial of critical care.
• Child Prostitution
• Presence of illegal drugs in the body.
• Manufacture or possession of dangerous substances in the presence of the child.
• Bestiality in the presence of a minor.
• Cohabitation with a registered sex offender.

Your records cannot be released to any other individual without your written consent. However, certain information may be released without your authorization under the following circumstance:

• When Juvenile Court is involved, records may be shared with Juvenile Court Officers.
• Information about a child may be shared with the child’s Guardian Ad Litem.
• Information may be shared in the event of a legitimate subpoena for court appearance.
• In the event of a medical emergency.
• When the receipt of information suggests that child or dependent adult abuse or neglect has occurred.
• Auditors may review your records to evaluate treatment effectiveness.

Counseling Associates of Central Iowa, PC is legally obligated to report any such information to DHS when there exists a danger to the child, dependent adult, or others.

This policy has been explained to me in my own language.