General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important that you have a clear understanding about the nature of this relationship, and what can be expected. This consent will provide a clear framework regarding how information related to this relationship is used and protected. Feel free to discuss any of this with your therapist. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. There is no promise that your behavior or circumstance will change. There is the offer to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally behavioral health professionals may need to consult with other professionals in their areas of expertise in order to provide the best treatment. Information may be shared in this context without using identifying information.

If you see your therapist accidentally outside of the therapy office, He or she will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge the therapist first, He or she will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Telehealth Clause

Telehealth involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications.
Telehealth includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that there are risks and consequences from telehealth and counseling in general, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Alba Wellness utilizes secure, encrypted audio/video transmission software to deliver telehealth.

4. I understand that if my counselor believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a different mental health professional.

5. I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my counselor, I may be directed to “face-to-face” psychotherapy.

6. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.

8. I understand that my express consent is required to forward my personally identifiable information for billing purposes only.

9. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.

10. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

11. I understand that different states have different regulations for the use of all counseling services.

Payment for Telehealth and in-office Services

Self-pay clients are required to pay for services in full at the time of service.
Deductibles and co-pays are due at the time of service.

Alba staff provides quotes for copays and deductibles from your insurance company. These are only quotes provided to us by your insurance company. Your responsibility is determined when insurance claims are finalized. However, insurance companies have the right to retroactively change your responsibility. We have no control over this process and do our best to keep you updated in regards to your responsibility. It is your responsibility to update us regarding changes in your policy, changes to your copay and deductibles.

Your insurance policy is a contract between you and the insurance company. We are not party to that contract and our relationship is with you. We cannot become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and "usual and customary" charges. Not all services are a covered benefit in all contracts.
We verify all insurance coverage for all clients, but these are only quotes per insurance companies. It is your responsibility to notify the office of changes or updates regarding your insurance.

Alba will submit claims for services to your insurance company on your behalf. If for any reason, your insurance company should fail to pay the contracted allowable rate or deny any services as a non-covered benefit, you accept full responsibility for those service and associated fees.

In the event that insurance does not cover in-office service or telehealth, and the individual wishes to pay out-of-pocket, or when there is no insurance coverage, a prompt pay discount may be available if requested.

By signing this form, I understand and agree to the following fee schedule. I am responsible for the applicable service fees, if insurance does not pay.

LPC 60 min. Initial Assessment	$120
LPC 45 min Counseling	$90
LPC 30 min Brief Therapy	$65
LPC 45 min family/couples counseling	$90
LPC 15 min Phone Consultation	$30
LPC Group Therapy (45-60 min)	$50
LPC legal/court rate	$175
Late cancellation(Less than 24 hr or No Show)	$55
LPC intern 60min Intake (Initial Assessment)	$65
LPC intern 45min Counseling	$55
LPC intern 30min Counseling	$55
LPC intern 45min Family/Couple counseling	$55
LPC intern 15min Phone Consultation	$20
LPC intern Legal/Court rate	$150
Medical Records/Simple Letters/Reports	$25

 At AWI, we attempt to balance the client’s wellbeing with the need to create a comfortable working environment. It is a simple reality that there are times when life is challenging and paying for services is difficult. Our process for addressing this concern is as follows:
a. Client may qualify for a fee on a sliding scale.
b. Client may see an intern for a reduced rate.
c. Client may be considered a “pro bono” case.
d. Client may be given references for services at another agency.

Parent/Guardian must sign if client is minor

By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge and I assume responsibility for charges not covered by insurance.

We understand that situations arise in which you must cancel your appointment. Therefore, it is requested that you must provide more than 24 hours notice to cancel or reschedule your appointment. This allows another person waiting to schedule in that appointment slot. Appointments which are canceled or rescheduled with less than 24 hours notification are subject to a $55.00 cancellation fee. Patients who do not show up for their appointment without a call to cancel are considered as no show and subject to a $55.00 fee as well. Patients who No-Show twice in a 12 month period, are denied any future appointments unless no show fees are paid in full. If client cannot pay the fees, they are provided referrals to other agencies. The Cancellation, Reschedule, and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. Our practice firmly believes that a good counselor/client relationship is based upon understanding and good communication.

Thank You

Parent/Guardian must sign if client is minor

Parent/Guardian must sign if client is minor

Upon entering into a counseling relationship, there are specific rights you should be aware of before consenting to treatment. Please review this document carefully and feel free to ask any questions you may have about its’ contents.

Purpose, goals, and techniques

Counseling is a professional relationship that empowers individuals to accomplish mental health, wellness, education, and career goals. To this end, your therapist will partner with you to identify specific problems you choose to address and help you develop solutions. This process involves discussions and activities identified by you and your therapist that explore the connections between your thoughts, emotions, and behaviors.

Potential Risks of Counseling

The discussion of sensitive issues may be part of the process and may put you in the position to experience some uncomfortable emotions/thoughts, as well as, face painful decisions about your life. Together you and your therapist will work through these thoughts and feelings

Right to appropriate referrals

You have a right to request referrals to other mental health professionals at any time. Your therapist is obligated to provide these referrals when:

Either you or your therapist determine, either individually or collaboratively, that the services provided are not meeting your needs.
When your needs are outside the therapist’s scope of practice
When you request referrals for any reason
Provider Consultation

Mental Health Professionals regularly seek consultation with their colleagues to ensure the highest quality of therapy for the clients and to analyze personal biases. Despite the extra expense to the therapist for this consultation, it is essential to maintain the highest standards for your care. All legal and ethical confidentiality laws and standards apply during these professional consultations.

Records

Your medical records are property of Alba Wellness. Individual clients, legal guardians, and parents have a right to request copies of records. In cases, in which, a couple or a family is seen by a therapist, all adults have a right to those parts of records that pertain to themselves as a client (as well as a right to their children’s records). This does not mean that the individual has a right to the information in the record regarding the other partys. You may be given a copy upon request for a fee of $25.

 

Right to Terminate Therapy

While therapists strive to partner with clients to address important issues, there are understandable circumstances in which a client may need to terminate therapy. In most circumstances, you and your therapist will work together to determine when therapy should come to an end and how to make that transition as easy as possible. However, should you decide at any point to terminate this relationship it is your right to do so.

Termination

I understand that after the final session or in the event that I have not attended a therapy session in three months, the client/therapist relationship will be considered closed unless I initiate further contact. I further understand that I can reinitiate therapy after my case is closed.

Rights of Confidentiality (limits of confidentiality)

All information discussed in sessions is completely confidential, unless specified in writing on the Consent for the Release of Information form. There are three (3) conditions under which confidentiality is breached. These are:

• Situations involving child or elder abuse 
• Situations involving abuse or exploitation of the disabled
• Situations in which a client expresses suicidal/homicidal thoughts, plans, and a willingness to carry out those plans

In situations when child or elder abuse is reported, it is our legal responsibility and policy to contact the appropriate state and local agencies. This requirement also extends to situations where there is reported exploitation or abuse of the disabled. Suicidal or homicidal thoughts when connected to a plan to carry out such actions, and a clear intention to follow through with such a plan legally require us to notify local crisis responders.

Adult Protective Services                                                          (800)252-5400
Child Protective Services                                                          (800)252-5400
San Antonio Police Department 911 or Non emergency               (210)207-7273
Universal City Police Department 911 or non emergency             (210)658-5353
Bexar County Sheriff's Department 911 or non emergency          (210)335-6000

As outlined in the Alba Wellness Privacy Practices, insurance companies can request your medical records as part of treatment reviews and verification of services provided by an Alba Wellness Inc. provider. By signing below, I agree that I have read and understand the above information.

Parent/Guardian must sign if client is minor

By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge

Parent/Guardian must sign if client is minor