Patient Information and Consent Agreement
CONFIDENTIALITY: We are committed to protecting the privacy of our communication and your clinical records. The following are some exceptions to the confidentiality as required by law or in order to provide you with services:
- Information (such as diagnosis, progress and dates of service) that may be shared with your insurance company.
- Information you and/or your child reports about child or elder abuse that we are obligated to report to the Department of Children and Family Services.
- When you sign a release of information that informs us that you are in danger of harming yourself or others.
- And as outlined in the HIPAA Notice of Privacy Practices.
AVAILABILITY/EMERGENCY SITUATIONS: You may leave a message at any time on our confidential voicemail at (410)742-3055. If you would like for us to return your call please be sure to leave your name and phone number along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal business hours within 24 hours.
If an emergency situation arises for which you feel immediate attention is necessary, understand that you are to contact emergency services in the community for those services by going to the nearest emergency room, or dialing 911. You may also contact the Life Crisis Center at (410) 749-HELP.
PURPOSE AND NATURE OF YOUR INITIAL EVALUATION: Every new client and any client returning to treatment will receive an “intake” or an evaluation before a treatment plan is developed. This evaluation process will review your complete history with information gathered via your completion of our Intake forms and diagnostic review(s). This process is usually completed with in the first three sessions.
- Additional options to the proposed treatment
- Potential reactions to the proposed treatment
- Estimated cost associated with treatment
PURPOSE AND NATURE OF THE THERAPY PROCESS: it is our intention to provide professional services that will assist yo in reaching your goals. Based upon the information that you provide and the specifics of your situation, we will provide recommendations to your regarding your treatment. We believe that therapists and clients are partners in the therapeutic process. After an evaluation has been completed will develop a treatment plan with your input. In the development of that treatment plan, varies modalities will be presented for you to consider. Remember, therapy is a service that your purchase and if you are not happy with the services received it is your responsibility to make that known so we can discuss any hindrances to your progress. We will also periodically initiate discussions about the progress of treatment. Due to the varying nature and severity of problems and the individuality of each client, we are unable to predict the length of your therapy or guarantee a specific outcome or result.
POTENTIAL RISKS: Therapy is a process of exploring your emotional life. For many, indentifying and expressing emotions can be challenging. Also for many, experiencing emotions can often be new and at times intense. Your therapist will help guide you through that process as well as offer you tools to learn how to both tolerate thee emotions as well as regulate them.
RIGHT TO TERMINATE TREATMENT AND DECLINE TREATMENT: Therapy is a process that unfolds differently for everyone. The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and progress you achieve. We want to make sur you are aware that you have a righto stop therapy at any point or refuse any suggested modality. If you or your counselor determine that you are not benefiting from treatment, either you or the therapist 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. If you are discontinuing therapy because of not feeling comfortable with your therapist, please let us know and we will arrange for you to be referred to a different provider either within our agency or to an outside agency. It is a good idea to plan for your termination in collaboration with your counselor. Your counselor will discuss a plan for termination with you as you approach completion of your treatment goals.
FINACIAL/INSURANCE ISSUES: If you do no wish to have your insurance billed for services or if we do not accept your insurance, payment in full is expected for each session at the time of treatment. Please make checks payable to ReConnections, LLC. There will be a $35 returned check fee if your check is returned.
If you are using insurance, your insurance company, responsible party, or their party payer ma be billed directly depending on the requirements of the particular plan. At each session you will be expected to pay your co-pay, co-insurance amount, or deductible if applicable. If your insurance company later denies payment or does not cover counseling, we will request that you pay the balance due at that time.
ASSIGNMENT OF BENEFITS AND PAYMENT AUTHORIZATION: I hereby authorize ReConnections, LLC to apply for benefits on my behalf for services rendered. I request that payment from my health insurance carrier(s) to be made directly to ReConnections, LLC. I further authorize the release of any necessary information including medical record information for this or any related claim to my health insurance carrier(s). I permit a copy of this authorization to be used in place of the original. I understand I am personally financially responsible for any amount not covered by my health insurance carrier(s). I am ware that I am placing my signature on file
I/we have read and received a copy of the Notice of Privacy Practices and Client rights document. I have also read this consent for treatment and understand and agree to the policies.