Forever Young Counseling
1645 Parkhill Dr. • Billings, Montana 59102
Nature of Psychotherapy Services
Psychotherapy is a collaborative process between you (and/or your child) and your therapist aimed at improving emotional well-being, mental health, and overall functioning. Treatment may include individual, family, or group therapy approaches tailored to each client's needs.
Therapy can involve discussing personal and sometimes difficult topics. While most clients find therapy beneficial, it is important to understand that results cannot be guaranteed. Some clients may experience temporary discomfort when exploring challenging emotions or life experiences. Your therapist will work with you to manage these experiences in a safe and supportive environment.
Therapeutic approaches used at this clinic may include, but are not limited to:
• Cognitive-Behavioral Therapy (CBT)
• EMDR
• Relational Therapy
• Dialectical Behavior Therapy Interventions (DBT Skills+)
• Family Systems Therapy
• Mindfulness-Based Interventions
• Solution-Focused Brief Therapy
Consent for Treatment
By signing this form, you (and/or the parent or legal guardian of a minor client) voluntarily consent to participate in psychotherapy services provided by [Clinic Name] and its licensed or supervised clinicians. You understand that you may withdraw consent and discontinue services at any time, with the understanding that proper clinical closure is recommended.
For adult clients (18 and older): Your signature at the end of this document constitutes informed consent for your own treatment.
For minor clients (under age 18): A parent or legal guardian with legal authority to consent to mental health treatment must sign this form.
Consent for Treatment of Minor Clients
Parental/Guardian Authorization
Montana law (Mont. Code Ann. § 53-21-112 and related statutes) requires that a parent or legal guardian provide written consent for mental health treatment of a minor under the age of 18, with limited exceptions noted below. By signing this form, you represent that you have legal authority to consent to mental health treatment for the minor named above.
If you share legal custody of the minor client, please indicate in one of the above text boxes.
I am the sole legal custodian and have full authority to consent to treatment.
I share joint legal custody. I represent that I am authorized to consent independently to mental health treatment under our custody agreement.
A court order or other legal document governs custody. A copy is attached or on file.
Montana Minor Consent Exceptions
Under Montana law, minors may have the right to consent to certain services without parental/guardian consent, including:
• Outpatient mental health treatment when a parent or guardian is not available and the minor is in crisis (Mont. Code Ann. § 53-21-112)
• Substance use disorder treatment (Mont. Code Ann. § 53-24-301)
• Sexual assault crisis services
If any of these exceptions apply or are believed to apply to your situation, please notify your therapist.
Participation of the Minor
We believe that children and adolescents benefit most from therapy when they are willing participants. While parental consent is legally required, we encourage parents and guardians to discuss treatment openly with their child. Our therapists will also work to engage minor clients in a developmentally appropriate way, explaining what therapy is and inviting their questions and input.
Confidentiality and Minor Clients
Maintaining an appropriate degree of privacy for minor clients is often essential to the therapeutic relationship and treatment effectiveness. Our general approach is as follows:
• Parents/guardians will receive general progress updates and information necessary to support their child’s treatment at home and in school.
• The specific content of therapy sessions with minors (especially adolescents) will generally be kept confidential, except as noted in Section 5 (Limits of Confidentiality).
• Your therapist will discuss expectations about privacy at the outset of treatment and will work collaboratively with you and your child to establish guidelines that support both the therapeutic relationship and family communication.
• If a minor client’s safety or welfare is at risk, the therapist will involve parents/guardians and/or other appropriate parties regardless of confidentiality agreements.
Access to Records for Minor Clients
Parents and legal guardians generally have the right to access their minor child’s treatment records under Montana law. However, a therapist may limit access if disclosure would be harmful to the child’s treatment or well-being. Questions about records access should be directed to your therapist or our clinic administrator.
Upon a minor reaching the age of 18, they become the holder of their own records and must provide written authorization for others, including parents, to access those records.
Non-Custodial Parent Access
If there are custody arrangements, court orders, or legal restrictions relevant to the minor’s care, please inform your therapist before services begin. We will request copies of any relevant legal documents. We are unable to share information with a non-custodial parent whose access to the minor’s records or treatment is legally restricted.
Confidentiality
What you share in therapy is confidential. Your therapist will not share information about your treatment without your written authorization, except in the legally required circumstances described below. We comply with all applicable state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) and Montana state law.
Information may be shared without your authorization:
• When a client discloses intent to seriously harm themselves or another identifiable person
• When there is reasonable suspicion of child abuse, neglect, or exploitation (mandatory reporting under Mont. Code Ann. § 41-3-201)
• When there is reasonable suspicion of abuse, neglect, or exploitation of a vulnerable adult or elder
• When ordered by a court of law
• When a client is gravely disabled and unable to care for themselves
• As required for billing and insurance purposes (limited to the minimum necessary)
• When coordinating care with other treating providers with appropriate authorization
Mandatory reporters: All clinicians at this clinic are mandatory reporters under Montana law and are required to report suspected child abuse or neglect to the Montana Child and Family Services Division (CFSD) or law enforcement.
Professional Boundaries and Communication
Your therapist’s relationship with you is a professional therapeutic relationship. To maintain appropriate boundaries and the integrity of treatment:
• Our therapists do not accept friend or connection requests on personal social media accounts.
• Sessions are conducted in the clinic, via secure telehealth platform, or in other clinically appropriate settings.
• Physical contact in sessions is limited to a handshake or brief, clinically appropriate touch (e.g., with young children in play therapy), as appropriate and with consent.
Between-session communication: For non-urgent matters, you may contact the clinic by phone or the client portal. Please allow one to two business days for a response. For urgent matters, please call 988 (Suicide and Crisis Lifeline) or 911, or go to your nearest emergency room.
Fees, Insurance, and Billing
Session fees are established at intake and are described in your financial agreement. By signing this consent, you acknowledge receipt of our Notice of Privacy Practices and Fee Agreement (provided separately).
• We accept most insurances. If you have insurance, we will bill your insurer on your behalf; you are responsible for any applicable copays, deductibles, or non-covered services.
• Sliding scale fees may be available based on demonstrated financial need. Ask our office for more information.
• Payment is due at the time of service unless other arrangements have been made in advance.
Cancellation Policy
We ask that you provide at least 24 hours’ notice to cancel or reschedule an appointment. Late cancellations and no-shows may result in a fee of $100 unless the absence was due to a genuine emergency. Repeated no-shows may result in discharge from services.
Telehealth Services
Forever Young Counseling offers therapy via HIPAA-compliant telehealth platforms. If you participate in telehealth sessions:
• You must be physically located in the state of Montana during the session (licensing requirements).
• You agree to conduct sessions in a private location where you cannot be overheard.
• Technical issues that prevent a session from occurring will be handled by rescheduling at no charge.
• Telehealth is not appropriate for all clinical situations. Your therapist will discuss whether telehealth is clinically appropriate for your or your child’s needs.
• For minor clients, a parent or guardian must ensure the minor is in an appropriate, private setting for telehealth sessions.
Use of AI in Documentation
We use an application called Upheal as part of our services. Upheal transcribes our conversations and helps us review, summarize, and analyze them, enhancing care and potentially improving treatment outcomes. Using Upheal reduces our administrative workload, allowing us to devote more attention to our time together, rather than to documentation. We may also use Upheal to support our practice, including billing you.
This notice explains our privacy practices, which fulfill our legal obligations around your protected health information (PHI), such as health records, and personally identifiable information (PII), such as name and email. We follow the rules set by the Health Insurance Portability and Accountability Act (HIPAA), 42 CFR Part 2 (Part 2), and other state-specific laws. Part 2 protections apply in addition to the privacy protections provided under HIPAA and generally prohibit disclosure of your substance use disorder (SUD) patient records (SUD Records), except as permitted by law. This policy is in effect as soon as you agree to it. If we make any significant changes, we'll let you know by email.
Under this notice, we:
Are required by law to maintain the privacy of records, to provide you with notice of our legal duties and privacy practices for your records, and to notify you following a breach of your PHI;
Are required to abide by the terms of this notice; and,
Reserve the right to change our privacy practices and shall issue a new notice and notify you if we do so.
How, why, and when do we process your PHI and PII?
Your consent allows the collection and processing of the following types of data:
PHI: Upheal processes PHI to accurately transcribe and generate documentation for sessions, and to support the administration of our practice. This includes any health data, habits, or lifestyle information you mention during a session and provide us access to. If we request specific technical support from Upheal, an Upheal technician may temporarily access and process your session transcript and/or PHI. Access ends once the issue is resolved.
PII: We may use Upheal to record sessions, create user profiles, and manage our practice, including billing. The PII we provide to Upheal may include your name, contact information, date of birth, sex, and billing information.
Usage data (excludes PHI or PII): We may give Upheal feedback about the technical experience of a session and other services, and Upheal uses that data to improve its services.
Recordings: Upon notifying you, we as your provider may store your audio and video recordings in Upheal or elsewhere for further analysis to enhance your individual care. Upon your request, we will delete recordings immediately. Upheal does not automatically store recordings after processing (see How long data is kept below).
SUD Records: If disclosed to us, we may use and disclose SUD Records only as permitted by Part 2. If you provide separate written consent, we may disclose your SUD Records on an ongoing basis for the purposes of treatment, payment, and health care operations, as well as use SUD counseling records to enhance your individual care. If you give written consent for your records to be shared for treatment, payment, or health care operations, then the healthcare providers or insurance companies who receive the records may share them again for those same purposes without getting your consent, as long as HIPAA allows it. You may revoke your consent at any time. We may also use and disclose SUD Records without your consent as allowed under Part 2 for limited purposes, such as in a medical emergency or as required by law.
Your consent to the following is optional and must be collected separately from this notice:
AI training: With your explicit consent, in order to improve Upheal’s AI services, Upheal may collect and process your data in a de-identified format (names, emails, and all identifying information is omitted from the data). The data includes: i) Session transcripts and insights, and ii) usage data, which may consist of session insights, clinical notes, datasets for AI training, and spoken language. You can withdraw your consent at any time, and your data will stop being shared.
How long is your data stored by Upheal and by us?
As your provider, we are responsible for maintaining and retaining medical records (including your PHI) under APA Record Keeping guidelines and as mandated by state law. We may use Upheal or another system for this purpose. We are able to delete all data stored in Upheal, and Upheal does not store any data after we delete it.
How long data is kept:
PHI, PII, and SUD Records: Upheal will keep your PHI and PII only as long as we store it there. If we use Upheal to meet state law health record keeping requirements, we may store personal information in user profiles, usage data, and medical records for up to 10 years in Upheal after the last processing.
Session If consent is given to store session recordings to improve our care, we will store the data for up to 10 years. If requested, we will immediately delete the recordings.
De-identified
What are your rights to your data processed by Upheal?
HIPAA grants you access rights to your health information including:
To obtain a copy of your PHI or SUD Records. However, this right does not apply to the private notes written by us whether inside or outside of Upheal.
To correct or amend your PHI.
To restrict what PHI or SUD Records we use or share, with prior consent. This includes restricting disclosures of records to your health plan for services paid in full.
To know who we have shared your PHI with.
To request a particular way of receiving confidential communications from Us.
To request an accounting of disclosures of your SUD Records for the past 3 years.
To request a list of disclosures by an intermediary for the past 3 years.
To receive a paper copy of this Notice of Privacy Practices.
To contact us and discuss this Notice of Privacy Practices with a contact person.
To request to not receive fundraising communications.
To file a complaint. You may file a complaint directly to us or the Office for Civil Rights at the Secretary of the US Department of Health and Human Services. You will not be retaliated against for filing a complaint.
The list above might vary depending on the jurisdiction where you live. To exercise the above rights, you may contact us. We commit to responding to valid requests within 30 days. We will not charge a fee for valid and reasonable requests under HIPAA.
You can ask us not to use or share certain PHI for treatment, payment, or our operations. Unless the request concerns your SUD Records, we are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Who else can access your data processed by Upheal?
Upheal may share your data, including PHI, with trusted, secure, contracted third-party services that are part of Upheal’s technical functions, such as data and payment processing. These services can only process your data as directed by Upheal.
If the law, a court, or a government agency requires us to share your data, we will inform you and only share the data if the disclosure is legally mandated. If there is any breach of your protected health information, we will promptly notify you. Records, or testimony relaying the content of SUD Records, shall not be used or disclosed in any civil, administrative, criminal, or legislative proceedings against you unless based on specific written consent or a court order, accompanied by a subpoena or other similar legal mandate compelling disclosure. SUD Records shall only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you.
Where does Upheal process your data?
For US-based care providers, your PHI and PII is processed within the US by Upheal. See https://www.upheal.io/privacy for more information, or contact support@upheal.io.
Crisis and Emergency Procedures
If you or your child is experiencing a mental health emergency, please do not rely solely on this clinic for assistance. Contact one of the following resources immediately:
• 988 Suicide and Crisis Lifeline: Call or text 988
• Crisis Text Line: Text HOME to 741741
• RiverStone Health / Billings Clinic Crisis Services: [local crisis line number]
• Emergency services: 911 or the nearest emergency room
Your therapist will develop a safety plan with you or your child if there are concerns about safety. Please discuss any safety concerns openly with your therapist.
Client Rights
As a client of this clinic, you have the right to:
• Receive services without discrimination based on race, color, national origin, disability, sex, age, religion, sexual orientation, or gender identity
• Be informed about your diagnosis, treatment options, and progress
• Participate actively in developing and modifying your treatment plan
• Refuse or withdraw consent for any aspect of treatment at any time
• Review and obtain copies of your records (subject to applicable law)
• Request correction of inaccurate information in your records
• File a complaint with the clinic, the Montana Board of Behavioral Health, or the U.S. Department of Health and Human Services if you believe your rights have been violated
• Receive a Good Faith Estimate of the cost of services (No Surprises Act)
Questions and Complaints
If you have questions about this consent, your treatment, or your rights, please speak with your therapist or contact our clinic administrator at 406-200-8518. If you have a complaint about services that cannot be resolved with the clinic, you may contact:
• Montana Board of Behavioral Health: (406) 444-3728 | dli.mt.gov/licensing/professional-licensing/behavioral-health
• Montana DPHHS Office of Inspector General: (406) 444-4306
• U.S. Dept. of Health and Human Services, Office for Civil Rights: hhs.gov/ocr (for HIPAA complaints)