INFORMED CONSENT TO TREATMENT: This form documents that we, the "parent(s)/guardian(s)” give my/our consent and agreement to Counseling Associates of Central Iowa, PC, the “therapist," to provide psychotherapeutic treatment to the "child" and to include me/us as necessary in the child's treatment.

While the parent(s)/guardian(s) can expect benefits from this treatment for the child, they fully understand that no specific outcome can be guaranteed. The parent(s)/guardian(s) understands that they are free to discontinue treatment of the child at any time, but it would be best to discuss with the therapist any plans to end therapy before doing so. The parent(s)/guardian(s) has fully discussed with the therapist what is involved in psychotherapy and understands and agrees to the policies about scheduling and missed appointments. The discussion about therapy has included the therapist's evaluation and diagnostic formulation of the child's problem(s), the method of treatment, goals and length of treatment, and information about the financial obligation. The parent(s)/guardian(s) has been informed and understands the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. The parent(s)/guardian(s) understands that therapy can sometimes cause upsetting feelings to emerge, and the child's problems may worsen temporarily before improving.

Emergency Procedure: The parent(s)/guardian(s) understands that the therapistis is not always available outside of business hours and cannot provide immediate emergency service. If an emergency arises, the parent(s)/guardian(s) understands they are to call 988 for the suicide hotline, 911 for the police, or report to the nearest hospital’s emergency room. Once contact with emergency services has been made, then contact the therapist.

Notice of Privacy: The parent(s)/guardian(s) has access to a copy of this form and of the HIPAA Notice of Privacy Practices (which can be revised without announcement) kept in the office of Counseling Associates of Central Iowa, PC. The parent(s)/guardian(s) understands that information about psychotherapy is kept confidential by the therapist and not revealed to others, besides the parent(s)/guardian(s), unless a parent(s)/guardian authorizes such release. There are exceptions that are noted in the HIPAA Notice of Privacy Practices. Some exceptions include, but are not limited to, the following:

1. The therapist is required by law to report to the proper authorities any suspected child abuse or neglect.

2. If the child tells the therapist that he/she intends to harm another person, the therapist must try to protect the endangered person by telling the police, the person, the school and/or other health care providers.

3. If the child threatens to harm himself/herself or if the child's life or health is in any immediate danger, the therapist will try to protect the child as necessary by telling the parent(s)/guardian(s), police and/or other health care providers who may be able to assist in protecting the child.

4. If the child is involved in certain court proceedings, the therapist may be required by law to reveal information about the child's treatment. These situations include child custody disputes, cases where the child's psychological condition is an issue, lawsuits or formal complaints against the therapist, civil commitment hearings, and court-ordered treatment.

5. If the child's health insurance or managed care plan will be paying the therapist directly, confidentiality will be waived if the therapist is required to give them information about the child's treatment.

6. The therapist may consult with other healthcare professionals about the child's treatment but in doing so, will not reveal the child's name or other information that would identify the child unless specific consent to do so is obtained from the parent(s)/guardian(s). When the therapist is away or unavailable, another therapist will answer calls and will need to have access to information about the child's treatment.

In the situations described above, the therapist will try to discuss with the parent(s)/guardian(s) before any confidential information is revealed and will reveal only the amount of information that is necessary. Appropriate safeguards will be used by Counseling Associates of Central Iowa, PC and their business associates to prevent unauthorized use or disclosure of Protected Health Information (PHI) as required by HIPAA.

The parent(s)/guardian(s), as legal guardians of the child, have rights to general information about what takes place in the child's therapy, information about the child's progress in therapy, information about any dangers the child might present to self or others, and upon request, to obtain copies of the child’s treatment record (with certain qualifications and exceptions). The parent(s)/guardian(s)understands that it is usually best not to ask for specific information about what was said in therapy sessions because this might break the trust between the child and the therapist. The parent(s)/guardian(s) agrees that in the event of custody, visitation, or if the child is contested in a legal proceeding, the parent(s)/guardian(s) and their attorneys will not require the therapist to testify at any of the proceedings because to do so would hurt the child's treatment. The therapist’s role is a therapeutic and not an evaluative one so a forensic professional would be better able and more appropriate to conduct any necessary evaluations. Because of these limitations, the therapist will not be able to give any opinions regarding custody, visitation, or any other legal issues. If such a proceeding does occur, the parent(s)/guardian(s) agrees that the therapist's role will be limited to providing written information regarding, and/or the record of, the child's treatment to a mental health professional appointed to perform such an evaluation, attorneys, law guardian, and the judge involved in the legal proceeding; the therapistwill provide what is required by law or upon the authorization of parent(s)/guardian(s). 

The therapist has explained to the parent(s)/guardian(s) that children with two parents/guardians have the best chance to benefit from therapy if both are involved and cooperate with each other and the therapist. If both child’s parents/guardians are consenting to therapy:

• Each parent/guardian agrees that he/she will not end the child's therapy without the agreement of the other parent/guardian, and that if theydisagree about the child continuing in therapy, we will try to come to an agreementbefore ending the child's therapy.
• Eachparent(s)/guardian agrees to cooperate with the therapist’s treatment plan for the child and understands that without cooperation, the therapistmay not be able to act in the child's best interests and may have to end therapy.
• Each parent/guardian shall continue to have the right to information about the child's treatment and to the treatment records of the therapistregarding the child and agree that the therapistmay release information or records to either parent/guardian without any additional authorization.

If the parent(s)/guardian(s)and the child are using a health insurance company for the claims, the parent(s)/guardian(s)has discussed with the therapist their financial responsibility for copayments, coinsurance and deductibles and the plan's limits on the number of therapy sessions. A diagnosis is required, and information and records may be required,by the health insurance company to process claims. The parent(s)/guardian(s)understands that they are fully financially responsible for treatment including any portion of the fees not reimbursed by the health insuranceand late cancellation and no-show fees. The therapist will discuss options for continuation of treatment if the health insurance benefits end or payment is not received from insurance and/or parent(s)/guardian(s). 

The parent(s)/guardian(s)understandsthat they have a right to ask the therapist about the therapist's training and qualifications and about where to file complaints about the therapist's professional conduct.

By signing below,the parent(s)/guardian(s)isindicating that they have read and understand this agreement, that they give consent to the therapist's evaluation/treatment to be administered, and that they have the proper legal status to give consent,with or without their presence,to therapy for the child.

 The therapist will keep the information you share confidential unless you give consent to release certain information. There are, however, exceptions to this rule that are important for you to understand before you share personal information with the therapist in a therapy session. In some situations, the therapist is required by law or by the guidelines of their profession to release information whether they have your permission. Some of these situations are listed below:

• You tell the therapist you plan to cause serious harm or death to yourself, and the therapist believes you have the intent and ability to carry out this threat in the very near future. The therapist must take steps to inform your parent(s)/guardian(s) of what you have said and the seriousness of this threat. The therapist must make sure that you are protected from harming yourself.
• You tell the therapist you plan to cause serious harm or death to someone else who can be identified and believe you have the intent and ability to carry out this threat in the very near future. The therapist must inform your parent(s)/guardian(s) and the person who you intend to harm.
• You tell the therapist you are being abused physically, sexually, or emotionally or that you have been abused in the past. The therapist is required by law to report the abuse to the Iowa Department of Human Services (DHS).
• You are involved in a court case and a request is made for information about your therapy. The therapist will not release information without your written agreement unless the court requires them to do so. The therapist will do within the law to protect your confidentiality and if they are required to release information to the court, they will inform you.

Except for situations such as those mentioned above, the therapist will not tell your parent(s)/guardian(s) specific things you share in your private therapy sessions. This includes activities and behavior that your parent(s)/guardian(s) would not approve of, or would be upset by, but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior continues or increases, then the therapist will need to use professional judgment to decide whether you are in serious and immediate danger of being harmed. If the therapist feels that you are in such danger, they will communicate this information to your parent(s)/guardian(s).

• Example: If you say that you have tried alcohol at a few parties, the therapist will keep this information confidential. If you tell the therapist that you are drinking and driving or that you are a passenger in a car with a driver who is drunk, the therapist will not keep this information confidential from your parent(s)/guardian(s). If you say, or if the therapist believes based on things you have said, that you are addicted to alcohol, the therapist will not keep this information confidential.
• Example: If you say that you are having protected sex with a boyfriend/girlfriend, the therapist will keep this information confidential. If you tell the therapist that on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations, the therapist will not keep this information confidential. You can always ask the therapist about the types of information that would be released. You could ask in the form of a “hypothetical situation,” in other words,“If someone told you that they were doing ____, would you tell their parents?”

Even if your therapist has agreed to keep information confidential from your parent(s)/guardian(s), they may believe that it is important for them to know what is going on in your life. In these situations, they will encourage you to tell your parent(s)/guardian(s) and will help you find the best way to do so. When meeting with your parent(s)/guardian(s), your therapist may describe problems in general terms, without using specifics, to help them know how they can be more helpful to you. You should also know that, by law in Iowa, your parent(s)/guardian(s) has the right to see any written records from your sessions. It is extremely rare that your parent(s)/guardian(s) would ever request to look at these records.

Your therapist will not share any information with your school unless they have your permission and permission from your parent(s)/guardian(s). Your therapist may request to speak to someone at your school to find out how things are going for you there. It may be helpful in some situations for your therapist to give suggestions to your teachers or the school counselor. If your therapist wants to contact your school or if someone at your school wants to contact your therapist, it will be discussed with you, and we will get your written permission. A very unlikely situation might come up in which your therapist does not have your permission, but your parent(s)/guardian(s) believes that it is very important to share certain information with someone at your school. In this situation, your therapist will use their professional judgment to decide whether to share any information.

Sometimes your doctor and therapist may need to work together; for example, if you need to take medication in addition to seeing your therapist. Your therapist will get your written permission and permission from your parent(s)/guardian(s) before  sharing information with your doctor. The only time your therapist will share information with your doctor without your permission is if you are doing something that puts you at risk for serious and immediate physical/medical/mental harm.

The purpose of meeting with a therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a therapist about these problems. Or you may be here because your parent, guardian, doctor, or teacher had concerns about you. When you meet with the therapist, you will discuss these problems. The therapist will ask questions, listen to you, and suggest a plan for improving these problems. It is important that you feel comfortable talking to the therapist about the problems that are bothering you. Sometimes these problems will include things you don’t want your parent(s)/guardian(s) to know about. Knowing that what you say to the therapist will be kept private should help you feel comfortable and have trust in the therapist. Privacy, also called confidentiality, is an important and necessary part of good therapy.

Signing below indicates that you have read the policies described above and understand the limits to confidentiality. If you have any questions at any time during your therapy, you can ask your therapist.

I/we will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I/we will be provided with periodic updates about general progress and/or may be asked to participate in therapy sessions as needed.

Although I/we know I/we have the legal right to request written records since our child is a minor, I/we agree NOT to request these records to respect the confidentiality of our child’s treatment.

I/we understand that I/we will be informed about situations that could endanger our child. I/we know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may be made in confidential consultation.

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 if necessary. You may revoke this consent at any time except to the extent that action has been taken in reliance upon it.

Private Pay: I agree to pay at every appointment.

Private  Insurance: I agree to pay my child’s 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. 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 utilization, review, or audit.

Insurance Benefits, Claims, Authorization: If you are interested in 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 your child received. It is your responsibility to contact your insurance company if you have questions regarding their payment or need an explanation of benefits.

Payment: Payment is due at the time services are rendered. Payment by 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 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 child’s balance owed to Counseling Associatesof Central Iowa, PC, we will determine whether to provide services to your child until appropriate referrals are made. If termination or withdrawal of service happens due to your non-payment, your child’s 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. When your child turns 18 years of age, they will become responsible for their balances.

Missed/Cancelled Appointments: Missed and cancelled appointments pose some issues for both your child and the therapist. The work of psychotherapy is sometimes challenging so your child may find it easier to avoid coming in for treatment. It is always better to speak about this with the therapist. We hold these scheduled appointments specifically for your child. The therapist sees a limited number of patients so that your child can get the focus and attention they 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 child’s appointment, please phone the office as soon as you can to let us know. If you are late for an 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.

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, HIPAAcompliant 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 the 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 child’s 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.

Types of Abuse:

• 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 child’s 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 a 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 a child/dependent adult abuse or neglect has occurred.
• Auditors may review 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.