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                                         Group Therapy Informed Consent Form                                    

Welcome to Group Therapy!

Please read through the information below and feel free to ask your questions about our sessions and/or anything about us. Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about the therapy.

WHAT IS GROUP THERAPY

Group Therapy is a unique kind of therapy where a group of people who are likely experiencing similar challenges in the period of their lives gets together to share their difficulties which as a result give and at the same time, receive help from each other.

We make sure to maintain a safe environment that is conducive both for sharing and accepting each other where each can grow and trust one another and where each and everyone will feel respected and valued.

CONFIDENTIALITY

We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Certain limitations are as follows:

Threatening one's self or another that may result in physical harm;
An act of physical or emotional abuse against a child or any person;
Sexual abuse against a child where the child is living with the abuser;
Whenever we are summoned by court order to disclose information against a participant. However, we shall notify you and let you exercise your privilege in the right to deny the disclosure of your records with us.
Your prior written consent to release records.

CONDUCT AND RELATIONSHIP

For the safety it is necessary that the following is required to be complied with by its members:

Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members; Members should maintain positivity and not induce disrespect among others;Members should not be drunk, nor they are allowed to take alcohol or take drugs before or after therapy; Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior. Refrain from having a relationship with a fellow member other than therapeutic while engaged in the session.

THE THERAPIST(S)

The therapists should maintain a professional relationship with the participants all the time and no more than that. Any relationship with a participant may result in a "dual relationship" and may affect the goals of the session.

WHAT TO EXPECT

The sessions consist of processing on the issues that a member is involved where the others will give their feedback and reaction towards the said issue. This helps each member understand the issue from a different perspective in order to understand others. This also helps with one's reflection about his or her situation which can then help for insight and personal growth.
 
CONSENT

I agree to adhere to the norms and expectations for group therapy as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction.

                                TELEHEALTH INFORMED CONSENT                       
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services,medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electroniccommunications. Telephoneconsultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services. I understand that telehealth involves the communication of my medical/mental health. I understand that I may opt out of the telehealth visit at any time. This will not change my. I understand that telehealth services can only be provided to patients, including myself,
I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:

• It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
• Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
• Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.

I agree that information exchanged during my telehealth visit will be maintained bythe doctors, other healthcare providers, and healthcare facilities involved in my care. I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records). I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. I understand that I must take reasonable steps to protect myself from unauthorized use. The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.

I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit. I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.I understand that electronic communication cannot be used for emergencies or time
sensitive matters.I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit. I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.). I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications. By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.

To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.

                NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES   

Last Updated/Effective Date: October 28, 2025

This Notice of Health Information Privacy Practices or “Notice” describes how Vested Mental Health Services, LLC may useand disclose your health information and how you can access this information. In this Notice, we use terms like“we,” “us” or “our” or “Vested" or "Vested Mental Health Services” to refer to Vested Mental Health Services, LLC and its affiliates. Please review this Notice carefully.

Psychotherapy Notes

Psychotherapy notes are created by mental health professionals to document or analyze conversations during private, group, joint, or family counseling sessions. Psychotherapy notes are kept separate from medical records.These notes exclude medication prescriptions, session times, treatment modalities, clinical test results, and
summaries of diagnosis, treatment plans, symptoms, prognosis, or progress.
Due to their sensitive nature and limited utility for most healthcare operations, psychotherapy notes require patient authorization for disclosure, including for treatment by another provider. Patients or their representatives may be denied access to these notes under the Privacy Rule. If Psychotherapy Notes are created for your treatment, we need your written authorization to use or disclose them,
unless:

(1) the creator needs them for treatment,

(2) they are used in supervised mental health training, or

(3) they are used in defending a proceeding you bring. Psychotherapy Notes are recorded by mental health professionals to document or analyze conversations during private, group, joint, or family counseling sessions and are kept separate
from medical records. They exclude medication details, session times, treatment modalities, test results, and summaries of diagnosis, treatment plans, symptoms, prognosis, or progress. If your provider believes providing copies could be harmful, they may deny your request.

Substance Use Disorder (SUD) Medical Records

Vested Mental Health Services, LLC’s SUD treatment records cannot be used for investigation or prosecution without written consent or a court order. Records used in audits or evaluations also require patient consent or a court order to be disclosed. Separate consent is required for using or sharing SUD counseling notes.
Vested Mental Health Services, LLC may use a single SUD records authorization for future treatment, payment, and operations. Records disclosed to HIPAA-covered entities may be redisclosed per HIPAA rules. De-identified SUD records may be shared with public health authorities. SUD records and testimony are protected in legal proceedings without consent or a court order. Unauthorized disclosures will be reported per applicable laws. SUD patients have rights under the HIPAA Privacy Rule, including requesting restrictions on disclosures to health plans for services paid in full, obtaining a disclosure accounting for the past three years, and opting out of
fundraising communications. Clinicians may use discretion when granting access to SUD records.

How and Why We Protect Your Privacy

We understand that information about you and your health is personal. By “health information,” we mean protected health information as defined under federal law (the Health Insurance Portability and Accountability Act,or HIPAA, and its implementing regulations). Not only is it our legal obligation, but it is our business imperative to
ensure the confidentiality of your health information. We continuously seek to safeguard your health information through administrative, physical, and technical means, and otherwise abide by applicable federal and state laws.

How We Collect and Maintain Your Health Information

The health information that we collect or maintain may include:

● Your name, age, date of birth, insurance policy information, email address, username, password, and other registration information. Health information that you provide us, which may include information or records relating to your medical or health history, health status and laboratory testing results, diagnostic images, and other health-related
information

● Health information about you prepared or obtained by the Healthcare Professionals(s) who provide clinicalservices through our electronic health record, such as medical and therapy records, treatment andexamination notes, and other health-related information.

● Billing information that you provide us, such as credit card information, or that we receive from a health plan, employer or other provider of healthcare benefits on your behalf.

How We Use and Disclose Health Information

We use and disclose your health information for the normal business activities that the law sees as falling in the categories of treatment, payment, and healthcare operations. Generally, we do not need your permission for these disclosures under applicable laws. Below we provide examples of those activities, although not every use or disclosure falling within each category is listed:

1. Treatment – We keep a record of the health information you provide us. This record may include your test results, diagnoses, medications, your response to medications or other therapies, and information we learn about your medical condition through therapy or psychiatry services. We may disclose this information so that other doctors, nurses, and entities such as laboratories can meet your healthcareneeds.

2. Payment – We document the services and supplies you receive when we are providing care to you so that you, your insurance company, or another third party can pay us. We may tell your health plan about upcoming treatment or services that require prior approval by your health plan.

3. Health Care Operations – Health information is used to improve the services we provide, to train staff, for business management, quality assessment and improvement, and for customer service. For example, we may use your health information to review our treatment and services and to evaluate the performance of
our staff in caring for you.

4. Marketing – By agreeing to our Privacy Policy, you authorize us to contact you with newsletters, educational materials, marketing, promotional materials, and other information we believe may be helpful  to you. We may also use and disclose your health information to:

● Comply with federal, state, or local laws that require disclosure.
● Assist in public health activities, such as tracking diseases or medical devices.
● Inform authorities to protect victims of abuse or neglect.
● Comply with federal and state health oversight activities, such as fraud investigations.
● Respond to law enforcement officers or court orders, subpoenas or other processes.
● Inform coroners, medical examiners and funeral directors of information necessary for them to fulfill their
duties.
● Facilitate organ and tissue donation or procurement.
● Conduct research following internal review protocols to ensure the balancing of privacy and research needs.
● Avert a serious threat to health or safety.
● Assist in specialized government functions, such as national security, intelligence, and protective services.
● Inform military and veteran authorities if you are an armed forces member (active or reserve).
● Inform a correctional institution if you are an inmate.
● Inform workers’ compensation carriers or your employer if you are injured at work.
● Recommend treatment alternatives.
● Tell you about health-related products and services.
● Communicate within our organization for treatment, payment, or healthcare operations.
● Communicate with other providers, health plans, or their related entities for their treatment or payment activities, or health care operations activities relating to quality assessment and improvement, care coordination, and the qualifications and training of healthcare professionals.
● Disclose health information to funeral directors, medical examiners, or coroners as required for their duties. After 50 years post-death, health information may be used or disclosed without restrictions.
● Provide information to other third parties with whom we do business, such as a record storage provider.
However, you should know that in these situations, we require third parties to sign a legal Business Associate Agreement (BAA) in order to attest that they will safeguard your information.
● We may also use or disclose your personal or health information for operational purposes. For example, we may communicate with individuals involved in your care or payment for that care, such as family or guardians, and send appointment reminders.All other uses and disclosures, not previously described, may only be done with your written authorization. Youmay revoke your authorization at any time; however, this will not affect prior uses and disclosures. In some cases,
state law may require that we apply additional protections to some of your health information.

Our Healthcare Professionals’ Responsibilities

We are required by law to:
● Maintain the privacy of your health information.
● Provide this Notice of our duties and privacy practices.
● Abide by the terms of the Notice currently in effect.
● Tell you if there has been a breach compromising your health information.

We reserve the right to change our privacy practices, and make the new practices effective for all the information that we maintain. Your Federal Rights

The law entitles you to:
● Inspect and copy certain portions of your health information. We may deny your request under limited circumstances. You may request that we provide your health records to you in an electronic format.
● Request amendment of your health information if you feel the health information is incorrect or incomplete. However, under certain circumstances we may deny your request.
● Receive an accounting of certain disclosures of your health information made for the prior six (6) years, although this excludes certain disclosures for treatment, payment, and health care operations. (Fees may apply to this request.)
● Request that we restrict how we use or disclose your health information. However, we are not required to agree with your requests, unless you request that we restrict information provided to a payor, the disclosure would be for the payor’s payment or healthcare operations, and you have paid for the health care services completely out of pocket.
● Request that we contact you at a specific telephone number or address.
● Obtain a paper copy of this notice even if you receive it electronically.

We may ask that you make a request in writing.

How to File a Complaint
If you believe that your privacy has been violated, you may file a complaint with us or with the US Department of Health and Human Services. We will not retaliate or penalize you for filing a complaint with us or the Secretary. To file a complaint with us or receive more information contact:

Phone: (216) 406-8937
Email: cwoodall@vestedmhs.com

To file a complaint with the Secretary of Health and Human Services:

Phone: (800) 537-7697
File an online complaint: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Address: 200 Independence AVE, S.E., Washington, DC 20201

                                                           Consent to Evaluate/Treat                                          

1. Consent to Evaluate/Treat  

The evaluation or treatment will be conducted by a psychotherapist, a psychologist, a psychiatric nurse practitioner, a psychiatrist, a licensed therapist or an individual supervised by any of the professionals listed. Treatment will be conducted within the boundaries of Ohio Law for Psychological, Psychiatric, Nursing, Social Work, Professional Counseling, or
Marriage and Family Counseling. I voluntarily consent that my child /myself will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by staff from Life Anew Behavioral Health Inc. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:

a. The Benefits of the proposed treatment
b. Alternative treatment modes and services
c. The manner in which treatment will be administered
d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
e. Probable consequences of not receiving treatment

2. Benefits to Evaluation/Treatment

Evaluation and treatment may be administered with psychological interviews, psychologicalassessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. I may be beneficial to my child or myself, as well as the referring professional, to understand the nature and cause of any
difficulties affecting me or my child’s daily functioning so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic performance, health status, quality of life, and awareness of strengths and limitations.

3. Charges

Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. I will
be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to me upon
request.

4. Confidentiality, Harm, and Inquiry

Information from me or my child’s evaluation and/or treatment is contained in a confidential medical record at Life Anew Behavioral Health Inc., and I consent to disclosure for use Life Anew Behavioral Health Inc. staff for the
purpose of continuity of me or any child’s care. Per Ohio mental health law, information provided will be kept confidential with the following exceptions: 1) if me or my child are deemed to present a danger to ourselves or others; 2) if concerns about possible abuseor neglect arise; or 3) if a court order is issued to obtain records.

5. Right to Withdraw Consent

I have the right to withdraw my consent for evaluation and/or treatment of my child at any time by providing a written request to the treating clinician.

6. Expiration of Consent

 This consent to treat will expire 12 months from the date of signature, unless otherwise specified.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation
and treatment. I also attest that I have the right to consent for treatment I understand that I have the right to ask questions of my service provider about the above information at any time.