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  • Welcome to Dabney Behavioral Health.

    This comprehensive and secure form is the first and most important step in beginning your care with us. Completing it thoroughly allows us to prepare for your first appointment and tailor our services to your specific needs. Please set aside approximately 45 to 60 minutes to complete this paperwork. Your information is kept strictly confidential and secure. We appreciate you taking the time to complete this, and we look forward to meeting with you.
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  • Contact Information

  • Important Contacts

    Emergency Contact
  • Reason for Seeking Services

  • Insurance, Payment & ID

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  • We require a photo ID to verify your identity and prevent insurance fraud. This is kept securely with your file.

  • Mental Health History

  • Medical History & Substance Use

  • Social & Cultural History

  • Background & Experience

  • Client Demographics

  • Life Experiences

    The following questions ask about potentially difficult experiences. Please answer to the best of your ability. This information helps us better understand your needs and is kept strictly confidential
  • Your Strengths & Goals

  • Informed Consent Form (Collaborative Form)

  • Informed Consent Form (Collaborative Form

    Dabney Behavioral Health Hospital and its affiliates/agents anticipate the exchange of information with other professional agencies. This release authorizes a free exchange of information, including, but not limited to, participation in scheduled meetings, review of records, or exchange of copied information for the purpose of securing services in order to meet the client’s programming/treatment needs.

    This information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), governing the privacy of client health information, including the HIPAA Privacy Rule, The Mental Health and Developmental Disabilities Confidentially Act, Americans with Disabilities Act (ADA), and other Federal and Illinois statutes and regulations. Moreover, Dabney Behavioral Health Hospital representatives and its affiliates/agents are required to adhere to confidentiality laws in this document.

    By signing this agreement, I give Dabney Behavioral Health Hospital and its affiliates/agents permission to share information on behalf of the client/patient. Unless revoked in writing, this agreement and exchange shall remain in force until the client is formally discharged from the organization.

    I understand that I have the right to revoke this agreement in writing at any time. Moreover, if I do not sign this form or revoke the authorization, information will not be shared, and it will be your (the client’s) responsibility to send their information to the appropriate agencies.


    Client Signature (required for all clients 12 years of age or older)Please Document if a youth 12 years of age refuses to sign.

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  • DBHHC Informed Consent

  • This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

    THE THERAPY PROCESS
    Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

    Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

    IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
    When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
    • You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
    • If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
    • You must follow all safety protocols established by the practice, including:
    • Following the check-in procedure;
    • Washing or sanitizing your hands upon entering the practice;
    • Adhering to appropriate social distancing measures;
    • Wearing a mask, if required;
    • Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
    • Telling your Provider if you or someone in your home tests positive for COVID-19.
    • Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.

    TELEHEALTH SERVICES
    To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:
    • Risks
    • Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
    • Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
    • Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
    • Benefits
    • Flexibility. You can attend therapy wherever is convenient for you.
    • Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
    • Recommendations
    • Make sure that other people cannot hear your conversation or see your screen during sessions.
    • Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
    • Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

    CONFIDENTIALITY
    Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
    • Your Provider may speak to other healthcare providers involved in your care.
    • Your Provider may speak to emergency personnel.
    • If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
    • If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
    • If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
    • If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

    RECORD KEEPING
    Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes/other secure storage service. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

    COMMUNICATION
    You decide how to communicate with your Provider outside of your sessions. You have several options:
    • Texting/Email
    • Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
    • Secure Communication
    • Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
    • Social Media/Review Websites
    • If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
    • Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
    • If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

    FEES AND PAYMENT FOR SERVICES
    You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:
    • No-Show and Late Cancellation Fees
    • If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.
    • Balance Accrual
    • Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
    • Administrative Fees
    • Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
    • Insurance Benefits
    • Before starting therapy, you should confirm with your insurance company if:
    • Your benefits cover the type of therapy you will receive;
    • Your benefits cover in-person and telehealth sessions;
    • You may be responsible for any portion of the payment; and
    • Your Provider is in-network or out-of-network.
    • Sharing Information with Insurance Companies
    • If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
    • Covered and Non-Covered Services
    • When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
    • When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider could tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
    • Payment Methods
    • The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
    ________________

    Adolescent & Adult Informed Consent Form

    Privacy of Information Shared in Counseling/Therapy: Your Rights and Our Policies

    What to expect:

    The purpose of meeting with a counselor or therapist is to help with problems in your life that are bothering you or keep you from being successful in essential areas of your life. You may be here because you want to talk to a counselor, therapist, psychologist, or other mental health professional about these problems. Or, you may be here because your parent, guardian, doctor, teacher, law enforcement, or the courts had concerns about you. When we meet, we will discuss these problems. We will ask questions, listen to you, and suggest a plan for improving these problems. You must feel comfortable talking to me about the issues that are bothering you. Sometimes, these issues will include things you don’t want your parents or guardians to know about for adolescents. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an essential and necessary part of good counseling.

    As a general rule, we will keep the information you share in our sessions confidential unless we have your written consent to disclose certain information. However, exceptions to this rule are important for you to understand before you share personal information with us in a therapy session. In some situations, we are required by law or our profession’s guidelines to disclose information whether or not we have your permission. Listed are some of the exceptions.

    Confidentiality cannot be maintained when:

    Ø You tell us your plan to cause severe harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the very near future. We must take steps to inform a parent or guardian of what you have told us and how serious we believe this threat to be. We must make sure that you are protected from harming yourself, including but not limited to self-harming.

     

    Ø You tell us your plan to cause severe harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future. In this situation, we must inform your parent or guardian and inform the person you intend to harm and the appropriate enforcement agency.

     

    Ø You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. We will need to use professional judgment to decide whether a parent or guardian or other appropriate authority should be informed in these situations.

     

    Ø You tell us, or we have reason to believe you are abused physically, sexually, or emotionally or that you have been abused in the past. In this situation, we are required by law to report the abuse to the Illinois Department of Children and Family Services (DCFS). For additional information https://www2.illinois.gov/dcfs/safekids/reporting/Pages/index.aspx

     

    Ø You are involved in a court case, and a request is made for information about your counseling or therapy. If this happens, we will not disclose information without your written consent unless the court requires us to. We will do all we can within the law to protect your confidentiality, and if we are required to disclose information to the court, we will inform you that this is happening.

    Communicating with your parent(s) or guardian(s):

    Except for situations such as those mentioned above, We will not tell your parent or guardian specific things you share with me in our private therapy sessions. These situations include, but are not limited to, activities and behavior that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of severe and immediate harm. However, suppose your risk-taking behavior becomes more serious. In that case, I will need to use my professional judgment to decide whether you are in severe and immediate danger of being harmed. If we feel that you are in such danger, we will communicate this information to your parent or guardian.

    Example: If you tell us that you have tried alcohol at a few parties, We will keep this information confidential. If you tell us that you are drinking and driving or that you are a passenger in a car with a drunk driver, we will not keep this information confidential from your parent/guardian. If you tell us, or if we believe that based on things you’ve told us, you are addicted to alcohol, we will not keep this information confidential.

    Example: If you tell us that you are having protected sex with a boyfriend or girlfriend, we will keep this information confidential. Suppose you tell us that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations. In that case, we will not keep this information confidential. You can always ask us questions about the types of information we would disclose. You can ask in the form of “hypothetical situations,” in other words: “If someone told you that they were doing ________, would you tell their parents?”

    Moreover, we feel your parents/guardians need to know if we believe some confidential or non-confidential information. In that case, we will encourage you to tell your parent/guardian and help you find the best way to tell them. Also, when meeting with your parents, we may sometimes describe problems in general terms, without using specifics, to help them know how to be more helpful.

    Communicating with other adults:

    School: We will not share any information with your school unless we have permission from your parent or guardian. Sometimes We may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for us to give suggestions to your teacher or counselor at school. In all situations, we will use our professional judgment to decide whether to share any information.

    Medical Doctors: Sometimes, your doctor and DBHHC staff may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. We will get your parent/guardian’s written permission in advance to share information with your doctor.

    In Case of Emergency:

    Call 911 in case of emergency – Dabney Behavioral Health does not have a 24/7 emergency response line.

     

    Crisis Hotlines

    National Domestic Violence Hotline

    https://www.acf.hhs.gov/fysb/ndvh

    800-799-7233

     

    National Sexual Assault Hotline

    https://www.rainn.org/resources

    800-656-4673

     

    National Suicide and Crisis Lifeline

    https://afsp.org/988-suicide-and-crisis-lifeline

    988 or 911

    Department of Children and Family Services

    https://www2.illinois.gov/dcfs/Pages/default.aspx

    800-252-2873

    Cares Line – State of Illinois – 24/7 Days a Year

    https://www.dhs.state.il.us/page.aspx?item=123539

    800-345-9049

    Illinois Warm Line (Mental Health and/or Substance Issues)

    https://www.dhs.state.il.us/page.aspx?item=123539

    866-359-7953

    Contact Rules

    Patients who are a “No Call/No Show” without a 24-hour Notice of cancellation via the patient portal or phone call 3 times within any given 6-month period can be discharged and subject to be reassessed by the Intake Team for medical necessity.

    Statement of Discharge

    Effective September 9, 2022, a Statement of Discharge for all patients discharged by the LPHA or other designated individual will be placed in the patient portal for download. Also, the patient can request a copy be mailed via the US Postal Service.

    Civil Rights:

    Ø You have the right to be treated with dignity and respect.

    Ø You have the right to services without discrimination on the basis of ethnicity, creed, race, religion, age, marital status, financial status, physical or developmental abilities.

    Ø You have the right to make decisions about your course of treatment and have treatment conducted in a private space.

    Ø You will not be denied, suspended, or terminated from services or have services reduced for exercising any of your rights.

    Rights to Treatment:

    Ø You have the right to an individualized treatment plan and be informed when there is a change or need to refer to other services.

    Ø You have the right to know the names and professional credentials of your staff members.

    Ø You have the right to discuss treatment services and change agencies if you feel the treatment is inappropriate to your needs.

    Ø You have a right to request a “Clinical Review” when you do not agree with the treatment staff team’s decisions. The assigned Clinical Reviewer will render an independent decision following the receipt of information from all parties.

    Ø You have a right to file a grievance if you feel that your treatment has not been appropriate or that your rights have been violated in any manner. This grievance will be initiated at the worker level and may go up to the Executive Director if not resolved before.

    Ø You have the right to treatment that is free from abuse, neglect, or exploitation.

    Ø You have a right to refuse treatment at any time. You have the right to refuse to participate in audio/videotaped sessions, including Zoom or activities.

    Ø You have a right to refuse to participate or to be interviewed for research or publicity purposes.

    DBHHC Responsibilities:

    Ø Protect your rights in accordance with Chapter Il Of the Mental Health and Developmental Disabilities Code. Protect your confidentiality according to the Confidentiality Act and the Health Insurance Portability and Accountability AQ (HIPAA).

    Ø Provide ethical and competent treatment, assign qualified staff to cases, and maintain accurate clinical records.

    Ø Protect your rights in accordance with Chapter Il Of the Mental Health and Developmental Disabilities Code.

    Ø Provide referral and linkage to Other social service agencies.

    Ø Provide an accounting of any disclosures we have made related to your health information upon your request.

    Ø Bill or collect for services either directly or through insurance or other third-party payers.

    Ø Communicate with courts as mandated by statutes, Rules, or Court decisions (IDMH and IDCFS).

    Mutual Responsibilities of DBHHC and Patient/Client:

    Ø Develop goals and timeframes for achievement.

    Ø Choosing and developing a treatment plan. Identifying and developing appropriate treatment alternatives.

    Ø Fulfilling any financial responsibility.

    All Rights Protected in accordance with:

    Ø Mental Health & Developmental Disabilities Code, Chapter Il, 2002; Health Insurance Portability and Accountability Act, 1996 (HIPAA); Mental Health & Developmental Disabilities Confidentiality Act, 2002

    Telehealth:

     

    Ø Dabney Behavioral Health Hospital clinical therapists and staff may communicate with me electronically to provide services via video conference platforms, email, or telephone.

     

    Ø I am aware that there is some level of risk that third parties might be able to read unencrypted emails and other media. I further agree that I am responsible for providing Dabney Behavioral Health Hospital and its agents with any updates to my email and/or mobile phone number or other media access points.

     

    Ø I understand that some therapy sessions may be recorded for training purposes.

    INFORMED CONSENT FOR TELEMEDICINE SERVICE
    INTRODUCTION

    Telemedicine involves using electronic communications to enable healthcare providers at different locations to share individual patient medical information to improve patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up, and/or education and may include any of the following:

    Patient medical records
    Medical images
    Live two-way audio and video
    Output data from medical devices and sound and video files
    Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.

    EXPECTED BENEFITS

    Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
    More efficient medical evaluation and management.
    Obtaining the expertise of a distant specialist.
    POSSIBLE RISKS

    As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

    In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making by the physician and consultant(s);
    Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
    In infrequent instances, security protocols could fail, causing a breach of privacy of personal medical information;
    In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

    BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

    I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine that identifies me will be disclosed to researchers or other entities without my consent,
    I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time without affecting my right to future care or treatment,
    I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction and may receive copies of this information for a reasonable fee,
    I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time. (name of Physician) has explained the alternatives to my satisfaction,
    I understand that telemedicine may involve electronically communicating my personal medical information to other medical practitioners who may be located in other areas, including out of state.
    I understand that it is my duty to inform (name of Physician) of electronic interactions regarding my care that I may have with other healthcare providers.
    I understand that I may expect the anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed or assured.
    I attest that I am located in the State of California or Illinois and will be present in the State of California or Illinois during all telehealth encounters with (Dabney Behavioral Health Clinicians).


    PATIENT CONSENT TO THE USE OF TELEMEDICINE

    I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

    I understand a copy of this form will be available for me to print.

    I hereby authorize (name of Physician) to use telemedicine in the course of my diagnosis and treatment.

    Cost of Services

    (All fees are subject to change without notice. A copy of updated fee schedules can be requested from the office staff)

     

    Ø IATP (Individual Assessment Treatment Planning) is billed at $90.00 per 15-minute increment.

    (CPT Code: H2000)

    Ø Clinical Testing and Assessment is billed $ 90.00 in 15-minute increments. (CPT Code: H2000)

    Ø Individual Therapy is billed at $55.00 per 15-minute increment. (CPT Code: H0004)

    Ø Family Therapy is billed at $55.00 per 15-minute increment. (CPT Code: H0004)

    Ø Crisis Intervention is billed at $95.00 per 15-minute increment. (CPT Code: H2011)

    Ø Documentation Fee (i.e., documents for workers' compensation, educational or clinical collaboration) $137.76 per document request.

    Private Pay (Individuals without healthcare insurance or with policies not Accepted by DBHHC):

    Ø $360 for IATP intake mental health assessment and evaluation per session, in addition to Clinical Testing and Assessment, is billed at $ 90.00 in a 15-minute increment.

    Ø $220 per session plus $55.00 in 15-minute increments after the first hour.

    All fees and/or insurance Co-pays are due at the time of service unless Dabney Behavioral Health Hospital has approved prior arrangements. If a client’s account is more than 30 days past due, DBHHC reserves the right to proceed with collection actions and to hold the client liable for collect fees, including but not limited to attorney and court costs.

    Credit Card Convenience Fee

    Effective February 2022, the DBHHC will be changing a convenience fee of (3.75%) or a minimum of $2.00 for each credit card transaction processed. No transaction fee will be assessed on cash, check, or electronic payments made at our location(s). 

    Electronic Signature:

    The ESIGN Act is a federal law passed in 2000. It grants legal recognition to electronic signatures and records if all parties to a contract choose to use electronic documents and sign them electronically. Dabney Behavioral Health Hospital permits patients/clients to sign their documents electronically by providing identification and verbal consent to a Dabney Behavioral Health Hospital representative. 

     

    Minor/Dependent Information

     Adolescent’s privacy:

    I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress and/or may be asked to participate in therapy sessions as needed. I understand that I will be informed about situations that could endanger my child. In these circumstances, I know this decision to breach confidentiality is up to the therapist’s professional judgment and may sometimes be made in a confidential consultation with their consultant/supervisor.

     

    Authorization Form to Provide Services

     

    Consent for Services/Treatments: I consent to the treatment provided by Dabney Behavioral Health Hospital and its affiliates/agents, employees, contractors, or designees. I authorize the mental and physical health services deemed necessary or advisable by caregivers to address my needs or my child’s needs.

    Authorization for Release of Personal Health Information: I authorize Dabney Behavioral Health Hospital and its affiliates/agents, employees, contractors, or designees to disclose my personal health information for the purpose of diagnosing or providing my treatment, obtaining payment for my care, or for the purposes of conducting the healthcare operations of the Service Provider. I authorize the Service Provider to release any information required in the process of applications for financial coverage for services rendered. This authorization allows the provider to release clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent/agency.

    Assignment of Insurance Benefits/Payment Guarantee/Collection Fees: I authorize payment to be made direct to the Service Provider for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the cost of collection, including a reasonable attorney fee.

    Complete if No Insurance, HMO, or Private Insurance coverage: Receiving DHS Funding – The Department of Human Services may pay for some or all of the cost for your mental health services.

    I authorize the Service Provider to bill the DHS for my services. I understand the provider will report demographic, household income, and mental health services information to the Illinois Department of Human Services.

    I Do Not authorize the Service Provider to bill DHS for my services, and I understand the provider will not report demographic, household income, and mental health service information to the Illinois Department of Human Services.  (           ) Initial and Date:__________________________________________________

    Privacy Policy: I acknowledge having received a copy of this document. I understand my rights include the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record. I understand that I may revoke my consent to release my healthcare information in writing, except to the extent the Service Provider has already made disclosures with my prior consent.

    Inactive Client/Patient Treatment plans

    Please note that all patient “Treatment Plans” must be updated every 6 months, and failure to schedule and complete a re-assessment will result in the patient being discharged from DBHHC. If discharged and the former patient wants to seek additional mental health services, they can request a new patient intake.

    Moreover, DBHHC does provide clinical training for graduate degree students seeking to complete their internship, practicum, and clinical licensure hours required to complete their educational or professional degree program and/or licensure.

    Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as you progress with therapy, you can ask your therapist or the agency’s administration at any time.
    Acknowledgment

    My signature on this document represents that I have received the Consent for Services form and that I understand and agree to the information therein. Further, I consent to use an electronic signature to acknowledge this agreement.

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  • Notice of Privacy Practices

  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    Corey & Cynthia F. Dabney Behavioral Health (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.


    YOUR RIGHTS
    Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

    To inspect and copy PHI.
    • You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
    • The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

    To amend PHI.
    • You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
    • The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

    To request confidential communications.
    • You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

    To limit what is used or shared.
    • You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
    • If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
    • You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

    To obtain a list of those with whom your PHI has been shared.
    • You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

    To receive a copy of this Notice.
    • You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

    To choose someone to act for you.
    • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

    To file a complaint if you feel your rights are violated.
    • You can file a complaint by contacting the Practice using the following information:
    Dr. Corey Dabney
    845 W. 69th Street, Chicago, IL 60621
    773-651-6809
    • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
    • The Practice will not retaliate against you for filing a complaint.

    To opt out of receiving fundraising communications.
    • The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

    OUR USES AND DISCLOSURES
    1. Routine Uses and Disclosures of PHI
    The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

    To treat you.
    • The Practice can use and share PHI with other professionals who are treating you.
    • Example: Your primary care doctor asks about your mental health treatment.

    To run the health care operations.
    • The Practice can use and share PHI to run the business, improve your care, and contact you.
    • Example: The Practice uses PHI to send you appointment reminders if you choose.

    To bill for your services.
    • The Practice can use and share PHI to bill and get payment from health plans or other entities.
    • Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

    2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
    The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

    To help with public health and safety issues
    • Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
    • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
    • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
    • Serious threat to health or safety: To prevent a serious and imminent threat.
    • Abuse or Neglect: To report abuse, neglect, or domestic violence.

    To comply with law, law enforcement, or other government requests
    • Required by law: If required by federal, state or local law.
    • Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
    • Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
    • Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
    • National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
    • Workers' Compensation: To comply with workers' compensation laws or support claims.

    To comply with other requests
    • Coroners and Funeral Directors: To perform their legally authorized duties.
    • Organ Donation: For organ donation or transplantation.
    • Research: For research that has been approved by an institutional review board.
    • Inmates: The Practice created or received your PHI in the course of providing care.
    • Business Associates: To organizations that perform functions, activities or services on our behalf.

    3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
    Unless you object, the Practice may disclose PHI:

    To your family, friends, or others if PHI directly relates to that person's involvement in your care.

    If it is in your best interest because you are unable to state your preference.

    4. Uses and Disclosures of PHI Based Upon Your Written Authorization
    The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

    Marketing, sale of PHI, and psychotherapy notes.

    You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.


    OUR RESPONSIBILITIES
    • The Practice is required by law to maintain the privacy and security of PHI.
    • The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
    • The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website [www.dbhhc.org or in the patient portal].
    • The Practice will inform you if PHI is compromised in a breach.

    This Notice is effective on 06/15/2024.

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  • Patient Portal Usage Agreement

  • Introduction and Purpose

    Welcome to DBHHC's Patient Portal! This portal is your lifeline for accessing services, updating information, and communicating with our practice. Just as you used the portal during the intake process to provide vital information, this process will continue throughout your time as a patient. To ensure uninterrupted services, it's essential to promptly review and update any new documents or information when you log in.

    Patient Responsibilities

    Timely Updates: You are required to review and update your information whenever new documents are made available on the portal. Failure to do so may affect your ability to receive services from DBHHC.

    Emergency Protocol: Please be aware that DBHHC does not provide 24/7 emergency services. If you experience any healthcare emergencies, immediately dial 911 and/or visit your nearest emergency room.

    Telehealth Guidelines

    To ensure a successful telehealth experience, please adhere to the following:

    Appropriate Background: Ensure that your surroundings are appropriate for a clinical session.
    Private Location: Participate in a private setting to maintain confidentiality.
    Preparedness: Be prepared and on time for your scheduled sessions.
    Camera On: Your camera must be on during the session.
    Appropriate Dress: Dress appropriately for a professional setting.
     

    Attendance Policy for Telehealth Sessions

    It is important to attend all scheduled telehealth sessions. Missing three sessions may result in discharge from our services. To avoid a session being marked as missed, patients must notify their therapist prior to the scheduled appointment time if they need to cancel or reschedule.

    HIPAA Compliance

    To maintain the highest standards of patient privacy, please follow these guidelines:

    Communication Guidelines: Do not send personal information via email or SMS texting. Use the secure Messages system within the TherapyNotes Patient Management System for all communications.
    Quality Management: All communication must be HIPAA-compliant to protect your privacy and the integrity of our services.
     

    Mandatory Reporter Disclosure

    As a Mandatory Reporter, I am legally required to report any suspected child or elder abuse or neglect. Reports will be made to the Illinois Department of Children and Family Services for minors or the Illinois Department of Aging for adults. This is done to ensure everyone's safety.

    Additionally, if there is any indication that you are a danger to yourself or others, I am obligated to take appropriate action, which may include reporting to relevant authorities to ensure your safety.

    Crisis Management

    If you or someone in your care is in crisis or experiencing suicidal ideations, please contact the CARES Hotline for a Mobile Crisis Response unit evaluation and/or dial 911:

    CARES Hotline: 1-800-345-9049
    TTY (Toll-Free): 1-866-794-0374
     

    Additional Insurance Information 

    Co-Pay Requirements: If your insurance requires a co-pay, a valid credit card must be on file. The card will be charged after your appointment. If funds are not available, therapy sessions cannot continue.
    Medicaid Insurance: Medicaid typically does not require a co-pay. Although your billing portal may reflect a high cost, this will be adjusted based on insurance payments and other internal adjustments. In most cases, Medicaid patients do not receive a bill.
    Patient Responsibility: If at any time an insurance company fails to pay for services rendered, the patient is responsible for the account balance.

    Acknowledgment and Agreement

    By signing below, you confirm that you understand and agree to the terms outlined in this document. You acknowledge that the patient portal is a critical tool for receiving services and that you will comply with all requirements to maintain access to those services.

    I understand the importance of updating my information promptly.
    I agree to follow the telehealth guidelines and HIPAA compliance policies.
    I acknowledge the crisis management protocol and understand what to do in an emergency.

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