PATIENT CONSENT AND AUTHORIZATION
Consent to Treatment:
I hereby consent to receive mental health treatment from Northampton Center for Couples Therapy (hereafter referred to as NCCT). I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option NCCT offers and that I may withdraw my consent at any time.
I accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. I understand that the changes I make will have an impact on my partner and on others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them [This is especially true if dependent children are involved]. On the other hand, therapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
Couple Retreat Therapy
Couples Retreat Therapy is an intensive 1-3 day retreat that is a unique service and is not the same as regular couples therapy. A Retreat therapist is a specialist that I am hiring for consultation and thus will not be an ongoing couples therapist for me in between Retreats or after I finish the therapy.
I understand that if I wish to see my Retreat therapist for ongoing therapy, I will need to fill out the appropriate paperwork in order to become a regular couples therapy patient at NCCT. I understand that this retreat requires my therapist to set aside considerable time. All Couples Therapy Therapy retreats must be paid in full within 24 hours of booking.
I also understand that there are circumstances in which Couples Retreat Therapy may not be the best treatment option. Such circumstances may include when there is active substance abuse, domestic violence, emotional abuse, or mental health problems that are not stable and/or untreated. I further understand that NCCT may choose at any time to discontinue services in the event that any of these circumstances are present, and at such time all fees paid to NCCT to date (regardless of duration of treatment) are nonrefundable. I understand that in such circumstances NCCT will make a good faith effort to provide me with alternative referrals for treatment, but that ultimately it is my responsibility to seek out and pursue treatment.
Online Therapy Sessions:
I understand that by choosing online therapy, I am agreeing to the following:
I also understand that there are circumstances in which online therapy may not be the best treatment option for me. Such circumstances may include when there is:
I further understand that NCCT may choose at any time to discontinue services in the event that any of these circumstances are present, and at such time all fees paid to NCCT to date (regardless of duration of treatment) are nonrefundable. I understand that in such circumstances NCCT will make a good faith effort to provide me with alternative referrals for treatment, but that ultimately it is my responsibility to seek out and pursue treatment.
I understand that our communications are private and protected by law. Because of laws protecting confidentiality, in most situations my therapist cannot share information about our work without my permission. However, there are certain specific limits to confidentiality. I fully understand these limits below.
Couples Retreat Therapy and Release of Medical Records:
I understand in order for any therapy information or medical records to be released, both members of the couple must provide written authorization. In addition, what I say during individual sessions of the Couples Retreat Therapy process will be considered to be a part of the medical record.
I also understand that information discussed in Couples Retreat Therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the couple. I agree not to subpoena my therapist to testify for or against either party or to provide records in a court action.
Communication and Availability:
Due to my therapist’s work schedule, my therapist is often not immediately available by telephone. When my therapist is unavailable, an automated voice mail answers his/her telephone. My therapist will make every effort to return my call on the same day I make it, with the exception of weekends and holidays. If I will be difficult to reach, I will inform my therapist of some times when I will be available. In a life-threatening emergency, I will call 911 or go to the nearest Emergency Room.
I understand that email is not a secure medium for communication and my therapist’s preference is that I contact him/her by phone. However, if I choose to contact my therapist using email, I am doing so with the full understanding that my therapist cannot guarantee the safety and security of that communication, despite NCCT taking all possible action to protect my privacy. I also acknowledge that email occasionally disappears or is delayed and that my therapist may never receive an email that I send.
I hereby give consent for Northampton Center For Couples Therapy to communicate and send me personal health information through text messaging to my mobile telephone number listed on my intake form. According to HIPAA (Health Insurance Portability and Accountability Act) guidelines, I am aware of the risks of unencrypted text messaging and must give consent in order to send and receive information via text message. Cellular services do not use encryption, which means that a third party may be able to access the transmitted information.
I understand that I am responsible for full payment of all fees for Couples Retreat Therapy services provided by NCCT. All Couples Retreat Therapy retreats must be paid in full within 24 hours of booking.
Once I have scheduled an appointment, NCCT will send me a series of questionnaires to fill out and send back to NCCT before the first meeting. It is imperative that NCCT receive these assessments a minimum of one week before my first meeting to allow time for my therapist to review my answers and begin to formulate an understanding of the dynamics that have brought me in for counseling.
Court Action Policy and Fees:
Clients are discouraged from having The Northampton Center for Couples Therapy subpoenaed or requesting records for the purpose of litigation. We are trained as clinical social workers, marriage and family therapists and mental health counselors and our work and therapeutic philosophy comes from non-adversarial positions. We have not been trained forensically or with the expertise to appear in court. We are unable to guarantee that any testimony that we are required by law to give will be solely in your favor. We can only testify to the facts of the case and our professional opinion.
If any clinician at The Northampton Center for Couples Therapy is to receive a subpoena then the attorney or office staff will need to call our office and set up a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice of any Court appearance so that schedule changes for our clients can be made within a reasonable time frame.
Please note: if a subpoena is received without a minimum of 72 hour notice there will be an additional $300 express charge.
Court action fees are as follows:
All fees are doubled if the clinician from The Northampton Center for Couples Therapy is scheduled to go out of town.
If a clinician is subpoenaed and the case is reset with less than 72 hour notice prior to the beginning of the day of the scheduled subpoena and or testimony is not given then the client will be billed $1,000.
Bills for court related actions are presented to clients on a weekly basis and payment is expected upon receipt. A zero balance will need to be kept at all times.
My signature below acknowledges that I understand and accept the terms and conditions of this authorization and agreement.
I am required to give a minimum of four weeks notice if I need to cancel or reschedule our retreat therapy appointment. Initial deposits are refundable when a cancellation occurs four or more weeks before our scheduled appointment. Cancellations after this period will be charged the full fee for the Couples Retreat Therapy session, plus related session-specific services.
Additionally all cancellations regardless of notice will incur any credit card processing fees that NCCT incurred in processing Couples Retreat Therapy deposits.
*Note ~ Due to the severe nature of New England weather, exceptions are made in the event of hazardous driving conditions and weather emergencies.
My signature below acknowledge that I understand and accept the terms and conditions of this policy.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before:
You may revoke all such authorization (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Patient’s Rights and Therapist’s Duties
Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 413.586.2300 for additional information. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to our Security Officer at 40 Main Street, Suite 206, Florence, MA 01062. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Our Security Officer can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
Other Uses of PHI in Healthcare
The effective date of this notice is April 14, 2003.
THE SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES FROM NCCT: