How To Protect Your Health Care Information From Disclosure

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1 Thank you for choosing North Valley Christian Counseling. We look forward to working with you. Please take a few minutes to fill out the following forms. We will also take a few moments at the beginning of your first appointment to answer any questions you may have about these forms and our practice. One of the questions we are often asked is how to find our office. You may visit our website at northvalleychristiancounseling.com to view a Google map. For you convenience, some instructions are also included below. ARROWHEAD: Go north on 79th Avenue from Bell Road. We on are the forth floor in the white four story building between Costco and Arrowhead Mall next to Desert Schools Federal Credit Union. METRO: Go north on 35 th avenue from Peoria Avenue. Turn right on the fifth drive way and you will see Trinity Bible Church through the iron fence. We are located in the first door on the left off the lobby in the Education building. Sincerely, the staff at NVCC.

2 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please speak with your counselor/psychologist at NVCC. This Notice of Privacy describes how this office may use and disclose your protected health care information to carry out treatment, payment, or health care operations and for those other purposes that are permitted or required by law. It also describes your rights to access and control you protected health information. Protected Health Information (PHI) is information about you that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. This office is required to abide by the terms of this Notice of Privacy Practices. This office may change the terms of the notice at any time. Upon your request, you will be provided with any revised Notice of Privacy Practices. Under most circumstances, this office is required by law to obtain your written permission for any disclosure (electronic, written, or oral communication) of identifying information about you and your treatment. If you or your counselor/psychologist believe that communication with a third party would be beneficial (for example, previous psychotherapists, physicians, school personnel, court system), you will be asked to sign a release of information to that effect. PAYMENT: Your PHI may be used as needed to obtain payment for your mental health care services. Please be aware that your PHI may be electronically submitted (i.e., sent via fax or the Internet) for these purposes. If you choose to use insurance to pay your healthcare bills, you will be asked to sign a release of information to your insurance company for purposes of authorization of sessions and payment. Examples of information sometimes required by insurance companies to approve or pay for services include your name, diagnosis, treatment plan, prognosis, and, if your chart is chosen for review, notes that document your progress in treatment. If you are being seen through Workers Compensation, you will be asked to sign a release of information to that organization for purposes of authorization of sessions and payments. Examples of information required by Workers Compensation to approve and pay for services include your name, diagnosis, treatment plan, prognosis, and notes that document your progress in treatment. If individual client accounts are left unpaid for more than 90 days, your name, address and phone numbers, and attendance in treatment may be given to a collection service for purpose of collection.

3 HEALTHCARE OPERATIONS: This office may use or disclose your PHI as needed in order to support the business activities of this practice. This office may share your PHI with third party business associates that perform activities such as billing and accounting services for the practice. Whenever an arrangement is made between this office and a business associate that involves disclosure of your PHI we will have a written contract that contains terms that will protect the privacy of your PHI. There are some circumstances that require your counselor/psychologist to disclose your PHI, even without your consent. The following are examples of the types of uses and disclosures of your PHI that this office must make. If appropriate, your counselor/psychologist will make efforts to communicate imminent disclosures to you prior to their occurrences If your counselor/psychologist suspects that a child has been hurt physically or sexually, or neglected (this includes witnessing violence in the home), Child Protective Services will be contacted. If an adult is living in a relationship that is violent, Adult Protective Services will be contacted. If you are at high (imminent) risk for suicide, communication with appropriate persons (e.g., hospital personnel, police officers) to ensure your safety may occur. If you report to your counselor/psychologist that you intend to kill another person, your counselor/ psychologist will contact the targeted person(s), appropriate persons to ensure your safety, and local law enforcement. If a judge issues a court order, your PHI may be disclosed to the relevant judicial body. I fully understand and accept/decline (circle one) the terms of this content. Signature Date Relationship to the client (Client or guardian) Signature Date Relationship to the client _ Witness Date

4 CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR OFFICE OPERATIONS I,, understand that as part of my health care, the office of North Valley Christian Counseling originates and maintains the paper and/or electronic records describing my health history, symptoms, diagnoses, treatment, and any plans for future care or treatment. I understand that my information serves as: A basis for planning my care and treatment A source of information for applying my diagnosis and services obtained to my bill A means by which a third-party payer can verify that services billed were actually provided I understand and have been provided with a copy of the Privacy Notice that provides a more complete description of information uses and discloses. I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or office operations. I understand that this office is not required to agree to the restrictions requested. I understand that I may revoke this request in writing, except to the extent that action has already been taken. I also understand that by refusing to sign this consent or revoking this consent, North Valley Christian Counseling may need to refuse to provide treatment by Section of the Code of Federal Regulations. I further understand that the office of North Valley Christian Counseling reserves the right to change this notice and practices in accordance with section of the code Federal Regulations. Should this office change this notice, a copy will be sent to the address I have been provided. I wish the following restrictions to the use or disclosure of my health information: I understand that as part of this office s treatment, payment, or office operations, it may become necessary to disclose my Personal Health Information to another entity, and I consent to such disclosure for these permitted purposes, including disclosures via fax. I fully understand and accept/decline (circle one) the terms of this content. Signature Date Signature Date Witness Date Relationship to the client

5 Billing and Cancellation Policy The following rates apply to services provided by NVCC. Payment is expected at the time of service unless other arrangements have been made. Your counselor/psychologist will provide a bill suitable for submission to your insurance company upon request. Initial Assessment minutes $120 Individual therapy minutes $120 Family Therapy minutes $120 Marriage therapy minutes $120 Appearance for court or depositions, whether testimony is given or not: Four hour minimum fee includes travel time and preparation ($250 per hour). Telephone testimony includes same fee of 250 dollars per hour and 4 hour minimum. NVCC reserves the right to charge a fee of $50 for missed appointments not cancelled within 24 hours in advance. I have read and agree to the above terms. Signature Date Relationship to Client (Client or guardian) Signature Date Relationship to client (Client or guardian) _ Witness Date

6 Information Questionnaire for Adults Name: Today s Date: Address: Home Phone#: City: Work Phone #: State: Zip: Cell Phone #: Date of Birth: Age: address: (Include address only if NVCC may contact you by .) Marital Status: (Please circle one) Single Married Divorced Separated Widowed Please indicate the date (month/year) for the marital status circled above: Spouse s Name: Date of Birth: Children s Names: Date of Birth Age Sex M / F M / F M / F M / F Emergency Contact Person: Phone #: Describe any current medical problems: Family Physician: Phone #: List any medications currently being taken: Highest Grade or Degree Completed: Major: Year: Employed by: Job Title: Spouse Employed by: Job Title:

7 Client Intake Name: Today s Date: Brief comment regarding reason for counseling: If you have been married before, please list first name of former spouse(s) and dates of marriage: Name: _ Married from: To: Name: _ Married from: To: My mother is still living and is years old. She lives in My mother has been deceased since. My father is still living and is years old. He lives in My father has been deceased since. My parents are not/never were divorced. My parents are divorced after years of marriage. Growing up, I lived with my: biological adoptive step foster parents. List all siblings, according to birth order: (include step and half siblings): Name: Age: M / F Name: Age: M / F Name: Age: M / F Name: Age: M / F Name: Age: M / F Please list where you were born and the last two cities/states you have lived in: Place of birth: City/State: From: To: City/State: From: To: Have you received professional/pastoral counseling within the last five years? Yes No With whom? When? Have you ever been hospitalized for a psychological condition? Yes No Name of hospital: From: To: Do you currently have trouble sleeping? Yes No If yes, describe: How is your appetite? Good Poor I eat when not hungry Other, Please describe: Do you drink alcohol? Yes No Describe how often:

8 Ruth Mann earned her Master of Arts in Professional Counseling degree from Ottawa University and a Christian Counseling diploma from Phoenix Seminary in She is currently a Licensed Associate Counselor and will be participating in counseling under the direct supervision of NVCC s Joan Cook, M.C., LMFT, or other licensed NVCC supervisors. Ruth did a counseling practicum with Scottsdale Bible Church Counseling Ministry, a chemical dependency practicum at the Salvation Army Adult Rehabilitation Center, and then completed her internship at Phoenix Christian Counseling Associates (PCCA). Ruth has also served 10 years in the Stephen s Ministry lay counseling program of her church, and led a group for sexual abuse survivors for several years as well. At NVCC, Ruth s areas of counseling include: Addictions Anger Anxiety Grief & Loss Self Esteem Personal Growth Substance Abuse Sexual Abuse Women s Issues Relationship Issues Pre-Marital Covenant Marriage Marriage Divorce Recovery Domestic Violence Ruth s faith is important to her and she lives an authentic Christian life. She agrees that confidentiality is crucial in order to maintain the level of professionalism at North Valley Christian Counseling and will strictly maintain confidentiality regarding all clients and staff. Ruth is not a medical physician and does not treat psychotic disorders or prescribe medication. The fee for counseling is $ per 50-minute session. However, fees may be modified based on your family s gross annual income and ability to pay. I have read and understand the above. Date My signature above indicates my consent to the use of prayer as an intervention in my counseling.