Non-discrimination Notice
Relate Counseling Center does not discriminate on the basis of race, color, national origin, sex, age, or disability. We provide accommodation for people with disabilities in a timely manner and free of charge when they are needed to perform services. Relate provides language assistance services for people with limited English proficiency, also free of charge. Please alert us if you would benefit from any accommodation.
If you have any concerns about our policies, please contact the Human Resources Director at Relate Counseling Center by calling 951-932-7277. You may also file a complaint with the Office for Civil Rights by email: OCRformsubmissions.dot@state.mn.us or phone: 651-366-3073.
Consent for Treatment:
• I consent to treatment with Relate Counseling Center and agree to all policies stated.
• A guardian(s) must give consent for treatment of a minor. Relate Counseling Center may require copies of court documentation related to custody and guardianship in order to validate consent.
• I acknowledge that I have access to the "Clients Rights and Responsibilities" and the "Notice of Privacy Practices," located on the Relate website: https://www.relatemn.org/about/intake-notices/
My signature indicates that I understand that federal regulations require that Relate Counseling Center obtains proof that I have received the information in the Notice. My signature does not indicate that I have read the Notice or agree with its contents.
• I understand that E-mail or texting is not a form of therapy or counseling and that Relate makes no guarantee of a response within any specific time frame. Therefore nothing of an urgent nature should ever be sent via e-mail or text.
• I acknowledge that email and texts are not encrypted, and therefore are not confidential. I understand the risk for compromised confidentiality and accept the risk of loss of privacy of confidential information associated with communication by electronic means. Relate Counseling Center bears no responsibility for possible loss of privacy or confidentiality by anything communicated through e-mail.
• Relate Counseling Center uses text messages and/or email messages for appointment reminders. I understand that I can “opt out” of these reminders at any time by contacting a staff member at Relate Counseling Center.
• I understand that I need to give at least 24 hour notice when cancelling or rescheduling an appointment. If I fail to do so, I will be subject to a $50 charge for the session. Relate Counseling Center also reserves the right to restrict scheduling to no-shows, cancellations, and delinquent accounts. Please note that insurance companies do not pay for missed appointments.
• I understand that if a clinician or other member of Relate Counseling Center is required, by subpoena or other means of summoning, to appear in court on my behalf that I will be responsible for a fee for all time and costs associated, including but not limited to deposition time, attorney meetings and calls, travel time, preparation time, research, costs for copying records, time in court, etc. Cost will be $130/hour for therapy and $250/hour for psychiatry.
• I understand that any verbal or physical aggression towards any person working for Relate Counseling Center or clients receiving services at Relate Counseling Center may be grounds for immediate termination of services.
• I agree to have my credit card information saved in Relate Counseling Center’s Merchant Services account. I understand that Relate Counseling Center will never charge my card without prior approval from me. (Not required for services at Relate Counseling Center)
Consent for Telehealth Services:
Telehealth allows my therapist to diagnose, consult, treat and educate using interactive audio, video and/or data communication regarding my treatment. I hereby consent to participating in psychotherapy via the internet. I understand I have the following rights under this agreement:
• I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person.
• I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger.
• Further, I understand that the dissemination of any personally identifiable images, or information from the Telehealth interaction, to any other entities shall not occur without my written consent.
• I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective.
• Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.
• In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.
Consent to bill Insurance:
Relate accepts commercial insurance as well as Medicare, Medical Assistance and Pre-Paid Medical Assistance Program insurance plans. Please bring your insurance cards to each appointment, so we may record your ID number and verify your eligibility information.
The cost of our services are covered by most health insurance plans, with the exception of certain HMO's. Insurance companies may NOT cover specified services such as treatment of marital, parent-child, or family problems, or treatment of bereavement. In this or any event in which insurance coverage is denied, you will be responsible for payment of fees. This includes all telehealth services. Please check with your insurance provider on telehealth coverage. We will submit claims for services to your insurance company. If for any reason your insurance, Medicare, Medical Assistance coverage, or financial circumstances change, we ask, if possible, you notify us 30 days prior to the change in status.
I hereby authorize payment directly to Relate Counseling Center for outpatient mental health benefits for services received by me or my dependents. I understand that I am fully and directly responsible to Relate for payment of services rendered, and my obligation to pay is not in any way contingent upon any insurance payments that I may or may not receive. I further understand that Relate does not accept responsibility for negotiating a settlement of disputed claims. It is agreed and understood that if an account balance should accrue, Relate has the right to suspend services and that if my account should become delinquent and Relate forwards my account to a collection agency and/or attorney, I, the responsible party, agree to pay collection costs, attorney fees, interest and court costs.
• I authorize Relate Counseling Center to disclose to my insurance company (if Medicaid, to the MN Medical Assistance Program), information concerning the nature and diagnoses, extent, dates, cost and outcomes of the services provided to me by this agency, for the purpose of payment of services, billing verification, and evaluation.
• I understand that my records are protected under state and federal confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations.
• I understand that I may revoke this consent at any time except to the extent that information has been released in good faith or release of information is a Service Line: edit condition of parole, probation, or court confinement. In any event, this consent expires automatically when my period of treatment ends and the financial liability for it has been satisfied, or within one year, whichever is earlier.
• I also understand that if I revoke this consent before any third-party payer or funding source has received data required for billing verification, I will assume full responsibility for the cost of the services provided to me. I understand that failure to pay my bill may result in my name being referred to a collection agency or a conciliation court.
Responsible Party is the party who completes and signs the intake and consent forms for themselves or their child.
If you have an agreement through the courts or other entities, it is up to the Responsible Party to recoup the amount owed to them by the other party.
I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction. I understand that I can withdraw my consent by providing written notification to Relate Counseling Center.
My signature below indicates that I have read this Agreement and agree to its terms.