INFORMED CONSENT TO TREATMENT
I. LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
A. Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
B. Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
C. Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
II. PAYMENT AND CANCELLATION POLICY
Mended Wing Counseling only accepts PPO insurance plans, some private insurance plans, and private pay at this time. Payment is expected at the time of your appointment. Cash, check and all major credit cards are accepted forms of payment. Rates are subject to change at any time. Rates may be reduced based on predetermined sliding scale. Insurance rates are based on individual plans and should be clarified prior to your first appointment if you have any questions pertaining to the co-pays.
Initial Intake Evaluation: $100.00 (60 Minutes)
Individual Counseling Session: $100.00 (45 Minutes)
Individual Counseling Session: $150.00 (75 Minutes)
Group intake: $35.00 (45 Minutes)
Group Session: $20.00 (90 Minutes)
If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full fee is charged for missed appointments or no show cancellations with less than a 24-hour notice. A bill will be emailed directly to all clients who do not show up for or cancel an appointment. Voicemail, text message, and email are available 24 hours a day, 7 days a week; so, if you are unable to reach your therapist directly, please communicate in one of the aforementioned methods to ensure that your attempt to cancel your appointment is received. Thank you for your consideration regarding this important matter.
In the event of nonpayment, Mended Wing Counseling reserves the right to terminate treatment and refer client to other services.
1. Records will not be held in the event of nonpayment.
2. Bartering is not acceptable form of payment.
3. Payment plans will be utilized in the first instance of nonpayment.
III. RECORD KEEPING
Mended Wing Counseling complies with prevailing national standards for record keeping practices.
A. The following records are kept:
1. Assessment data
2. Informed consent contract
3. Treatment plans
4. Signed authorizations for release of treatment information
5. Notes concerning any disclosure of information
6. Billing and payment information
7. Information concerning referrals made to other professionals for services
8. Session notes concerning each treatment session
B. The information which must be kept includes:
1. Identifying data, client’s name, address and age
2. Reason for psychotherapy services
3. Date of each contact with primary client, to include the date in which psychotherapy services began and the date of last contact with client
C. Records are generally kept in electronic format, although some paper format may be used if needed.
D. Records are stored per the two-lock rule i.e. protected by password, firewall, and backup files after being converted from a Microsoft Word to a PDF format and then the computer is stored in a locked cabinet.
E. Informed Consent Contract, Treatment plans, and Release of treatment information are signed electronically by both counselor and client using electronic signature software.
F. Assessment data, notes concerning disclosure, billing and payment information, and session notes are signed by counselor using electronic signature software.
IV. TREATMENT STANDARDS
Counselors with Mended Wing Counseling, LLC competently utilized evidenced based practices and strive to create a safe and welcoming environment in which therapy can occur. As such, policies are in place to offer flexible, individualized care that maintains the standards of the profession.
A. Theoretical Orientation
We use evidenced-based techniques drawn from cognitive-behavioral, interpersonal process, dialectical behavioral, mindfulness-based, person-centered, psychoeducational, contingency management, emotion-focused, and motivational enhancement therapies in both group and individual settings.
B. Phases of Therapy
The phases of therapy include assessment, treatment planning, group/individual sessions, reassessment, and termination. As part of the assessment, the counselor will gather current and historical data to offer the client a diagnosis, prognosis, and recommended treatment. During treatment planning, the counselor and client will identify goals, objectives, and target dates. As the target dates approach, the counselor and client will together assess the client’s progress, and determine the course of further treatment. Termination is determined by both the client and counselor, based on goals and objectives, and is viewed as an essential aspect of effective therapy.
There is no standard length of treatment. Duration is based on your individual needs and is initially assessed during the treatment planning phase of therapy. It is mutually re-assessed on an ongoing basis.
D. Frequency of Session
Sessions are generally once or twice weekly but is initially determined during the treatment planning phase of therapy. Additional sessions can usually be scheduled when the need arises.
E. Length of Session
In effort to be sensitive to individual needs, we offer sessions of both the standard 50-minute hour and a longer 75-minute session. Session length is initially assessed during the treatment planning phase of therapy. Please see rates.
F. Scheduled Absences
Clients and counselor alike are expected to notify each other of vacations or other planned absences in as much advance notice as possible. During counselor absences, referrals will be provided, if the client so desires.
G. Phone Calls
Brief phone calls are acceptable and require no fee. Psychotherapy in not conducted by phone so if more time is needed, an additional session should be scheduled. If the call is urgent, client should mention so in the message so the counselor may return the call at the first available moment. If there is an emergency requiring immediate attention, clients are expected to call 911 or other emergency services such as the BEST team.
Though clients have the right to be informed of expected results, no specific promises are made regarding the results of treatment. Any number of unexpected occurrences could affect the course of treatment and should be addressed as they arise. If the mental health issues of the client are out of the counselors range of competence or outside the scope of practice, the counselor is legally required to refer, terminate, or consult.
There are times when a counselor will be required to consult with other professionals, such as when the mental health concern requires services outside the scope of competency. The confidentiality of the client is maintained at all times during a consultation.
V. CLIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical
Records and disclosures of protected health information. These rights include:
A. To consent to or refuse services.
B. To competent, culturally-sensitive services.
C. To receive a comprehensive and thorough psychosocial evaluation/history.
D. To a diagnosis and prognosis at as early a stage of therapy as possible.
E. To a written treatment plan that is created together with the counselor and utilized, with necessary amendments and changes, throughout the course of therapy.
F. To understand the costs of individual therapy sessions and projected costs of total therapy sessions upon request, before committing to a course of therapy.
G. To a beginning, middle, and end to therapy. If protracted or ongoing therapy is required, then the client has the right to understand why their diagnosis might warrant this course of action.
H. To be informed of expected results.
I. To have own treatment responsibilities explained thoroughly as well as understand the therapist’s responsibilities to the therapy process and to the client. This includes the responsibility of the therapist to try a different course of treatment and/or refer clients to another therapist if therapy is ineffective after a reasonable period of time.
J. To complete confidentiality as provided for by state and federal laws and regulations.
K. To request that your record be amended.
L. To request restrictions on what information from your records is disclosed to others.
M. To request an accounting disclosure of protected health information that you have neither consented to nor authorized.
N. To determining the location to which protected information disclosures are sent.
O. To have any complaints about policies and procedures included in official records.
P. To receive information about the methods of therapy, techniques used, duration of therapy, and fee structure.
Q. To know the counselor’s credentials, experience, and professional background.
R. To seek a second opinion from another therapist at any time.
S. To requesting a paper copy of this Agreement.
VI. TECHNOLOGY ASSISTED COUNSELING
Technology assisted counseling requires an additional set of policies, in addition to those previously outlined. These additional policies are based on the ethical standards created by the American Counseling Association.
A. Modality: The vehicle of technology assisted counseling will be determined by client and therapist. Client accepts all risks associated with any given modality, including but not limited to the inability to guarantee confidentiality.
B. Client Verification: In an effort to ensure confidentiality, clients will be verified at the beginning of each session, either visually or with a password predetermined by therapist and client.
C. Symptom level: Clients with risk factors such as suicidality or self-harm behaviors are inappropriate for this level of care. If symptom acuity increases over the course of therapy, client will be transferred to a local clinician or treatment center.
D. Client Age: Clients under the age of 18 are not appropriate for online counseling. Clients will be required to provide their date of birth and state ID during the intake.
E. Laws and Statutes: The counselor will need to assess the laws and statutes regarding counseling in the state of the client, if different, as most legal authorities believe that counseling takes place in the state in which the client resides. It is incumbent upon the counselor to know and be in compliance with the laws and statutes of both states. This process may take as long as two weeks.