Please leave the name, birthdate, address and phone number of your spouse/significant other/parents (if applicable).
Please list any medications.
Please list the names and ages of others living in your household.
Please leave an emergency contact.
Introduction. This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any question that you may have regarding its contents before signing it. You may have questions about me, my qualifications, therapy, or anything not addressed here. It is your right to have a complete explanation for any questions you may have, now or in the future. Please feel free to ask questions or share any concerns that may arise. Although I know this may be uncomfortable at times, your openness and honesty will allow me to better serve you. I am glad you are here and I look forward to working with you.
Information about Your Therapist. Whenever you wish, I will discuss my professional background with you and provide you with information regarding my experience, education, special interests, and professional orientation. You are free to ask questions at any time about the above, and anything else related to your therapy or other concerns.
Fees. The fee for service is $225.00 for the first session / Initial Assessment or Discovery Session- 60 minutes, Couples or Family Therapy $185 per 45 minutes session, Individual Therapy / Coaching, $150 per 45 minutes session, Group Therapy $50 per 60 minutes session, Supervision $100 per 60 minutes, Group Supervision $70 per 60 minutes for a group of four. I reserve the right to periodically adjust the fee if necessary. You will be notified of any fee adjustment in advance. Fees are payable either prior to services being rendered, when the insurance claim comes back or immediately after the time of service. Payment can be made via Square, credit card, cash or check.
If there is a need for telephone contact, or letter writing, with you or a third-party, other than for scheduling purposes, you understand that you are responsible for payment of the agreed-upon fee (on a pro rata basis) for any calls lasting longer than 10 minutes.
Appointment Scheduling and Cancellation Policies. Sessions are typically scheduled to occur one time per week at the beginning of treatment, although I may suggest a different amount of therapy depending on your progress and treatment goals. Your consistent attendance greatly contributes to a successful outcome. Scheduled appointment times are reserved especially for you. Space is limited and it is best for all of our clients to be considerate of that time. If an appointment is missed, or canceled with less than 48 hours notice, you will be charged the rate of whatever your insurance generally pays including your co-pay or my rate for that missed session. Missed sessions can not be charged to your insurance carrier and thus, will need to be paid in full. Should you arrive late, you understand that you will not be able to make up that time. This ensures that everyone gets the best treatment possible.
Insurance. By signing this document you agree that insurance is an agreement between you and your insurance provider as to how counseling fees will be reimbursed. If you are unaware of what your financial responsibility is regarding your deductible, co-pay or co-insurance please contact your insurance carrier to obtain this information and ensure that you are clear on what you are responsible to pay. Our services to you is to file your insurance, but we do not guarantee coverage and it is your responsibility to check on that or wait until you receive the first EOB from us. If there is a problem with payment from your insurance it is your responsibility to ensure payment or pay us while you manage your insurance carrier.
By signing this you acknowledge that you understand that payment is expected at the beginning of each session.
You also acknowledge that your insurer may not pay for services that it determines are not medically necessary or are an exclusion in your insurance benefit plan document. If your insurer denies payment of these services you agree to be personally and fully responsible for the payment of services. By signing this form, you agree to pay for the services identified above if your insurer denies payment because the services are not medically necessary or excluded under the terms of the benefit plan.
A credit card is REQUIRED for all clients to cover any outstanding balances pending issues with insurance coverage or cancelation fees with less than 48 hours notice. Please be sure to fill out completely and list a valid e-mail so you can be contacted prior to the card being charged for any balance due, or to hold your therapy spot, as well as e-mail your receipts.
Delinquent Accounts. You understand that you are responsible for all charges incurred and that services must be paid in full at the time of each visit. We will not be able to continue therapy until accounts are current to ensure that Integrity Counseling can continue to provide quality therapy to our clients. Should your account become delinquent, you agree to pay interest at 5% per month, and if it becomes necessary for the account to be referred for collection action, you agree to pay the actual balance due plus any collection expenses of 30-50% of any balances owing, and any attorney’s fees.
I understand that by signing this financial agreement that I been informed of the total cost of my behavioral health sessions in compliance with the No Surprise Act of 2022. I also acknowledge that all clients with straight Medicare and Medicaid are exempt from any balance billing or cancellation fees and are not required to provide a credit card to remain on file. I acknowledge that as a client utilizing Medicare or Medicaid I must keep my benefits in good standing, provide any documentation, attend scheduled appointments and provide 48 hours notice for all non-emergency cancellations in order to provide the best care possible for all clients and that three or more non-emergency cancellations, no shows, or loss of coverage may result in a referral to another treatment provider if needed.
Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
- You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.
- If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 days in advance, make sure your health care provider or facility gives you a good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
- If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate and the bill.
For question or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurpries/consumers, email FederallPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059
Deductibles, co-pays, and coinsurance payments are charged, on average every two weeks when the submitted claim comes back from the insurance company.
We will let you know what the deductible, copay, and coinsurance estimate is from the insurance company when we do the Verification of Benefits (VOB). In order to be precise, we make sure the claim gets submitted and comes back, in order to avoid charging the incorrect amount.
Risks and Benefits of Therapy. Therapy is a process in which we will discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so that you can experience your life more fully. It provides an opportunity to better and more deeply understand oneself, as well as any problems or difficulties you may be experiencing. Therapy is a joint effort between us. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Our clinicians have been trained extensively in various Evidence-Based and Trauma-Informed practices including CBT, DBT, EMDR, TF-CBT, Motivation Interviewing, and mind/body exercises to develop affect regulation and coping skills. Treatment will be based on a thorough Intake Assessment and Treatment Plan to help individualize your treatment.
Participating in therapy may result in a number of benefits to you, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on your part, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield the benefits listed above, but many people greatly benefit from therapy when they work with their therapist and attend sessions regularly.
Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, anxiety, etc. There may be times in which I will challenge your perceptions and assumptions, and offer different perspectives. The issues presented by you may result in unintended outcomes, including changes in personal relationships. Sometimes a decision that is positive for one family member is viewed quite differently by another. You should be aware that any decision on the status of your personal relationships is your sole responsibility.
During the therapeutic process, many people find that they feel worse before they feel better. Similar to the process of healing from a physical wound. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. You should discuss with me any concerns you have regarding your progress in therapy. Due to the varying nature and severity of problems and the individuality of each patient, I am unable to predict the length of your therapy or to guarantee a specific outcome or result. But I am excited to work with you and offer all my training, expertise, empathy and creativity to help you reach your goals.
Discussion of Treatment Plan. It is my intention to provide services that will assist you in reaching your goals. Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives and my view of the possible outcomes of treatment. Sometimes more than one approach can be helpful in dealing with a certain situation. During the course of therapy, I will draw on various treatment approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches may include but are not limited to behavioral, cognitive, system/family, developmental, trauma-informed care, and/or psycho-educational techniques.
We believe that therapists and patients are partners in the therapeutic process. You have the right to agree or disagree. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, our expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that we do not provide, we have an ethical obligation to assist you in obtaining those treatments and we will be happy to help you in any way we can.
Termination of Therapy. The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is good idea to plan for your termination, in collaboration with me. We will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or we determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy. It is best to discuss this in a planned termination session if at all possible.
Professional Consultation. Professional consultation is an important component of a healthy therapy practice. As such, we regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, we will not reveal any personally identifying information regarding you or your situation.
Collaboration with Other Professionals. In order to provide quality services, we often need to collaborate with other professionals, such as your physician, psychiatrist, past therapists, and/or other mental health professionals. You will be asked to complete a release of information authorizing these exchanges. It will be your decision as to whether or not you feel comfortable with signing these documents, but they will be very helpful in your treatment if you feel comfortable releasing this information.
Confidentiality. The information disclosed by you is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality include, but are not limited to, situations where you pose a threat of serious harm to yourself or someone else; cases involving suspected child, elder or dependent adult abuse; cases in which I am court-ordered to testify or produce records; or as outlined in the “Notice of Privacy Practices”.
If you participate in martial or family therapy, we will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that we utilize a “no secrets” policy when conducting family or marital/couples therapy. This means that we do not keep secret information gathered in individual conversations (whether on the phone or in an individual session) if the information revealed in some way violates the integrity of the couples/family therapy (such as revealing an affair, substance problem, or intent to leave the relationship). Such information will need to be revealed to the other partner for therapy to effectively continue. Please feel free to ask me about my “no secrets” policy and how it will benefit you and your loved ones.
Patient Litigation. We will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, are parties. We have a policy of not communicating with patients’ attorneys and will generally not write or sign letters, reports, declarations, or affidavits to be used in any patient’s legal matter. We will generally not provide records or testimony unless compelled to do so. Should we be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, you agree to reimburse us for any time spent for preparation, travel, or other time in which we have made ourselves available for such an appearance at the rate for such services of $250 per hour.
E-mail and Phone Communication. Some patients prefer to communicate about appointment times or other administrative issues via e-mail. Please use the telephone for anything urgent or time-sensitive, as we cannot guarantee that we will see an emergency email.
Emergencies: Please understand that we are unable to personally provide continuous 24-hour crisis services. In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance, go to the nearest emergency room. We will do my best to return your call on the next business day for any non-emergency calls. Please do not use email for urgent situations.
Enter Name of Patient or Authorized Representative Agreeing to the above terms.
This section must be completed by the parent or legal guardian of each child who attends session. Some custody agreements require the signatures of both parents for treatment. Because of this, it is generally our policy to require the signature of both parents in any divorce situation.
The State of Michigan provides significant confidentiality to minors seeking mental health treatment. In fact, minors over 14 years of age have many privacy rights similar to those of adults. Our role as is to help minors learn to communicate openly and directly with their parents, and thus, we typically involve parents in the counseling process. That said, when children are making poor and dangerous decisions parents will be brought into the conversation as soon as possible, which in the case of many situations – such as suicidal ideation or attempts – is immediately.
Notice of Privacy Rights provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. If we change my notice, you may obtain a copy of the revised notice from us by contacting us at the phone number above.
If you have any questions about our Notice of Privacy Practices, please contact us.
HIPAA Notice of Privacy Practices
Effective Date: 6/2/2014
If you have any questions about this notice, please contact Robin A. Harvell, MA, LPC at 269-635-2396. Please note that this notice is required by Federal law, and the information it contains is mandated by that law. If you have any questions about how your Protected Health Information (PHI) is used, please contact me.
I. THIS NOTICED DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)
I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I’ve created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice.
However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies. I will promptly change this Notice and post a new copy of it on my website as noted at the beginning of this document. You can also request a copy of this Notice from me, or you can view a copy of it on my website as noted at the beginning of this document.
III. HOW I MAY USE AND DISCLOSE YOUR PHI.
I will use and disclose your PHI for many different reasons. For some of these uses or disclosures, I will need your prior authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.
A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:
1. For treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if you’re being treated by a psychiatrist, I can disclose your PHI to your psychiatrist in order to coordinate your care. However, it is my practice to only do so if you have directly authorized me in writing, unless a threat to your safety is involved.
2. To obtain payment for treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
3. For health care operations. I can disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to our accountants, attorneys, consultants, and others to make sure I’m complying with applicable laws.
4. Other disclosures. I may also disclose your PHI to others without your consent in certain situations. For example, your consent isn’t required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.
B. Certain Uses and Disclosures Do Not Require Your Consent. I can use and disclose your PHI without your consent or authorization for the following reasons:
1. When disclosure is required by federal, state or local law; judicial or administrative proceedings; or, law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
2. For public health activities. For example, I may have to report information about you to the county coroner.
3. For health oversight activities. For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
4. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
5. To avoid harm. In order to avoid a serious threat to you or another person, I may disclose PHI to law enforcement personnel or persons able to prevent or lessen such harm.
6. For specific government functions. I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
7. For workers’ compensation purposes. I may provide PHI in order to comply with workers’ compensation laws.
8. Appointment reminders and health related benefits or services. I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer.
C. Certain Users and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization. There are specific disclosures that would require your authorization, but that this practice does not do. These include disclosing your PHI for marketing purposes (marketing of services other than those of Families Counseling), sale of PHI to third parties, and fundraising purposes.
In these, or any other situation not described in sections III A, B, and C above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven’t taken any action in reliance on such authorization) of your PHI by me.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect to your PHI:
A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. I am not required to agree to your request unless you are asking me to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid me “out-of-pocket” in full. If I agree, I will comply with your request unless the information is needed to provide you with emergency treatment. You may not limit the uses and disclosures that I am legally required or allowed to make.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that I not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and I will honor that request.
B. The Right to Choose How I Send PHI to You. You have the right to ask that I send information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail) I must agree to your request so long as I can easily provide the PHI to you in the format you requested.
C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that I have, but you must make the request in writing. If I don’t have your PHI but I know how does, I will tell you how to get it. I will respond to you within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. Instead of providing the PHI you requested, I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance. If you request copies of your PHI, I will charge you not more than $ for each page.
In my practice, I keep “treatment notes” which are a regular part of your PHI. I do not keep what are called “psychotherapy notes”, which are a separate sort of record and are generally not accessible to clients.
D. The Right to Get a List of the Disclosure I Have Made.
You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003.
I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it, and tell others that need to know about the change to your PHI.
F. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of it.
G. Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. I will take no retaliatory action against you if you file a complaint about my privacy practices.
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me via the address and/or phone number at the beginning of this document.
VII. EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on June 2, 2014.
PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD
PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD
I consent to engaging in telehealth with Midwest Wellness, LLC as a part of the therapy process and my treatment goals. I understand that telehealth psychotherapy may include mental health evaluation, assessment, consultation, treatment planning, and therapy. Telehealth will occur primarily through interactive audio, video, telephone and/or other audio/video communications.
I understand I have the following rights with respect to telehealth:
1) I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
2) The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my sessions is generally confidential. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent,
3) I understand that there are risks and consequences from telehealth including but not limited to, the possibility, despite reasonable efforts on the part of Midwest Wellness, LLC that: the transmission of my personal information could be disrupted or distorted by technical failures and/or the transmission of my personal information could be interrupted by unauthorized persons.
In addition, I understand that telehealth based services and care may not be as complete and in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to e mental health profession who can provide those services in my area. I also understand that there are potential risks and benefits associated with any form of mental health treatment, and that despite my efforts and efforts of my therapist, my condition may not improve, or may have the potential to get worse.
4) I understand that I may benefit from telehealth services, but that results cannot be guaranteed or assured. I understand that the use of Skype, Facetime, GoToMeeting, and Google audio/video systems are not 100% secure and may have issues with wifi connectivity. All attempts to keep information confidential while using these systems will be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. Signing this form shows an awareness of these issues and a decision by this client to use these systems for telehealth services. I will not hold Midwest Wellness, LLC or its staff liable for gathering or use of client information by these service providers.
5) I understand I have the right to access my personal information and copies of case notes. I have read and understand the information provided above. I have discussed these points with my therapist, and all of my questions regarding the above matters have been answered to my approval.
6) By signing this document I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer based psychotherapy services. If I am in crisis or in an emergency I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document I understand that emergency situation may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threatening or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433.
