Assessment Intake Paperwork

By signing below, I acknowledge that this form serves as a request for mental health services through Groundwork Healing, LLC. Once received, Groundwork Healing, LLC, will begin to process said request and will contact the client and/or guardian within 1-2 weeks to confirm receipt of the request and provide an estimated wait time for services; please note that estimated wait times for services are based on the specific service need and corresponding clinician availability.

Please contact Groundwork Healing, LLC, with questions regarding our intake process.

Groundwork Healing, LLC provides a wide range of excellent counseling and mental health services by well-trained, qualified, and licensed professionals. Your treatment will include an initial assessment, development of a treatment plan, and evaluation of your treatment experiences. Groundwork Healing, LLC uses brief therapy techniques when appropriate. Please feel free to discuss any questions regarding your treatment with your therapist.

Check-In: Please remember to check in with the receptionist upon arrival and when leaving. It is important that any co-pay or deductible is paid at the time of service. Without payment, we are unable to provide treatment. Please update us with any changes to your address, phone number, and/or insurance company.

Confidentiality: Groundwork Healing, LLC's treatment services are confidential, except in certain circumstances. You must give permission for us to speak to anyone about you. We must report to the Department of Health and Human Services information we obtain about neglect, exploitation, and abuse of children and dependent or incompetent adults. We will make efforts to warn and protect any intended victims of violence. We will attempt to protect you if we believe you may hurt yourself. We will attempt to discuss our concerns with you, and include you in our planning. Groundwork Healing, LLC abides by the rules of HIPAA as explained in our Notice of Privacy Practices.

Minors: Your therapist will decide what information to share with guardians of minors. In making these decisions, we consider the child's need for confidentiality, and the needs of parents to fulfill their responsibility to protect and nurture a child. Please discuss any concerns you have with your therapist.

Peer/Family Support: Your therapist has resources available to you about support services.

Quality Improvement: In order to assess how successfully we are serving you, we will ask you annually to complete a survey. We thank you for your cooperation. Reminders: To better serve you, we will call or text to remind you of your next scheduled appointment. This is a generic call or automated text. These reminders will be opt-in only.

Winter Weather Cancellations: If services are cancelled due to weather, attempts will be made to call and inform clients of cancelled sessions by 5pm the day before. Decisions about cancellations will be made by 3pm the day before.

Emergency/Urgent Care: We provide 24-hour phone services for urgent needs. If you have not made specific arrangements with your therapist, there are therapists on call. Please call our office at (207) 941-0879 (please call (207) 992-0863 if no answer A therapist will return your call, usually within two hours. If you have a life- threatening emergency, please call 911 or go to your local emergency room. For non-life-threatening situations, you may call or text the Suicide and Crisis Lifeline at 988.

Parking: Clients may park in either lot designated for parking at 12 Stillwater Avenue. Clients do not need a parking permit.

This form is an agreement between you (client or guardian), Groundwork Healing, LLC, When we use the word "you" below we are referring to the client: it can mean you, your child. or a person whom you are the legal guardian of. if you have written his or her name here:

When we examine, test, diagnose, treat. or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide what treatment is best for you, and to provide you with this treatment. We may need to share this information with others who provide treatment to you, need to arrange payment for your treatment, or for other business or government functions. In most cases, as defined in our Notice of Privacy Practices, your written consent will be needed to disclose your PHI. Your PHI may include: records covered by federal rules governing confidentiality of alcohol and drug abuse treatment programs; records covered by state rules governing mental health services; and records concerning you, or your child's, diagnosis or treatment for HIV or AIDS.

By signing this form, you are agreeing to let us use your information here and to send it to others. Our Notice of Privacy Practices explains in more detail your rights, and how we can use and share your information. If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices, we cannot treat you. In the future we may change how we use and share your information and therefore may change our Notice of Privacy Practices. If we do change it, you can get a copy from our Privacy Officer. If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment. or administrative purposes. We require all requests to be in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it (by writing a letter to our Privacy Officer telling us you no longer consent) and we will comply with your wishes about using or sharing information from that time on. but note that we may already have used or shared some of your information and cannot change that.

By signing below, you are confirming that you have read the above and have been offered a copy of our Notice of Privacy Practices.

Thank you for choosing Groundwork Healing, LLC as your mental health provider. We are committed to your successful treatment. Please understand that payment of your co-pay, deductible, or other fees are considered part of your treatment.

Payment of co-pay, deductible or non-covered services are due prior to services being rendered.

Groundwork Healing, LLC accepts cash, check, and debit/credit card (MasterCard, Visa, and American Express).

Insurance: If we are contracted with your insurance, we will bill your insurance and you are responsible for any co-pay, deductible, or non-covered services at the time services are rendered. We must have your current insurance information at the time you are being seen, or you will be required to pay in full. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. In the event that we do not accept assignment of benefits, it is your responsibility to get pre-approval for services. If your insurance has not paid your account in full, within 60 days, the balance will become your responsibility. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and customary under your insurance and/or Medicare or MaineCare program. If there is a change to your insurance, you must notify us immediately.

MaineCare Clients: We provide most services paid for by the MaineCare insurance program. MaineCare regulations only allow you to see one therapist at a time, therefore, please inform us if you are currently receiving other services, or have received services, by a mental health clinician during the current calendar year.

 

Reasonable and Customary Rates

Service Description	Rate	Session Length
Initial Assessment	$150.00	60 Minutes
Individual/Family Psychotherapy	$130.00	60 minutes
Group Psychotherapy	$65.00	90 minutes
Forensic Services/Court Appearance	$150.00	Per hour
Report Preparation and Report Writing	$750.00	Per report
Consultation/Supervision	$150.00	Per hour

Other Fees

Return Check Fee	$30.00	Per check
Collection Accounts	A collection fee of 30% will be added to the existing balance

Minor Clients: The adult accompanying a minor (parent(s)/guardian) is responsible for payment at the time of services. Groundwork Healing, LLC will not bill a third party for payment.

Missed Appointments: Unless canceled at least 24 hours in advance, a charge of $130.00 may be applied for all missed appointments. Please help us serve you better by keeping your scheduled appointments.

Delinquent Accounts: Accounts over 90 days, without payment arrangements, will be referred to collections. A collection fee of 30% will be added to the existing balance.

 

I have read, had the opportunity to ask questions, and been offered a copy of this information. 

Groundwork Healing, LLC, requires all clients with private insurance, or who are self-pay, to keep a credit, debit or Health Savings Account (HAS) card on file. We understand that some clients, for legitimate reasons, may not have a credit, debit or HSA card, and in such situations, payment will be expected prior to services being rendered. This policy will help to ensure that balances are paid on time and will make payment of your bill easier. If you have checked-in to a hotel, or used a car rental service, you will be familiar with a credit card on file policy 

Your card information will be stored securely, in accordance with our HIPAA-compliant standards. Your card's security code will not be required or kept on file. Your card information will be used to process the cost of your session and will be processed via our HIPAA-compliant payment system. If you are a self-pay, client this will be the full cost of your session. If you have private insurance, our office staff will inform you of your financial responsibility before processing payment. It may be necessary that you are charged the full rate of your session until your insurance has been adjudicated, at which time you will be contacted with your updated policy rates and any credits on your account refunded.

Your card information will be processed within five (5) business days of the date of service for your session. Keeping your card information on file does not in any way infringe upon your rights as a cardholder. You may at any time dispute a charge made to your card or question your insurance company's decisions. If you have any questions or concerns regarding this policy, please contact our office staff at (207) 941-0879.

Your card information will only be used for the following purposes:

• Session payments not collected at the time of your visit
• No show or cancellation fees
• Insurance discrepancies
• Any outstanding balances 31 days beyond the date of service

By signing below, I authorize Groundwork Healing, LLC to keep my signature and my card information securely on file. I further authorize Groundwork Healing, LLC, to charge my card for any of the aforementioned purposes.

If you have been referred for this assessment by the State of Maine Department of Health and Human Services, the State of Maine Department of Corrections, or another entity, they may be responsible for the costs and fees associated with your assessment. Groundwork Healing, LLC requires that a release of information form be completed for any referring entity and/or payor.

 

If you are self-referring for an assessment, you are responsible for the costs and fees associated with your assessment, including co-pays, deductibles, and non-covered services, as outlined in our financial policy. Insurance companies, including MaineCare, do not cover non-face-to-face services which include: phone calls, record review, report writing, and court testimony. You are responsible for payment of these services.

Thank you for trusting Groundwork Healing, LLC with your mental health needs. While we understand that life can be unpredictable at times, we kindly ask that, should you need to cancel or reschedule an appointment, you provide our administrative office with 24-hour notice. By providing us with advanced notice, we are able to schedule other clients who may be waiting for an appointment. In keeping with our goal of providing the best patient care to all of our clients, we ask that you please review our cancellation/no-show policy below:

•Any established client who does not show-up for an appointment, or cancels or reschedules an appointment with less than 24-hour notice, will be considered a no-show and may be charged the full cost of their session, $130.00, billed to the client, not the insurance.
•A late arrival of 15 minutes or more will be considered a no-show and may result in the client being charged the full cost of the session.
•In addition to the above stated fee, for an established client, within any 12-month period, the first no-show may result in removal from the recurring schedule. The second no-show may result in the client being placed on a same-day scheduling basis, and the third no-show may result in the discharge of the client.
•Any new client who does not show-up for their first appointment, or cancels or reschedules that appointment with less than 24-hour notice may automatically be placed at the bottom of the agency’s waitlist, and may be required to pay for their first session in advance.
•For your convenience, Groundwork Healing, LLC does try to provide text, email, or phone call reminders ahead of scheduled appointment times, however, should a client not receive a reminder, the above stated policy will remain in effect.

Again, we understand that life happens and that we all experience unforeseen emergencies from time to time that keep us from maintaining scheduled appointments. Should this happen, please contact our administrative staff who may be able to waive the cancellation/no-show fee. You may contact Groundwork Healing, LLC, 24-hours a day, 7 days a week, at (207) 941-0879, to let us know of any scheduling changes. Should you reach our answering service, please leave a detailed message and we will return your call at our earliest convenience.

By signing below, you hereby acknowledge the terms and conditions of Groundwork Healing, LLC's cancellation/no-show policy.

The following is a summary of your rights as a recipient of outpatient (non-residential) services under the Rights and Recipients of Mental Health Services. You may receive a copy of the Rights of Recipients of Mental Health Services booklet from our office or from the Department of Behavioral & Developmental Services, 40 State House Station, Augusta, Maine 04333 (287-4200 or TTY 287-2000. If you are hearing impaired or do not understand English, an interpreter will be made available to assist you understanding your rights.

1. Basic Rights: You have the same civil, human, and legal rights, to which all citizens are entitled. You have the right to be treated with courtesy, respect, and dignity.

2. Right to Confidentiality and Access to Records: You have the right to have your records kept confidential; to be released only with your informed and signed consent. (Specific circumstances where the agency can release or share information as described in the Rights book You have the right to review your record at any reasonable time, and to add written comments to clarify information you believe is inaccurate or incomplete.

3. Right to an Individual Treatment Service Plan: You have the right to a written service plan, developed by you and your worker, based on your needs and goals. The plan must: be based on your actual needs; identify how a need will be met if the service is not available; include tasks to be completed, and by whom; time frames for accomplishment of tasks and goals; and criteria to determine success. If you do not agree with the plan. you have the right to request and receive a second opinion. You have a right to a copy of the plan.

4. Right to Informed Consent: No service or treatment can be provided to you against your will. You have the right to be informed of possible risk and anticipated benefits of all services and treatment. You may designate a representative who is authorized to help you understand and exercise your rights, help you make decisions, or to make decisions for you. The guardian also has the right to be fully informed.

5. Right to File a Grievance and Appeal: You have the right, without retribution, to grieve any violation of your rights or any questionable practice. You have the right to a written response, including reasons for the decision. You may appeal the decision to the Department of Behavioral & Developmental Services. For assistance contact: Office of Advocacy, 60 State House Station, Augusta, Maine 04333 (287-2205) or Disability Rights Center, P.O. Box 2007, Augusta, Maine 04333 (1-800-452-1948).

 

By signing below, you are confirming that you have read the above and have been offered a copy of the Outpatient Rights of Recipients of Mental Health Services who are Adults/Children in Need of Treatment.

What are Telehealth services?

Telehealth services use technology to allow a provider to deliver services to a client who is at a different location. Video conferencing enables you to receive therapy without the need to visit the office or travel long distances. If video conferencing is unavailable, using the telephone may be an option.

What is important to know about Telehealth services?

Using Telehealth is voluntary. You may choose to have services provided face to face. Even if you agree to use Telehealth, you can decide to stop by simply telling your provider or the office, even during a session. Telehealth may not be appropriate in some circumstances. If this is the case, your provider will let you know. If appropriate, services will not differ from the services provided in person except for the means of communication. Telehealth services are subject to the same state and federal confidentiality requirements that apply to in person sessions. Equipment and software used for Telehealth will meet all applicable state and federal privacy and security standards. You may have access to all information associated with Telehealth services as provided under state and federal law. Other people may be present at one or both locations to help operate equipment or for other reasons. You have the right to know who is present during your session and to exclude anyone from either location. Telehealth sessions are not recorded unless you consent to do so. All recorded images and information will be maintained in compliance with all state and federal health care confidentiality laws.

What are the risks and benefits of Telehealth services?

Potential Risks: Services may be less effective if you are uncomfortable with the means of communication. Transmitted information may not be sufficient and may impact clinical decisions around your care. There is a small risk that there could be an unauthorized interception of the communication or breach of privacy of personal medical information.

Expected Benefits: Increased accessibility and availability to services and more convenient delivery of services requiring less travel, distance, and cost.

What are my rights/responsibilities using Telehealth services?

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Telehealth.
• I understand I have the right to withhold or withdraw my consent for the use of Telehealth services at any time during the course of my care. The withdrawal will not affect my ability to receive future care or treatment.
• I understand that my provider can withhold or withdraw consent for the use of Telehealth.
• I agree to not record any Telehealth sessions without written consent.
• I understand that my provider will not record any Telehealth sessions without my written consent.
• I agree to inform my provider if any other person can hear or see any part of our session before the session begins. I understand that my provider will do the same.
• I understand that I must be a resident of the State of Maine to be eligible for Telehealth services. understand that all rules and regulations which apply to the practice of therapy in the State of Maine also apply to Telehealth services.
• I understand that I am responsible for the configuration and functioning of any electronic equipment used by me for Telehealth services.
• I have read and understand the information that has been provided regarding Telehealth services. I have had the opportunity to discuss the information with my provider and to ask any questions.

By signing below, I give my consent to participate in Telehealth services.