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Understanding My Treatment/Assessment

· Voluntary: I am willing to consent to treatment and or assessment.

· Benefits/Right/Risks: I comprehend there are no guarantees results that have been made to me about the outcome of the treatment or mental health assessment. Therapy is the Greek word meaning change. Individuals often learn things about themselves that they don’t like. Often growth cannot occur until past issues are experienced and confronted, often causing distressing feelings such as sadness, anxiety, distress or frustration. The progress of therapy depends upon the quality of the efforts of both the therapist and individual, along with the reality that individuals are responsible for the lifestyle choices/changes that may result from therapy. For example, one risk of marital therapy is the possibility of exercising the divorce option.  I comprehend that the process for treatment/mental health assessment, and I comprehend the potential risk in addition to benefits of the treatment/mental health assessment. At any time, questions can be asked pertaining to any aspect of the counseling process, and the qualification of the therapist. I will be treated with respect and dignity. I will be informed of the standards and expectations of receiving services in which violations can lead to disciplinary actions or discharge. Therapy is effective when the individual is open and can speak honestly about one’s emotions and experiences which can cause different emotional changes.

Confidentiality:

· Discussions between a therapist and the individual are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases, suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn, notify, or disclose; fee disputes between therapist and the individual; a negligence suit brought by the individual against the therapist; or the filing of a complaint with a licensing board or other state or federal regulatory authority. 

· If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing the Receipt form for the Informed Consent and Privacy Practices, you are giving your consent to the therapist to share confidential information with all persons mandated by law, with the agency that referred you, and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services. You are also releasing and holding harmless the therapist from any departure from your right of confidentiality that may result. 

Mental Health Services 

· ALL Polarity Center (APC) recognizes that there may be challenges to seek help from a mental health professional; we hope  with our assistance, you will be able to understand your situation and feelings, therefore be able to move toward resolving your difficulties. The therapist will strive to assist you in growing towards greater health and wholeness; by providing counseling services within a biopsychosocial, reality base/choice therapy approach, wholistic view, with options of additional therapeutic modalities. Our therapists work within the context of each individual’s beliefs, and no attempt is made to impose a personal theology.

Appointments and Cancellations 

· Appointments are made by calling 361-504-4040 or 361-726-7520, Monday, Tuesday, Thursday, Friday, and Saturday between the hours of 8:00 am and 8:00 pm. Please call to cancel or reschedule at least 24 hours in advance, or you will be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. Medicaid clients are not charged a fee per the law. Individuals who repeatedly miss appointments may be discharged from services (see the No Show & Cancellation Policy form). Your therapist reserves the right to cancel your appointment if you show up sick or with minor children that might interfere with the counseling session. 

Number and Length of Sessions 

· The number of sessions needed depends on many factors and will be discussed by the therapist. The length of therapy sessions range depending on several factors, and the therapist will discuss this with you.

Relationship 

· Your relationship with the therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is critical the therapist does not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. The therapist is responsible for assisting you but is not in a position to be in a social and personal relationship with you. Gifts, bartering, and trading services are not appropriate and should not be shared between you and the therapist. 

Goals, Purposes, and Techniques of Therapy 

· There may be multiple interventions to effectively treat the challenges you are experiencing. It is important for you to discuss any questions you may have regarding the treatment recommended by the therapist and to have input into setting goals of your therapy. As therapy progresses, these may change. 

Duty to Warn 

· In the event that the therapist reasonably believes the client is a danger, physically or emotionally, to themselves or another person, consent is given for the therapist to warn the person in danger and to contact any person in a position to prevent harm to themselves or another person, including law enforcement and medical personnel. This authorization shall expire upon the termination of therapy. 

Billing/Payment for Services 

· You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested (In circumstances of unusual financial hardship, we may negotiate a fee adjustment or payment installment plan). 

·  The charge for your initial one-hour session (50 minutes with therapist) is $120.00. The charge for any subsequent one-hour (50 minute) session is $120.00. Shorter sessions will be a percentage of the full fee. APC will look to you for full payment of your account, and you will be responsible for payment of all charges. If you have insurance, different copayments are required by various group coverage plans. Your copayment is based on the Mental Health Policy selected by your employer or purchased by you. In addition, the copayment may be different for the first visit than for subsequent visits. You are responsible for and shall pay your copay portion of the therapist’s charges for the services at the time services are provided. You are responsible for notifying APC immediately of any changes to your insurance. If you fail to notify APC of any changes to insurance, you may be billed for services that are not covered directly. 

· If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the Practice to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. (If such legal action is necessary, the costs will be included in the claim).

Court 

· Although it is the goal of the therapist to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. In the event disclosure of your records or the therapist’s testimony are requested by you or required by law, you will be responsible for and shall pay the costs involved in producing the records;  and the therapist’s normal hourly rate of $120.00 for giving that testimony. Such payments are to be made at the time prior to the time the services are rendered by the therapist. The therapist may require a deposit for anticipated court appearances and preparation.

Therapist’s Incapacity, No longer employed at APC, or Death 

· In the event the therapist becomes incapacitated, no longer providing therapy at APC or dies, it will become necessary for another therapist to take possession of individuals records. By signing the Informed Consent and Privacy Practices Receipt, you give your consent to another licensed mental health professional at ALL Polarity Center to take possession of your files and records and provide you with copies upon request, or to deliver them to a therapist of your choice. 

Contact Information 

· By signing the Informed Consent and Privacy Practices Agreement, you are consenting for APC to communicate with you by mail, e-mail, and phone at the address and phone numbers provided at the initial appointment, and you will immediately advise APC in the event of any change. You agree to notify the Center if you need to opt out of any form of communication. 

Notice of ALL Polarity Center Privacy Practices

This notice tells you how we make use of your health information at our Center, how we might disclose your health information to others, and how you can get access to the same information. Please review this notice carefully and feel free to ask for clarification about anything in this material you might not understand. The privacy of your health information is very important to us and we want to do everything possible to protect that privacy. 

We have a legal obligation under the laws of the United States and the state of Texas to keep your health information private. Part of our responsibility is to give you this notice about our privacy practices. Another part of our responsibility is to follow the practices in this notice. This notice took effect on October 12, 2012 as a tentative document. We have the right to change any of these privacy practices as long as those changes are permitted or required by law. 

Any changes in our privacy practices will affect how we protect the privacy of your health information. This includes health information we will receive about you or that we create here at ALL Polarity Center. These changes could also affect how we protect the privacy of any of your health information we had before the changes. When we make any of these changes, we will also change this notice and give you a copy of the new notice. 

When you are finished reading this notice, you may request a copy of it at no charge to you. If you request a copy of this notice at any time in the future, we will give you a copy at no charge to you. 

If you have any questions or concerns about the material in this document, please ask us for assistance, which we will provide at no charge to you. Here are some examples of how we use and disclose information about your health information. We may use or disclose your health information… 

1. To your physician or other healthcare provider who is also treating you. 

2. To anyone on our staff involved in your treatment program. 

3. To any person required by federal, state, or local laws to have lawful access to your treatment program.

4. To receive payment from a third-party payer for services we provide for you.

5. To our own staff in connection with our Center’s operations. Examples of these include, but are not limited to the following: evaluating the effectiveness of our staff, supervising our staff, improving the quality of our services, meeting accreditation standards, and in connection with licensing, credentialing, or certification activities.

6. To anyone you give us written authorization to have your health information, for any reason you want. You may revoke this authorization in writing anytime you want. When you revoke an authorization, it will only affect your health information from that point on.

7. To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, we will give you an opportunity to object. If you object, or are not present, or are incapable of responding, we may use our professional judgment, in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In so doing, we will only use or disclose the aspects your health information that is necessary to respond to the emergency.

8. To the appropriate State agency if, we suspect the neglect or abuse of a minor or adult. If, in our professional judgment, we believe that a patient is threatening serious harm to another, we are required to take protective action, which may include notifying the police, or seeking the client’s hospitalization. If a client threatens to harm him or herself, we may be required to seek hospitalization. 

APC will not use your health information in any of our Center’s marketing, development, public relations, or related activities without your written authorization. We cannot use or disclose your health information in any ways other than those described in this notice unless you give us written permission. 

As individual of ALL Polarity Center, you have these important rights:

A. With limited exceptions, you can make a written request to inspect your health information that is maintained by us for our use. 

B.  You can ask us for photocopies of the information in part “A” above. There will be a $5.00 charge for copies made here at the 

Center. If you need copies of your health information due to a Third party request, we will charge a fee of $25.00 for the first 10 

pages, then $1.00 for each additional page. 

D.  You have a right to a copy of this notice at no charge. 

E.   You can make a written request to have us communicate with you about your health information by alternative means, at an

  alternative location. (An example would be if you request that we contact you on an alternative phone number other than your

 residence, or if your primary language is not spoken at this Center ) Your written request must specify the alternative means and 

location. 

F. You can make a written request that we place other restrictions on the ways we use or disclose your health information. We may 

deny any or all of your requested restrictions. If we agree to these restrictions, we will abide by them in all situations except those

 which, in our professional judgment, constitute an emergency. 

G. You can make a written request that we amend the information in part “A” above. 

H.  If we approve your written amendment, we will change our records accordingly. We will also notify anyone else who may have

 received this information, and anyone else of your choosing. 

I.  If we deny your amendment, you can place a written statement in our records disagreeing with our denial of your request. 

J.  You may make a written request that we provide you with a list of those occasions where we or our business associates disclosed 

your health information for purposes other than treatment, payment, or our Center’s operations. This can go back as far as six 

years, but not before October 12, 2012. 

K. If you request the administration in “J” above more than once in a 12-month period we may charge you a fee based on our actual

  costs of tabulating these disclosures.

L. If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights 

in this notice you may complain to us in writing to the following person: Chester A.“June-June” Jones, Chief Executive Officer, 

ALL Polarity Center LLC 13310 Leopard St. Corpus Christi, TX. 78410-4486 Telephone: 361-504-4040 | Fax: 361-504-4121. 

M. You may also submit a written complaint to the Licensed Professional Counselor Board with the State of Texas. We will provide  

you with that address and phone number upon written request