Forward Choices, LLC 6040 W Lisbon Ave, Suite 103 Milwaukee, WI Telephone: Fax:

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1 Psychotherapist-Patient Services Agreement/Consent to T reatment Wisconsin Notice Form Notice of Health Care Service Provider Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Welcome to Forward Choices, LLC. This document (the Agreement) 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 new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the beginning of this session. Although these documents are long and sometimes complex it is very important that you read sign this document it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. PSY C H O L O G I C A L SE R VI C ES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation we will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures we should discuss them whenever they arise. If your doubts persist we will be happy to help you set up a meeting with another mental health professional for a second opinion. M E E T IN GS Forward Choices, LLC therapists normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if the therapist assigned is the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, your therapist will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled you will be expected to pay for it unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control. If it is possible, we will try to find another time to reschedule the appointment.] Page 1 of 7

2 PR O F ESSI O N A L F E ES Our hourly fee is $ In addition to weekly appointments, we charge this amount for other professional services you may need though we will break down the hourly cost if we work for periods of less than 1 hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require my participation you will be expected to pay for all of my professional time, including preparation and transportation costs, even if we are called to testify by another party. [Because of the difficulty of legal involvement, we charge $ per hour for preparation and attendance at any legal proceeding.] C O N T A C T IN G US Due to our work schedule, Forward Choices therapists are often not immediately available by telephone. Our regular office hours are between 9 AM and 8 PM; however, we probably will not answer the phone when we are with a patient. When we are unavailable the telephone is answered by an answering service [machine, voice mail, or by secretary] [that is monitored frequently, or who knows where to reach us]. We will make every effort to return your call on the same day you make it with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach your therapist and to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If your therapist will be unavailable for an extended time he or she will provide you with the name of a colleague to contact, if necessary. Uses and Disclosures for T reatment, Payment, and Health Care Operations We may use or disclose your protected health information (PH I), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: refers to information in your health record that could identify you. Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist/therapist. Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. applies only to activities within our clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. applies to activities outside of our clinic, such as releasing, transferring, or providing access to information about you to other parties. Uses and Disclosures Requiring Authorization We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. : If you file a worker's compensation claim we are required to obtain written consent to release records relevant to that claim to your employer or its insurer. Page 2 of 7

3 Professional Misconduct - Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care to substantiate disciplinary concerns only with written release signed by the client. Report of professional misconduct is to be reported to the Department of Regulation and Licensing. Uses and Disclosures with Neither Consent nor Authorization We may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If we have reasonable cause to suspect that a child seen in the course of our professional duties has been abused or neglected, or have reason to believe that a child seen in the course of our professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, we must report this to the relevant rtment. Duty to Warn and Protect - When a client discloses intentions or a plan to harm another person or persons the health care 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. Prenatal Exposure to Controlled Substances - Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. - I the spouse or parents of a deceased client have a right Adult and Domestic Abuse: If we believe that an elder person has been abused or neglected we may report such information to the relevant county department or state official of the long-term care ombudsman. Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that we release records to them in order for the Examining Board to investigate a complaint we must comply with such a request. Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release the information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance, if this is the case. Serious Threat to Health or Safety: If we have reason to believe, exercising our professional care and skill, that you may cause harm to yourself or another, we must warn the third party and/or take steps to protect you, which may include instituting commitment proceedings. Minors & Parents - Patients under 14 years of age who are not emancipated and their parents should be aware that the we decide that such access is likely to injure the child, or we agree otherwise. We will complete. Before giving parents any information we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. Other Provisions When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies frame, and the name of the clinic or collection source. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. All consultations will be noted in your Clinical Record. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures. You should be aware that we practice with other mental health professionals as well as administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of Page 3 of 7

4 confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work we do not say the name of the on is not provided to us we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the clinic (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines. PR O F ESSI O N A L R E C O RDS You should be aware that, pursuant to HIPAA, we keep Protected Health Information about you in professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier as well as psychotherapy notes. While the contents of Psychotherapy Notes vary from client to client they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your records if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in your therapists presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, we charge a copying fee of $0.45 per page (and for certain other expenses). We may withhold your records until the fee is paid. Client data of clinical outcomes may be used for program evaluation purposes but individual results will not be disclosed to outside sources. Patie Civil Rights Your civil rights are protected by federal and state laws. Cultural/Spiritual/Gender Issues You may request services from someone with training or experiences from a specific cultural, spiritual, or gender orientation. If these services are not available, we will help you in the referral process. Treatment - You have the right to take part in formulating your treatment plan. Denial of Services - You may refuse services offered to you and be informed of any potential consequences. Medical/Legal Advice - You may discuss your treatment with your doctor or attorney. Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. Upon your request, we will send your bills to another address.) Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, we will discuss with you the details of the request process. Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process. Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, we will discuss with you the details of the accounting process. Right to a Paper Copy You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically. Costs of Services - We will inform you of how much you will pay. Page 4 of 7

5 Termination of Services - You will be informed as to what behaviors or violations could lead to termination of services at our clinic. Confidentiality - You will be informed of the limits of confidentiality and how your protected health information will be used. We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will post changes at the clinic. We dedicate ourselves to serving the best interest of each client. We will not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps, preferences, or other personal concerns. We maintain an objective and professional relationship with each client. We respect the rights and views of other mental health professionals. We will appropriately end services or refer clients to other programs when appropriate. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. We will continually attain further education and training. We hold respect for various institutional and managerial policies, but will help improve such policies if the best interest of the client is served. : You are responsible for your financial obligations to the clinic as outlined in the Payment Contract for Services. You are responsible for following the policies of the clinic. You are responsible to treat staff and fellow patients in a respectful, cordial manner in which their rights are not violated. You are responsible to provide accurate information about yourself. Non-Voluntary Discharge from Treatment - A client may be terminated from the Center non-voluntarily, if: A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the non-voluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to re-apply for services at a later date. BI L L IN G A ND PA Y M E N TS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. The Person Responsible for Payment of Account is required to sign the form, Fees and Service Policy, which explains the fees and collection policies of the clinic. [In circumstances of unusual financial hardship we may be willing to negotiate a fee adjustment or payment installment plan.] 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 me to disclose otherwise confidential information. In most collection situations, the only information we provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] INSUR A N C E R E I M BURSE M E N T In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you Page 5 of 7

6 receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a oning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy.] You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement you agree that we can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Scott Williamson BA, at You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. Effective Date, Restrictions and Changes to Privacy Policy This notice went into effect on May 1, We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will post a revised notice in the clinic. Page 6 of 7

7 Consent to T reatment I,, the undersigned, hereby attest that I have voluntarily entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, at Forward Choices, L L C, hereby referred as the Clinic. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge. My signature below indicates agreement with the following statements. I have been informed of my individualized treatment recommendations and the benefits of proposed treatment and services through Forward Choices, LLC. I have been informed of possible outcomes and side effects of my individualized treatment recommendations. I have been informed of the cost of treatment and services provided through Forward Choices, LLC The way that treatment is to be administered and services are to be provided through Forward Choices, LLC have been explained to me in a clear manner. The approximate duration and desired outcomes of my treatment recommendations have been clearly explained to me. I have been informed of my rights as a consumer including my right to be directly involved in the development of my individualized treatment plan. I have been provided with knowledge of Alternative treatment modes and services that may be available to me. I have been informed how to utilize Forward Choices, LLC grievance procedure as governed under Ch. DHS 94. I have been informed how to obtain emergency mental health services during periods outside of the normal operating hours of Forward Choices, LLC. I have been informed of Forward Choices, LLC discharge policy, including circumstances under which I may be involuntarily discharged for inability to pay or for behavior reasonable the result of mental health symptoms. The probable consequences of not receiving the proposed treatment and services suggested through Forward Choices, LLC have been explained to me. The time period for which this informed consent is effective, is to be no longer than 15 months from the time that consent is given. I have been explained and understand the right to withdraw informed consent at any time, in writing. I understand that as a recipient of services, I may get more information from I certify that I have been provided with a copy of the Grievance Procedure and Form, and understand I have received this statement and any explanations to questions I consent to treatment and agree to abide by the above stated policies and agreements with Forward Choices, L L C. Client Signature: Date: Client Printed Name: Parent/Legal Guardian Signature: Therapist Signature: Date: Date: Therapist Printed Name: Page 7 of 7