New Client Enrollment Form - English

Office Policies and HIPAA Notice CCD Office Policies and HIPAA Notice CCD provides outpatient counseling services in a professional, respectful, and confidential setting. Please review this notice carefully and keep a copy for your records. CCD Contact Information [Insert CCD contact details from the uploaded document here, including office address, phone number, email, and any emergency or after-hours contact instructions.] This practice provides services based on clinical judgment and the needs of each client. Group Therapy may be used when clinically appropriate and may involve discussion among group members. Confidentiality is intended to be protected, but complete privacy cannot be guaranteed in any shared setting. Telephone and Emergency Procedures should be followed as directed by the clinician; voicemail, text, and email are not secure emergency channels, and emergency or crisis situations require immediate action through 911, the nearest emergency room, or the appropriate crisis service. Payments are due according to office policy and may include fees for services not covered by insurance. Litigation Limitation: by engaging in treatment, the client understands that clinical services are not intended to support litigation, legal disputes, or forensic purposes unless expressly agreed to in writing. Termination of services may occur by mutual agreement, clinical recommendation, nonattendance, nonpayment, or for other professional reasons. Late Cancellation and No-Show Policy: missed appointments and late cancellations may be charged according to office policy. Social Media Policy: CCD staff do not engage in clinical communication through social media and clients should not use social platforms for urgent or confidential matters. Blueprint Assessments may be used to support treatment planning and monitor progress. HIPAA / Patient Health Information Rights Your health information is protected under HIPAA. You have rights to receive a notice of privacy practices, request access to your records, request corrections where appropriate, ask for restrictions in certain situations, request confidential communications, and receive an accounting of certain disclosures as allowed by law. Information may be used or shared for treatment, payment, healthcare operations, or as otherwise permitted or required by law.

HIPAA / Notice of Privacy Practices Summary HIPAA / Patient Health Information Rights We protect your personal health information and use it only for treatment, payment, and healthcare operations, unless you give permission or the law requires otherwise. You have rights to access, review, and request limits or corrections to your records, to receive a notice of privacy practices, and to know how your information may be used or shared. Any additional details from the uploaded HIPAA notice should be read together with this summary.

Fees: Our current fees are as follows: Initial Intake Appointment (60 minutes): $160.00 Subsequent Therapy (37- 57 minutes): $135.00 Couples Therapy or Family Therapy (50 minutes): $160.00 If you use your insurance, most insurance agreements require you to authorize us to provide a clinical diagnosis and, sometimes, additional clinical information, such as treatment plans or summaries before they will pay benefits. If your insurance company contacts CCD and requests additional information, we will not release any information without first discussing the insurance request with you. We will obtain your written authorization before releasing any information. Insurance companies claim to keep information confidential, but you should check with your insurance company directly if you have questions about their confidentiality practices. It is important to remember you always have the right to pay for services privately to avoid the issues described above.

Billing Authorization Language: By acknowledging this section, you authorize us to bill your insurance or other payer for covered services and to release only the information needed for billing and payment processing. You understand that you remain responsible for charges not paid by insurance or other payers, subject to your plan rules and our office policies.

Telehealth Services Informed Consent and Agreement Telehealth Services Informed Consent and Agreement Telehealth means the delivery of behavioral health services using electronic communication technologies when the client and clinician are not in the same location. This may include video sessions, audio, or other approved remote communication methods. Rights Regarding Telehealth You may ask questions about telehealth services, understand the limitations of remote care, and choose not to participate if you do not consent. You may also choose in-person services when available and clinically appropriate. Risks and Consequences Telehealth may involve privacy limitations, technical interruptions, delays, loss of connection, misunderstandings due to the remote format, and limits on emergency response. Services may be interrupted by equipment failure, software problems, or connection issues. Confidentiality cannot be guaranteed in the same way as in-person care, and clients are encouraged to use a private location and a secure internet connection. Delaware Laws / Training Statement Telehealth services are provided in accordance with applicable Delaware laws and professional standards. The clinician is responsible for using appropriate training, judgment, and safeguards when delivering remote care. Emergency / Crisis Guidance Telehealth is not appropriate for emergencies. If you are in immediate danger or experiencing a crisis, call 911, go to the nearest emergency room, or contact the appropriate crisis hotline or emergency service in your area. Payment for Telehealth Services You are responsible for payment for telehealth services according to the practice’s fee policies and any applicable insurance or coverage rules. Patient Consent to Telehealth By continuing, you acknowledge that you understand the nature of telehealth, its benefits and limitations, and that you consent to receive services via telehealth when selected or recommended.