I voluntarily consent to receive behavioral health and/or substance use counseling services from Scars to Strength Counseling. I understand that services may include individual counseling, case coordination, and clinically appropriate interventions delivered by qualified clinicians. Participation in therapy is voluntary, and I may withdraw consent at any time by notifying the practice in writing. Services may be provided via telehealth and/or in-person at the discretion of the client, clinician, clinical appropriateness, and office availability. Therapy outcomes cannot be guaranteed. This consent applies to all services provided by Scars to Strength Counseling unless otherwise revoked in writing. 

Limits of Confidentiality

Information shared during counseling sessions is confidential and will not be released without your written authorization except as required or permitted by law. Exceptions to confidentiality may include, but are not limited to:

• If there is reason to believe that you may pose a danger to yourself or others
• If there is suspected abuse, neglect, or exploitation of a child, elder, or disabled individual
• If records are subpoenaed or otherwise required by court order or legal proceeding
• If disclosure is necessary in the event of a medical or psychiatric emergency
• If coordination of care is clinically appropriate and authorized by you through a signed Release of Information
• If disclosure is otherwise required by federal or state law, including applicable reporting obligations

Scars to Strength Counseling makes reasonable efforts to protect the privacy and confidentiality of all client information in accordance with HIPAA and applicable state and federal regulations, including 42 CFR Part 2 when applicable to substance use treatment records.

I understand that Scars to Strength Counseling provides behavioral health and substance use counseling services via telehealth, which may include video conferencing, telephone sessions, and other secure electronic communication methods.

I understand that telehealth involves the use of electronic communications to enable healthcare providers at different locations to share information for the purpose of evaluation, diagnosis, consultation, treatment, and continuity of care.

I understand that the benefits of telehealth may include increased access to care, convenience, and continuity of services. I also understand that there are potential risks to telehealth, including but not limited to technical difficulties, interruptions, unauthorized access, or limitations in assessment due to the remote nature of services.

I understand that I am responsible for ensuring I am in a private, safe location during telehealth sessions and that confidentiality may be compromised if others are present or able to overhear the session. Client agrees to provide current physical location at the time of telehealth sessions upon request.

Telehealth services may only be provided while the client is physically located in states where the clinician is authorized to practice. If technological issues interrupt the session, the clinician may attempt to reconnect or continue by phone when appropriate.

I understand that telehealth services are not appropriate for emergencies. In the event of a mental health emergency, I agree to contact local emergency services by calling 911 or go to the nearest emergency room. 

I understand that I may withdraw my consent for telehealth services at any time by notifying Scars to Strength Counseling in writing, and that doing so will not affect my right to receive in-person services if available.

By signing below, I voluntarily consent to receive behavioral health and/or substance use counseling services via telehealth from Scars to Strength Counseling.

Financial Responsibility Agreement

I understand that I am financially responsible for all services provided by Scars to Strength Counseling, whether payment is made directly by me or billed to my insurance carrier.

I understand that insurance verification is a courtesy and does not guarantee payment. I understand that I am responsible for any portion of fees not covered by my insurance, including but not limited to copayments, coinsurance, deductibles, denied claims, or services deemed not medically necessary by my insurance provider.

I understand that I am responsible for providing accurate and current insurance information and for notifying Scars to Strength Counseling of any changes to my insurance coverage. Failure to do so may result in denied claims, for which I will be financially responsible.

Card on File Authorization

Client authorizes Scars to Strength Counseling to charge stored payment methods for copays, balances, no-show fees, or approved charges.

I understand that if my insurance carrier does not reimburse for services rendered, I am responsible for the full cost of the session.

I understand that payment is due at the time of service unless other arrangements have been made in writing.

Missed Appointments & Late Cancellations

I understand that appointments must be canceled or rescheduled at least 24 hours in advance. Appointments canceled with less than 24 hours’ notice or missed without notice may be subject to a cancellation fee. I understand that this fee is not billable to insurance and is my responsibility.

Billing & Account Balances

I understand that unpaid balances may result in suspension of services until the balance is resolved. I understand that I may request clarification regarding charges or billing at any time.

By signing below, I acknowledge that I have read, understand, and agree to the financial responsibility and payment terms outlined above.

I acknowledge that I have been provided with, or have been given access to, the Notice of Privacy Practices for Scars to Strength Counseling.

I understand that the Notice of Privacy Practices describes how my protected health information (PHI) may be used and disclosed for purposes of treatment, payment, and healthcare operations, as well as my rights regarding my protected health information.

I understand that Scars to Strength Counseling is required by law to maintain the privacy and security of my protected health information and to abide by the terms of the Notice of Privacy Practices currently in effect.

I understand that I have the right to request restrictions on certain uses or disclosures of my protected health information, to request confidential communications, to inspect and obtain copies of my records, and to request amendments to my protected health information, as outlined in the Notice of Privacy Practices.

I understand that a full copy of the Notice of Privacy Practices is available upon request and may also be provided electronically through the client portal or practice website.

I understand that I may request a paper copy of the Notice of Privacy Practices at any time, even if I have agreed to receive it electronically.

By signing below, I acknowledge that I have received, read, and understand the Notice of Privacy Practices for Scars to Strength Counseling.

I authorize Scars to Strength Counseling to disclose and/or obtain information related to my treatment for the purpose indicated below.

I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations unless otherwise protected by law. I understand that this authorization will expire on the date listed above unless revoked earlier.

Emergency & Crisis Acknowledgment

I understand that Scars to Strength Counseling does not provide emergency or crisis services.

I understand that if I am experiencing a mental health emergency, I should contact local emergency services by calling 911 or go to the nearest emergency room.

I understand that if I am in crisis outside of scheduled sessions, I may contact the 988 Suicide & Crisis Lifeline by calling or texting 988, or use other local crisis resources available in my area.

If I attend services in person and experience a medical or psychiatric emergency while onsite, I understand that Scars to Strength Counseling staff may contact emergency services or designated emergency contacts when clinically appropriate or necessary for safety.

By signing below, I acknowledge that I understand and agree to follow these emergency and crisis procedures.

Supervision Disclosure

I understand that counseling services at Scars to Strength Counseling may be provided by clinicians practicing under supervision in accordance with state regulations.

I understand that supervision may include consultation, case discussion, and review of clinical documentation to ensure quality of care.

I understand that the supervising clinician is Gregorit Sanchez, LADC1, Clinical Supervisor and that I have the right to request information regarding the supervision process or to contact the supervisor if needed.

Clients will be informed of the name and credentials of their treating clinician and supervising clinician when applicable.

By signing below, I consent to receive services under this supervision model.

Professional Conduct & Safety

Scars to Strength Counseling is committed to maintaining a safe, respectful, and therapeutic environment for all clients and staff. Threatening behavior, harassment, discrimination, intimidation, possession of weapons, destruction of property, or aggressive conduct toward clinicians, staff, or other individuals may result in termination of services and/or contact with emergency services or law enforcement when appropriate.

Clients are expected to attend sessions free from the influence of alcohol or non-prescribed substances when clinically appropriate for outpatient treatment participation. If a clinician determines that a client is unable to safely or effectively participate in a session due to intoxication or impairment, the session may be rescheduled or terminated.

Attendance & Late Arrival Policy

Clients are encouraged to arrive on time for all appointments. Sessions may be shortened if a client arrives late in order to maintain the scheduled treatment calendar. Repeated missed appointments, excessive cancellations, or ongoing attendance issues may impact continuation of services.

Waiting Room & Confidentiality

To protect client privacy and confidentiality, clients are asked to respect the privacy of others in common areas and avoid discussing confidential information in the waiting room or shared office spaces.

Illness & Infection Control

If a client is experiencing symptoms of a contagious illness, including fever, vomiting, flu-like symptoms, or other potentially infectious conditions, telehealth services may be recommended when clinically appropriate.

Children, Guests, & Visitors

Unless previously discussed and clinically appropriate, clients are asked not to bring additional individuals, children, or guests to appointments due to confidentiality, space, and safety considerations.

Recording Policy

Audio, video, or photographic recording of sessions is prohibited unless explicitly authorized in writing by the treating clinician.

Telehealth Backup Procedures

If technical issues interrupt a telehealth session, Scars to Strength Counseling may attempt to reconnect using the agreed-upon contact method, including telephone communication when clinically appropriate and permitted.

Scars to Strength Counseling is committed to providing accessible and inclusive behavioral health services. Clients may request reasonable accommodations related to physical accessibility, communication needs, language assistance, or other support needs to facilitate participation in services.

Client Attestation

I attest that the information I have provided throughout this intake process is accurate and complete to the best of my knowledge.

I understand that providing false, incomplete, or outdated information may impact my treatment, billing, or continuity of care.

By signing below, I confirm my understanding and agreement with all information and policies presented in this intake packet.