Lefkowich Counseling LLC

Steven Lefkowich, LADC

Steve@amethystrecoverysolutions.org

 

1. Description of Services

Thank you for choosing Lefkowich Counseling LLC for your substance use services. My role as a Licensed Alcohol and Drug Counselor (LADC) is to provide a thorough assessment based on the information you share, clinical interviews, and standardized assessment tools. These assessments are used to determine treatment recommendations, which may include counseling, education, and community resources.

2. Limits of Confidentiality

All information disclosed during your assessment will remain confidential and will not be shared without your written consent, except in the following circumstances as required by law:

Risk of Harm to Self or Others: If you express a credible threat of harm to yourself or others.
Abuse or Neglect: If there is a reasonable suspicion of child, elder, or vulnerable adult abuse or neglect.
Court Orders: If required by court order or other legal proceedings.
Medical Emergencies: If an emergency medical situation arises that requires immediate intervention.
A full explanation of confidentiality is provided in the HIPAA Notice of Privacy Practices, available upon request.

3. Client Rights and Responsibilities

You have the following rights as a client:

Right to Understand: You have the right to understand the nature of the assessment, what it will involve, and the results and recommendations derived from it.
Right to Refuse Services: You may refuse or discontinue the assessment at any time, understanding the potential implications this may have for treatment recommendations.
Right to Access Records: You may request access to or a copy of your records, with some exceptions required by law.
Your responsibilities include providing accurate and complete information and participating in the assessment to the best of your ability.

4. Fees, Payment, and Cancellation Policy

Fees: The fee for this assessment is $__0______. Payment is due at the time of service. If you require a payment plan, please discuss this before your scheduled appointment.
Cancellation Policy: Appointments must be canceled at least 24 hours in advance. Late cancellations or missed appointments will incur a fee of $__0______.

5. Nature of Services Provided

This assessment service is intended to evaluate substance use and mental health concerns and to provide recommendations based on the results.
No ongoing treatment or therapy services are provided by Lefkowich Counseling at this time. Should you wish to seek further counseling, referrals can be provided.

6. Release of Information

As part of the assessment process, you may choose to authorize communication with other health professionals or agencies. If applicable, please complete a separate Release of Information Form.

7. Consent to Participate and Agreement

By signing below, you acknowledge that you:

Have read and understood this Consent for Services form.
Agree to participate in the assessment as described.
Understand the scope and limitations of the assessment services provided by Lefkowich Counseling LLC.
Are aware of the confidentiality policies, your rights, and the fees associated with this assessment.
If you have questions about any aspect of this form, please discuss them with Steven Lefkowich LADC before signing.

Federal and state laws protect the privacy of my records:

I, the above-named client, understand that my substance use disorder records are protected under federal law (including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164) and state law (including the Minnesota Health Records Act, Minn. Stat. §§ 144.291-34), and cannot be disclosed without my written consent unless otherwise provided for by law.
The purpose of this Consent and Authorization for the Release of Substance Use Disorder Treatment Information (this “Consent and Authorization) is to give my written consent to the disclosure of some or all of the records relating to my substance use disorder treatment.  I understand that my records, once released pursuant to this Consent and Authorization, may no longer be protected by the above-mentioned federal and state laws.

Revocation and expiration:

I understand that I may revoke this Consent and Authorization at any time by notifying Lefkowich Counseling in writing.  I further understand that any such revocation will not apply to disclosure made in reliance on this Consent and Authorization before Lefkowich Counseling LLC received my written notice of revocation.
Unless earlier revoked by me, this Consent and Authorization will expire one (1) year from the date it is signed by me unless earlier revoked by me.
I understand that, upon my request, YourPath will give me a copy of this Consent and Authorization.