Agreement for Therapy and Informed Consent

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1 Agreement for Therapy and Informed Consent Welcome to the counseling program of St. Joseph Family Center. This Agreement for Therapy contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides privacy protection and client rights with regard to the use and disclosure of your protected health information (PHI) for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice). The Notice explains HIPAA and its application to your protected health information in greater detail. Please read it carefully and note any questions you might have so that we can discuss them. The document Sessions, Fees and Cancellations explains St. Joseph Family Center s fees and related policies. Please read it and discuss it with your therapist. It is incorporated in this Agreement for Therapy when you sign it. If you experience a material change in your circumstances, for better or worse, the fees may be adjusted with your consent. When you sign this Agreement for Therapy, it will represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it, there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy, or you have not satisfied financial obligations you have incurred. The counseling program of St. Joseph Family Center is a multi-specialty group of providers offering counseling services. Each of our therapists brings a unique perspective to the Center, allowing us to respond effectively to diverse needs and concerns. We provide an open, honest, collaborative atmosphere to help you feel comfortable exploring new solutions and developing new skills. We also will have interns working with us as part of their professional training. They are bound by the same obligations as our permanent staff. Complete information for your therapist is on a separate sheet. Catherine (Del) Armstead, Ph.D. has a doctorate degree in Counseling Psychology. She holds a license to practice psychology in the State of Washington, #PY Monica M. Bauer, OSF, MS, LMFT, has a Masters in Pastoral Counseling. She is a Licensed Marriage and Family Therapist, #LF Michael Knight, MA, LMHC has a Masters Degree in Transpersonal Counseling Psychology. He is a licensed Mental Health Counselor #LH Diana P. Hornbogen, M. Ed, LMFT, has a Masters in Education-Counseling and 2 years Post-masters training in marriage & family therapy. She is a licensed Marriage and Family Therapist #LF Marian Beaumier, LICSW, has a Masters of Social Work. She is a Licensed Independent Social Worker, LW Ed Hinson, MS, LMHC, has a Masters in Counseling Education from Portland State University. He is a Licensed Mental Health Counselor, LH You have the right to choose the counselor whom you believe best suits your needs and purposes. We will work with you to help you find a counselor with whom you feel comfortable, and we will refer you to other counselors and providers of health services as you need.

2 Therapeutic Model Our therapeutic model recognizes that each person is an individual with biological, psychological, sociological, and spiritual aspects of their being. Depending on your needs and preferences, we blend systems, dynamic, cognitive, behavioral, and biological approaches. 2 We will discuss therapy goals and the proposed course of therapy with you periodically throughout therapy. If you have any concerns or questions, please bring them to our attention. You have the right at any time to refuse therapy, change therapists, or request a change in therapeutic approach. Risks and Benefits of Counseling You may initiate a discussion of possible positive or negative effects of entering, continuing, or discontinuing counseling at any time. While benefits are expected from the counseling process, specific results cannot be guaranteed. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and your understanding of yourself. Some of these life changes, as well as topics of discussion in sessions, could be temporarily distressing. We will work with you to achieve the best possible results for you. Confidentiality You have the right to confidentiality under the laws of Washington. That means, with some exceptions, anything you disclose in therapy and information we obtain about you from any source, even that you are a client, is confidential and can be disclosed to others only with your written authorization. However, disclosure without your consent or authorization can be made, or may be required by state or federal law, if the disclosure is: to a government agency requesting information for the public s health care oversight activities; to proper authorities if we should have reason to believe that a child, a disabled adult, or an elderly person has been abused or neglected, or if we feel you are of danger to yourself or others; to the courts if under a valid subpoena or court order; to licensing boards if we are under disciplinary investigation; to the Department of Labor and Industries and your employer if the services we are providing are relevant to a worker's compensation claim you have filed; or Pursuant to a complaint or lawsuit you file against us. The law allows for several other types of disclosures to assist in comprehensive care. Your counselor will inform you if a disclosure is required in your case. If disclosure is required without your authorization, we will attempt to discuss the situation with you to clarify options and look for alternate solutions. We will limit our disclosures to that minimally necessary. Other Limits to Confidentiality: For both clinical and administrative purposes, such as scheduling, billing, and quality assurance, members of St. Joseph Family Center and administrative staff may have information about you. We also may have contracts with accountants or attorneys who may have information about you. If you request, we can provide you with the names of these individuals, who contractually promise to maintain confidentiality. Minor Children: Washington State law becomes complicated in the case of children under the age of 18. For any child under the age of 13, and any child under 18, whom the parent or guardian presents for treatment, the parent(s) or legal guardian holds confidentiality. This means that the parent is entitled to information about the child and is the person who authorizes any release of information about the child. We will discuss with the parents the child's general progress and specifics if indicated. We will attempt to act in the child's best interests in deciding to disclose confidential information without the child's consent. For a child between the ages of 13 and 18, who presents him or herself for treatment, the child holds confidentiality. In this case, the parent(s) and/or legal guardian does not have the right to access information about the child s treatment and it is the child who authorizes any release of information. If you have brought your child in for treatment (if available) both parents signatures are required on this document. By signing it, you agree to never seek the clinical record or testimony of the therapist in any child custody dispute.

3 Marriage/Family Therapy: In the case of relationship or family therapy, or when multiple family members are seen by the same therapist, we assume confidentiality to be waived among participants unless other prior arrangements are made. All family members eligible to authorize disclosure of information must provide authorization prior to any disclosure made. 3 If you have come in for couple s therapy, your signature on this document indicates that you agree to never seek the clinical record or the testimony of your therapist in any future court proceedings such as in a child custody matter or martial dissolution. Consultations and Supervision: We may occasionally find it helpful to consult about a case with other professionals. We make every effort to avoid revealing your identity. Those consultants, of course, also are legally bound to keep your information confidential. We will note any consultations in our clinical record. Clinical supervision is provided for each counselor; the clinical supervisor will have access to your information unless you inform your counselor that you do not want your information revealed. Professional Records Pursuant to HIPAA, we may keep your Protected Health Information in two sets of professional records. One set constitutes your Clinical Record and includes information about your reasons for seeking counseling, a description of the ways in which your issues impact your life, your diagnosis, the goals we set for treatment, progress toward those goals, your medical and social history, your treatment history, past treatment records, written reports from any professional consultations, billing records, and any reports sent to anyone. You may request in writing to examine and/or receive a copy of your Clinical Record. There may be a fee associated with copying your record. Your request will be further discussed with you at the time you make it. The second set of professional records is Psychotherapy Notes. The notes are for your counselor s own use and are designed to assist your counselor in providing the best treatment. They may include the contents of your session and your counselor s analysis of the session. These Psychotherapy Notes are kept separate from your Clinical Record, and are not included in any disclosure unless you provide written authorization. You may request in writing to examine and/or receive a copy of the Psychotherapy Notes, but access may be denied under HIPAA regulations. There may be a fee associated with copying the Notes. Your request will be further discussed with you at the time you make it. Client Rights HIPAA provides you with several new and expanded rights with regard to your Clinical Record and disclosures of protected health information. These include the rights to request restrictions on what information from your Clinical Record we disclose to others; to request an accounting of most disclosures of protected health information that you have neither consented to nor authorized; to determine the location to which protected information disclosures were sent; to have any complaints you make about our policies and procedures recorded in your records; and to obtain a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. Contacting Us There is typically someone here to answer phones from 7:30am until 6pm. Counselors are often not immediately available by telephone. In emergencies, if you cannot reach us, or you feel that you cannot wait for us to return your call, you should contact your family physician, call the Crisis Line at (509) , call 911, or go to the Sacred Heart Medical Center Emergency Room or the Emergency Room at your nearest hospital. Electronic Communications: Please feel free to contact us by . Electronic communication is becoming an easy and fast way to communicate and handle routine questions, and our office may use electronic communication for administrative purposes. However, any new technology can have difficulties, and may not be secure. Please let us know if you have difficulty with our using this form of communication. Also, please call us if there is any urgency to your communication, if we have not responded within three working days, or if our response is not sufficient for your needs. Following are some guidelines-- and cautions--for the use of electronic mail with us.

4 Guidelines: Please be aware that phone messages are more efficient and prompt. Please put your therapist s name at the beginning of the Subject Line so that the receptionist may catch and deliver the . Please put an identifier such as" Appointment" in the subject line. Remember to put your name in the body of the message. Examples of Uses: Appointment requests, changes, or reminders Insurance questions Billing questions Follow-up reports or inquires Cautions: The receptionist or other providers within the practice may read your . Your message will become part of your Clinical Record. Your communication is not secure--we do not have encryption capability. 4 Billing and Payment Therapy sessions generally are 45 to 50 minutes ("clinical hour") in length. Fees vary based on the service and the provider. We accept several insurance plans and have a sliding scale fee that can be requested and is approved based on income, family size, and other factors. If you would like us to bill your health insurance company, we ask you to sign our Insurance Information and Authorization Form and give us a copy of your insurance card. Your fees will be discussed with you at your first session. We will ask you to pay your therapy fee or co-pay before the beginning of each session. Any fees which remain unpaid will be billed to you. Bills that have remained unpaid for 120 days will be sent to collections unless other arrangements have been agreed upon by you and us. We prefer to work with you on a payment plan rather than to use collection services. Please speak with your counselor and/or the billing representative if payment is a barrier to your receiving treatment. In the event that you have paid in advance and are due a refund, that refund will be provided when your treatment has ended. Parents/Guardians of minor children are responsible for payment, even in the case of a child seeking services without consent of their parent/guardian. Cancellations and Missed Appointments: If you know that you will be unable to attend your appointment on any given day, please let us know at least 24 hours in advance. Except for emergency situations, you will be billed for missed appointments and late (less than 24 hour notice) cancellations. Please note that insurance companies will not pay for missed appointments and cancellations, therefore, you will be responsible for those fees. Other fees: Fees for telephone calls (after the first 10 minutes), attendance at meetings with other professionals you have authorized, preparation of records or summaries, or other services you might request from us are pro-rated based on our normal hourly fees, with a minimum fee of 10 minutes. Billing for court related work will be at the hourly rate, and will include travel and preparation time. Cancellation for courtrelated work is required 24 hours in advance to avoid a late cancellation fee. The fee to process a returned check is $ Concerns and Complaints If for any reason you should have a concern or complaint about the services we deliver, please let us know. You will be provided a copy of the consumer Grievance Procedure, and a copy is displayed in the waiting room. We will cooperate with you in resolving any complaint or grievance. You also have the right to contact the appropriate licensing board at the Department of Licensing, Business and Professions Administration, P.O. Box 9012, Olympia, WA 98504; (360)

5 Client Agreement I have received the Notice of Privacy Practices. I have read and I understand and agree to the above-stated policies. I have asked and received answers to any questions I may have. I give my informed consent for counseling services at St. Joseph Family Center. 5 Client's Signature Date I have discussed this disclosure with the client: Therapist's Signature Date

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