MindBeingWell Therapy HIPAA Client Services Informed Consent Client Contract Form
Welcome to MindBeingWell:The Wellness Project. This document contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Personal Message to My Clients Dear patient and caregiver: Welcome to my holistic psychiatric practice where there is a synthesis of allopathic psychotherapy, holistic and naturopathic therapies to help heal the mind. The goals of treatment here are: 1) to understand the underlying causes of mental health and overall health problem. 2) to heal the whole person. 3) to teach patients new ways to maintain wellness. 4) to minimize dependency on prescription medications and supplements. 5) to bring the mind and body to a state of optimum health and functioning. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Wellness Goals/Therapist Goals of MindBeingWell 1) I want to help people be free from an illness without creating a chronic need for prescription medications, doctor visits, and long term psychotherapy. 2) I have experience in and have been successful at helping patients get off their prescription medications. 3) I believe that the best doctor is the doctor within one’s own body, and I work to provide the tools that help the body to heal better and faster. 4) I believe that the best clinical care results from being open to learning and sharing information—throughout the healing process—and that even more important than knowing what we know, is the humility to acknowledge that which we don’t know. 5) I am motivated by a single-minded commitment to the patient’s welfare and health. I do not take sides against medications, or for supplements. I do not campaign for one right way, or my way of doing things. Working Relationship Agreement to : 1) you agree to accept whatever the treatment outcome may be, including the risk of a recurrence of your mental illness(es) as part of using an alternative approach for psychiatric care. 2) You agree to accept that success in treatment is not and cannot be guaranteed. 3) You agree to accept your role as a partner in this treatment endeavor, rather than that of a customer, whose purchase of a product can be refunded to you if you are not pleased with the outcome. 4) You agree to accept my fallibility and limitations as a therapist in alternative medicine, expecting nothing more than allowing the healing process to unfold as a natural result of our mutual desire for and efforts in creating your health and well being. 5) You agree to accept that irreconcilable differences may arise. If irreconcilable differences and conflicts arise over the treatment course, and one or both of us do not wish to continue the therapeutic alliance, than the treatment would need to be terminated, leaving you the option of finding treatment elsewhere. The Physician’s Board of Quality Assurance or malpractice attorneys should never be used as a tool for furthering communication, threatening the viability of this holistic practice, negotiating differences, used as monetary compensation or disciplinary action for perceived injury, or forcing a continuation of treatment. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has
been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.. You should evaluate this information and make your own assessment about whether you feel comfortable questions about my procedures, we should discuss them whenever they arise.
APPOINTMENTS Appointments will ordinarily be 30-120 minutes in duration, at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you cancel without a 24 hour notice, your appointment scheduling fee will be retained by MindBeingWell. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL FEES Fees range from $75 to $500 You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash or credit card as payment. I reserve the right to use an attorney or collection agency to secure payment. Nutrition journals, Ayurvedic Guides, other miscellaneous tools used in well therapy will range in price from $50 to $200. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other services which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
INSURANCE In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I do not work with insurance companies. If you prefer to use a provider participating with your insurance plan, I will refer you to a colleague.
PROFESSIONAL RECORDS I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for
seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me.
CONFIDENTIALITY My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
CONTACTING ME I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) Go to your Local Hospital Emergency Room, or 2) Call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice. OTHER RIGHTS If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or former clients. You have the right to: Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to our Privacy Officer. Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, we are not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to our Privacy Officer. In your written request, you must inform us of what information you
want to limit, whether you want to limit use or disclosure, or both, and to whom you want the limits to apply. If we agree to your request, we will comply with your request unless the information is needed in order to provide you with emergency treatment. Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to our Privacy Officer. We will accommodate all reasonable requests. Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to our Privacy Officer. In certain situations that are defined by law, we may deny your request, but you will have the right to have the denial reviewed. We may charge you a fee for the cost of copying, mailing or other supplies associated with your request. Amend your PHI as provided by law. To request an amendment, you must submit a written request to our Privacy Officer. You must provide a reason that supports your request. We may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by MBW (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by MBW, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with our denial, you have the right to submit a written statement of disagreement. Receive an accounting of non-routine disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to our Privacy Officer. The request must state a time period which may not be longer than six years and may not include dates before September 17, 2007. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but we may charge you for the cost of providing additional lists in that same 12 month period. We will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred. Receive a paper copy of this Privacy Notice from us upon request. To file a complaint with MBW, please contact MindBeingWell@welltherapy.healthcare. All complaints must be in writing. If your complaint is not satisfactorily resolved, you may file a complaint with the Secretary of Health and Human Services, Office for Civil Rights. Our Privacy Officer will furnish you with the address upon request. To obtain more information, or have your questions about your rights answered, please contact us.
OUR RESPONSIBILITIES MindBeingWell (MBW): Is required by law to maintain the privacy of your PHI (Personal Health Information) and to provide you with this Privacy Notice upon request. Is required to abide by the terms of this Privacy Notice. Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that we maintain. Will not retaliate against you for making a complaint.