Explanation of Services and Informed Consent for Treatment

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1 Explanation of Services and Informed Consent for Treatment The following is offered for your information about services at Mind Spa. If you have further questions, please feel free to bring them up with us. Goal. The goal of all the services provided by Mind Spa is promoting emotional and behavioral health and functioning. We are dedicated to meeting your specific mental health needs, as an individual, couple, or family. Benefits of Therapy. There are a lot of benefits common to those who seek therapy. These include a change of perspective on past situations, current situations, and future choices; increased healthy coping strategies; improved mood; decreased anger and outbursts; improved view of self; enhanced relationships; improved sense of assertiveness; and overall decrease in symptoms related to mental health conditions. Potential Risks of Therapy. There are times when therapy can pose some difficulties. These include positive changes in yourself that can cause conflict in relationships; initial period of intensified symptoms; feeling overwhelmed; feeling of discomfort from disclosure of personal information; and financial hardship. Staff. Mind Spa s professional services are provided by our team of licensed counselors and providers. Cheyenne, WY Dr. Sheri Fluellen, PhD of Philosophy, Counseling from Oklahoma State University and MA of Marriage and Family Therapy from Sioux Falls Seminary: Licensed Psychologist in WY and CO Candise Leininger, MA in Counseling Education from University of Wyoming: Licensed Professional Counselor (LPC) in WY Lindsay Simineo, MA of Community Counseling from Denver Seminary: Licensed Professional Counselor (LPC) in WY Sarah Tilley, MA of Community Counseling from Regent University: Licensed Professional Counselor (LPC) in WY David Briggs, Ed. S. in School Psychology from University of Northern Colorado: Certified Specialist in School Psychology Supervised by: Dr. Sheri Fluellen, PhD Sara Bryan, MA of Clinical Counseling from University of Northern Colorado: Licensed Professional Counselor (LPC) in WA, CO and WY Julie Kostrey, MA of Counseling Psychology from Adler School of Professional Psychology: Licensed Professional Counselor (LPC) in IL Supervised by: Dr. Sheri Fluellen, PhD Brandon Dixon, Masters of Social Work from University of Wyoming Provisional Clinical Social Worker (PCSW) in WY Supervised by: Sarah Tilley, LPC 1 Revised 5/22/2015

2 Robin Gorsuch, MA in Clinical Counseling from University of Northern Colorado: Supervised by: Sarah Tilley, LPC Alyssa de la Torre, MA in Clinical Mental Health Counseling from University of Northern Colorado: Supervised by: Candise Leininger, LPC Adam Stuart-Walker, MA in Community Mental Health Counseling from Chadron State College: Supervised by: Candise Leininger, LPC Helena, MT Ch. Jim Patterson, MDiv, MA of Marriage and Family Therapy from Assemblies of God Theological Seminary: Licensed Marriage and Family Therapist (LMFT) in WY and MT Licensed Clinical Professional Counselor (LCPC) in MT Responsibilities of Mind Spa and your Therapist. We promise to treat you as a responsible individual, giving you the utmost respect in providing you with the best professional services possible. We continually safeguard your welfare and rights, and we uphold high professional standards in all our relationships. Mind Spa therapists adhere to the ethical codes of their professional organizations (such as American Psychological Association (APA) and American Counseling Association (ACA)). Mind Spa does not discriminate against any patients based upon race, sex, national origin, disability, religion, age, or sexual orientation. Our practice promotes honesty and truthfulness, and we encourage this in our clients as well. We are able to help most people with most problems. However if we feel at any point that you would be better served by another professional or by adding resources, we will work with you to find the best resources for you. The following disclosure statement is required by the Wyoming Mental Health Professions Licensing Act: Sexual intimacy with a client is never appropriate and should be reported to the licensing board for the state of Wyoming. Any concerns about your therapist s conduct should be brought to the attention of the supervisors within Mind Spa or to the Mental Health Professions Licensing Board at: 2001 Capitol Ave, Emerson Bldg, Rm 104, Cheyenne WY 82002, Your Responsibilities as a Client. Coming to Mind Spa is a positive step you ve taken to improve your life. Treatment is voluntary, and we operate with the understanding that you have decided to come here to resolve concerns or improve your quality of life. We expect that you will take an active part in your treatment by talking about your concerns, collaborating in developing treatment goals, and following through with plans. If you ever have any questions or concerns about your treatment, we highly encourage you to bring these up with your therapist. We ask that you be on time to your appointments and that if cancellation is unavoidable, you will contact us as soon as possible. Due to the limited availability of appointment times, we ask that you respect our policy: 2 Revised 5/22/2015

3 If for any reason, you cancel within 24 hours of your appointment time or do not show to your appointment, you will be responsible for a missed appointment fee of $25 for Individual/Couple/Family and $15 for Group. We offer a one-time courtesy waive of this fee for the first missed appointment. Please sign below to indicate that you read and understand this policy. Privacy and Confidentiality. In general, your personal health information (PHI) and information discussed in appointments is confidential and may not be released to anyone outside Mind Spa without your permission. We will need to obtain your authorization prior to releasing any PHI and psychotherapy notes for situations not described in this consent. The following is a list of Mind Spa policies relevant to your confidentiality: a) If Mind Spa specifically was given a referral from another helping agency (another counselor, physicians office, etc), our policy is to provide that agency feedback that one of our counselors has met with you for your intake. We will not share any other information with them without your consent. Your signature on this form gives us consent to contact your referral source, if there is one. If you desire that we do NOT contact your referring provider or agency, please initial here: b) We provide the minimal necessary information to health insurance companies during the process of submitting claims on your behalf. c) We utilize outside resources for accounting, bill collections, and legal services. Only minimum and necessary information is released to such individuals, and all outside professional service providers are held to standards of privacy and confidentiality. d) To ensure the highest quality of care, we engage in consultation services with other mental health and medical specialists as needed. We only share relevant treatment information to maintain privacy. Lists of our commonly used professionals are available in our administrative office. Per the Wyoming Privileged Communication Statute of 1999, Section of the Privacy Rule, and other Wyoming laws that address confidentiality, the following is a list of circumstances in which we are legally held responsible to potentially disclose information without your consent or authorization: a) Abuse or harmful neglect of children, the elderly or disabled or incompetent individuals if known or reasonably suspected b) Information related to counseling as necessary to defend against a malpractice action brought by a client c) An immediate threat of physical violence against a readily identifiable victim is disclosed d) An immediate threat of self-inflicted harm is disclosed to the counselor e) The patient or client is examined as a result of a court order f) In the context of investigations and hearings brought by the client and conducted by the Wyoming Professional Licensing Board, where violations of this act are at issue g) The validity of a will of a former client is contested h) The client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation 3 Revised 5/22/2015

4 Additionally, there are some very narrowly defined disclosures allowed to law enforcement agencies, a health oversight agency (such as HHS or a state department of health), a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence. Records of Care. Every appointment with Mind Spa is documented. Paper documentation is kept in a locked filing system. Electronic documentation is kept secure via multiple levels of protection. Information from your mental health record with Mind Spa may not be released without your consent unless under court subpoena or to government agencies with a legitimate legal right to access. Any release of records will be in full accordance with limitations imposed by the Privacy Act of If you would like records to be released, you may complete an Authorization for Release of Information form. You have the right to request your mental health records at any time, and your written authorization will be required for any releases that you request. If Mind Spa ever becomes aware of or suspects a breach in our security, we will give notice of the breach to all potentially affected patients, in accordance with applicable laws and the Final Rule (2013). Hours and Facility. Our standard Cheyenne business hours are from 8:00 AM and 6:00 PM, Monday through Friday. Some flexibility is available outside of those hours upon discussion with your therapist. Alcohol, drugs, and weapons are not allowed in the building, and we ask that you do not come to any appointments under the influence of substances. Insurance and Filing Claims. Mind Spa team members are dedicated to following the billing process with your insurance company and will file your claims for you with your insurance company. To ensure prompt payment from your insurance company, your signature on the Assignment of Proceeds form will grant us permission to have your insurance company send their payment directly to Mind Spa. You have the right to restrict disclosure of Protected Health Information (PHI) to your health plan if you pay out-of-pocket in full for your mental health care at Mind Spa. If you are using insurance to help pay for your mental health care, please understand that your health care is ultimately your responsibility financially. Deductibles, copays, and other arrangements within your insurance plan continue to be your responsibility and are due at time of service payable to Mind Spa. Fees. Our standard fees are as follows: Intake appointment: $ min individual follow-up appointments: $ min individual follow-up appointments: $ min individual follow-up appointments: $ min couples/family follow-up appointments: $200 Group therapy: $50 Legal. If we participate in any legal matters that may arise, we will charge for all time associated with the legal matter. This includes, but is not limited to, consultation with attorneys or other parties related to the legal issue, document writing, preparation for court, appearing in court, and time spent getting to and from court. 4 Revised 5/22/2015

5 Additional fees may apply in other special circumstances, including but not limited to psychological testing, report writing, recommendation letters, and printing and mailing copies of mental health records. We offer a discount on services for those that pay cash for all appointments at the time of service and do not utilize insurance. We have a sliding fee program for those who are part of a low income household and who don t have health insurance. We also offer a hardship program for those who are part of a low income household and who have health insurance, but may still not be able to afford their deductibles, copays, coinsurances, or other Mind Spa expenses. Please see our administrative staff for more information on these programs. Payment. We require that you pay your copays, coinsurance, deductibles, and/or session fees on the day they occur. Monthly statements will be sent out showing any amount that you may owe. Minimum payments are required for every month that there is a remaining statement balance. This payment structure is to help patients avoid substantial debt. Standard Monthly Payment Schedule: Statement Balance of $ $ 50 Pay balance in full $ 51 - $ 300 Minimum of $50 monthly payment $ $ 600 Minimum of $75 monthly payment If a balance of $600 is reached, therapy will be paused until the balance is paid on, or we can give you a referral. Hardship/ Sliding scale agreement Monthly Payment Schedule: Statement Balance of $ $ 25 Must pay balance in full $ 26 - $ 150 Minimum of $ 25 monthly payment $ $ 300 Minimum of $40 monthly payment If balance of $300 is reached, therapy will be paused until the balance is paid on, or we can give you a referral. This payment structure is to help patients avoid substantial debt. If a payment has insufficient funds, your account will be assessed a $30 fee. If your account maintains a balance, finance charges will be applied at a rate of 18% annually. If your account reaches Final Notice Status, a $25 service charge will be assessed to the account. For patients who have reached final notice, we will use our discretion and make a recommendation to transfer your therapy to another mental health provider or agency in town that can better meet your financial situation. If your balance remains unpaid for 90 days and we have no arrangement for a payment, we will turn over the debt to the court system or a 5 Revised 5/22/2015

6 collections company. Disclosure of your information is limited to demographic information, dates of service, fees incurred, and payments made. Information related to treatment content will not be disclosed. If there are any issues regarding your treatment at Mind Spa not discussed above, please inform our administrative staff or your therapist. Client Signature Date Client Name Printed 6 Revised 5/22/2015

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