Consent for Services

This form is called a Consent for Services (the "Consent"). Your therapist, counselor, social worker, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information and if you have any questions, contact your Provider.

THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together collaboratively to achieve goals that are mutually defined. This means that you will follow a process supported by evidence-based research, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow and "trust" the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. You will get to review your Provider's policies and procedures, identify emergency contacts, communication practices, talk about fees, and decide if you want health insurance to pay your fees depending on your plan's benefits. You will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. A treatment plan will be formed that includes the type of therapy, frequency of sessions, your treatment goals, and the steps that will take to achieve them. Over time, you and your Provider may edit your treatment plan to ensure it is aligned with your current goals. After the intake, you will attend regular therapy sessions at your Provider's office or through visual and audio video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, your goals will be achieved and that is when progress will be reviewed, supports are identified that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

IN-PERSON VISIT PROTOCOL
You can only attend if you are cold and flu symptom-free (for list of symptoms, see: https://www.cdc.govl). If you are experiencing symptoms, you can switch to a telehealth appointment or reschedule. If you need to cancel or change your appointment, please give at least 24 hour notice if possible. Your Provider understands that emergencies come up and life happens, they will discuss with you situations that would call for possible late cancellation fee.

TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. You must be physically located in the State of Ohio. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. Do not use video or audio to record your session unless you ask your Provider for their permission in advance.

There are some risks and benefits to using telehealth:
• Privacy and Confidentiality: You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology: At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management: It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
• Flexibility: You can attend therapy wherever is convenient for you. However, your Provider does ask that you are not actively driving for your safety. Please make sure that other people cannot hear your conversation or see your screen during sessions. Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions:
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed.
• If your Provider believes there is a specific, serious and reasonably foreseeable threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at risk of harming yourself due to a serious and reasonably foreseeable threat, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will assess the situation by working with you to discuss other potential options to keep you safe.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

 

***CHILDREN IN ALTERNATIVE PLACEMENT or CHILDREN OF DIVORCED OR SEPARATED PARENTS***

Copy of legal guardianship paperwork such as current custody agreement, court orders, signed letter from a judge, Medical Power of Attorney, and/or Individual Child Care Agreement (ICCA) must be received at the time of intake otherwise follow up appointment cannot be scheduled until it is received, as instructed by the Licensing State Board.

RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
• Contacting The Caring Collective LLC via texting 419-515-6865 and emailing TheCaringCollective@Outlook.com are forms of communication should be used to communicate appointment scheduling, reminders, and asking brief non-treatment questions. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.

• Automated appointment reminder phone calls and text messages will come from 215-515-9997; automated appointment reminder emails will come from appointmentreminders@therapyportal.com These are automated systems through TherapyNotes where they are not monitored and cannot accept replies.
• Secure communications through the Client Portal are the best way to communicate personal information, though no method is entirely without risk.

• Client Portal can be accessed through https://www.therapyportal.com/p/caringcollective/ where you can complete paperwork, view scheduled appointments, log into telehealth appointments, and send secure messages to your Provider and/or administration.

• If a true emergency situation arises, please call 911 or 988 or go to any local Emergency Room (ER). Do not text, email, call, or leave a message for your Provider as they are often not available due to being in appointments during the day or reachable outside of their work schedule.
• If you try to communicate with your Provider via Social Media or Review Websites, they cannot respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy, per State Board Licensing regulations.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider's professional platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

FEES AND PAYMENT FOR SERVICES
Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive
• Your benefits cover in-person and telehealth sessions
• What you may be responsible to pay such as copay or any portion of the payment

Sharing Information with Insurance Companies
If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work. When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance. When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

MINORS

We realize that there may be special arrangements with a non-custodial parent or other party for payment of medical bills; however we do not get involved in domestic issues with third parties. The parent signing the child’s consent document will be considered the responsible parent and will be required to pay at the time of service. We cannot bill the other parent.

You may be required to pay for services and other fees:
• If you are unable to attend therapy, you must contact your Provider at least 24 hours before your session. Otherwise, you may subject to a No Show/Late Cancelation fee of $75. Insurance does not cover this.

• If you are more than 15 minutes late to your scheduled appointment, that is considered a No Show/Late Cancelation and may be charged the fee of $75.
• Full payment of copay, coinsurance, and any additional fees are due at the time of your session. If you are unable to pay, please inform your Provider as they may be able to offer payment plans. If not, your Provider can refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• Your Provider may charge a $40 an hour administrative fee for writing a letter or report at your request. Consulting with another healthcare provider or other professional outside of normal case management practices may result in a $40 an hour administrative fee. Providers cannot be considered as Expert Witnesses in legal proceedings as this is outside scope of practice. If subpoena regarding treatment, there may be a charge of $150 an hour for preparation, travel, and attendance for a court appearance. Payment is due in advance.

• You may be charged a reasonable fee up to $40 if requesting paper copy of PHI.
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Providers may terminate treatment after appropriate discussion with you and a termination plan is in process. Providers may determine that psychotherapy is not being effectively used or if you are in default on payment where they can initiate termination. Providers will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, a referral list of qualified psychotherapists will be given to you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for thirty consecutive days, unless other arrangements have been made in advance, for legal and ethical reasons, Providers must consider the professional relationship discontinued.

COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them directly or file a complaint by contacting the Practice using the following information: The Caring Collective LLC, P.O. Box 145, Berlin Heights, Ohio 44814. You also have the right to contact the licensing board that issued your Provider's license through www.elicense.ohio.gov online portal, contact your insurance company (if applicable), or the US Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints