Thomason Counseling Services, LLC
2596 N. Stokesberry Pl. #105, Meridian, ID 83646.
Ph. 208-918-1636 Fax. 208-936-3788
shane@thomasoncounseling.com
Informed Consent
What to Expect
Your first visit will help me to get a general understanding of your situation to determine how I might best help you. Because this is your work and your process, please don’t hesitate to ask questions.
This Form Is an Agreement between You and Me
You may cancel this agreement in WRITING at any time. This cancellation will be binding on me unless I’ve already relied on this agreement to take action, or if your health insurer requires me to send information needed in order to process claims made for your services if you haven’t paid your bill in full.
This Form Contains Information about HIPAA
HIPAA (Health Insurance Portability and Accountability Act) regulates the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that I provide you a Notice of Privacy Practices. This notice, also posted on the bulletin board in the waiting room, explains HIPAA’s application to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. We will give you a copy of this Agreement, including the notice.
Counseling Purpose
Counseling is a way of working through your problems in order to begin resolving them. It is a:
· Process of collaboration between you and me, working as a team toward implementing healthy goals.
· Process you will need to take an active part in by working on, and thinking about the things you talk about with me
My role is to:
· Provide a supportive and safe environment in which you can explore the areas of your life that are of concern
· Assist you or your family in the process of making life decisions by exploring different options
· Support you or your family in reaching autonomy, where you are more effective in handling difficult areas in your life
My primary approach, which is based out of Cognitive-Behavioral, Solution Focused, and Client-Centered therapies, is to help you discover what is best for you and your family. I will be approaching these sessions with an objective eye, taking a professional view point, and keeping your interests and concerns a top priority. I will always try to find what is most helpful in each session to assist you in dealing with issues as they may arise. We will work together in setting realistic goals of how you or your family would like to think, feel, and be at the end of counseling. Counseling has been shown to have many benefits, however, there are no guaranteed results. At times you may experience strong emotions. I will always strive to create the safest environment possible for you to feel free in expressing them. There may be times in which you leave session feeling unhappy or distressed. I will also provide you tools to manage those feelings more effectively. Because this is such a personal process, I may not be the best personality fit for you. If you feel like this is the case, you are always free to end counseling with me without a fear of judgment; further, I can make an appropriate referral to another therapist in order for you to continue your therapy process.
Possible Therapy Goals
· Gain insight and understanding of both problematic and positive life patterns as they affect you and your loved ones
· Learn new information about significant components of relationships, including communication styles, conflict resolution and responsible commitment
· Gain insight into effective methods of establishing a wellness-oriented lifestyle within the physical, psychological and social aspects of living
Client Rights
· You may leave the premises at any time. You will not be detained against your wishes, unless you are an imminent danger to yourself or others.
· You may refuse any service or counseling technique that you do not want.
· You have the right to discontinue services at any time. If termination is done against my recommendation, I will document this in your medical records. For those court-ordered or required by probation/parole, your terms with court or probation/parole may overrule the right to discontinue counseling at will.
· You can expect to receive treatment that is beneficial to you and respects your values and is free from any form of abuse.
· You may report immoral or unethical activities to the Idaho Bureau of Occupational Licenses.
· You have to right to receive written information about fees, methods of payment, my qualifications and licensure level, insurance coverage, possible length of services, emergency procedures and cancellation policies.
· You have the right to ask questions at any time about what occurs during counseling and be provided satisfactory answers.
· At least one parent/guardian must be involved in the counseling of any minor child.
Appointments
Individual and family sessions may last 45 or 60 minutes. Also, insurance companies often require an initial intake assessment, which may take longer than 60 minutes. Once the appointment is made, the time is set aside for you. If you cancel an appointment, please provide notice at least 24 hours before the session. If you fail to contact me 24 hours prior, you will be charged your copay amount, or a $25 no-show fee (whichever is higher) for the time you reserved the appointment. Insurance doesn’t cover charges for no-shows or last minute cancellations. You will be personally responsible for any such charges. If you have two or more no-shows or last minute cancellations, I may choose remove you from the schedule and give you other options for scheduling. If you are over 15 minutes late, I may cancel your appointment and no-show fees will apply. There are times when I may be unable to start your session on time. If I am late, you will be given your full session time.
Fees, Health Insurance, and Managed Care
Counseling fees are anywhere from $90 to $130 depending on the type of service. All fees are due at the time of service. If you are using your insurance benefits, I will bill your insurance company. Please take the time to inform yourself of what service your insurance provides. Please note that in the event your insurance provider doesn’t pay for services, you are responsible for all fees. For problems involving payments and insurance, please contact me at 208.918.1636. Many insurance plans are managed care plans. Under these plans, the insurance company periodically requires me to submit your diagnosis, progress, and treatment plan to their reviewer, who then determines if further treatment is medically necessary. We want you to know that if you have a managed care plan, this information will be released to the reviewers. Sometimes, clients are concerned about releasing this information, as future coverage or insurance costs may be affected. If you don’t want me to release this information, you can choose not to use your insurance coverage and pay for services yourself at the time of each visit.
Your approval/signature of this form authorizes me, Shane Thomason of Thomason Counseling Services, to release your confidential information to your insurance carrier for the purposes of verifying benefits, billing, and other information requested by your insurance company. It also indicates that you understand that you are responsible for all fees not reimbursed by the insurance carrier.
Professional Standards
I am required to adhere to the professional code of ethics adopted by the Idaho Counselor Licensing Board. If you have reason to believe that I have acted in an unethical manner you have the right to file a complaint in writing to the Idaho Bureau of Occupational Licenses located at 1109 Main Street, Suite 220, Boise, ID 83702, or by phone at 208.334.3233.
You may, at any time, seek a second opinion or request to see another counselor. If you are dissatisfied with my services, it is your responsibility to seek another provider or to end treatment (unless treatment is court-ordered). A referral to another provider will be given upon request.
Confidentiality and Client Records: Notice of Privacy Policies and Practices
Federal and state laws governing confidentiality can be quite complex. This notice explains some specific patient rights that you have under these laws.
Client Records
I will maintain a clinical medical record file on your case. You may examine and/or receive a copy of your file if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. There is a charge of $30 per hour for writing reports and for copying materials. PLEASE NOTE: If you are being seen in couples, group, or family therapy, Idaho laws concerning confidentiality are not clear. I will not release information to other parties without written permission of all individuals involved in the therapy session, except when allowed/required to do so by state or federal law, unless a court order requires me to release information about your case.
If you request that your records be released to another professional, your requests will be fulfilled within 30 days of your written request to transfer this information, provided there is no outstanding balance on your account with me. The above-mentioned fee of $30 per hour will be charged for these requests, with a minimum charge of ½ hour or $15.
Confidentiality
Information provided by you during our therapy sessions is legally confidential. I cannot be forced to disclose information without your consent with the following exceptions:
· Information may be released to parents of minor children who have the legal right to access their children’s medical information.
· Authorized by other state laws.
· If I am a defendant in a civil, criminal, or disciplinary action arising from therapy.
· You are a defendant in a criminal proceeding, and the use of confidential information would violate your rights to a compulsory process.
· If you are a danger to yourself or others, or if there is suspected child abuse, neglect, or other harm.
· When I deem necessary to consult with a supervisory or clinical team regarding treatment (without utilizing any protected health information about you and only engaging in consultation with other professionals who also must maintain confidentiality)
You may choose to engage in electronic communications with me, including email and texting. If you choose to do so, it is important for you to understand that confidentiality may be difficult to guarantee in this format. If you would like to use this form of communication with me, please let me know in writing.
Court Appearances
At times, a client may ask me to appear in court on their behalf or the behalf of their children. Counseling is primarily a therapeutic relationship with goals focused on personal growth and healing, with all information shared in a session being confidential. Therefore, it is my policy to refuse all requests to appear in court on the behalf of any client. In the case that I am subpoenaed to testify in court, an hourly fee of $250 will be assessed for preparation, travel and time in court. Four hours of services to be paid prior to the court appearance and the remainder of the balance, if any, will be due upon completion of the work related to the subpoena.
Children as Clients
It is my goal to consult with you on a regular basis, and to involve you in your child’s therapy as needed but with respect to your child’s privacy. In order for counseling to be a success, children, like adults, need privacy in order to feel safe in exploring whatever issues they may be dealing with. This level of confidentiality would not include those instances in which the child’s or another’s safety is believed to be at risk.
At times, it is necessary for me to end a session early. It is my policy that a responsible adult MUST be present in the waiting room while the child is in session.
Thomason Counseling Services, LLC
2596 N. Stokesberry Pl. #105, Meridian, ID 83646.
Ph. 208-918-1636 Fax. 208-936-3788
shane@thomasoncounseling.com
Telehealth Treatment Consent
1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
6. In brief, I understand my provider will not be physically in my presence. Instead, we will see and/or hear each other electronically. Some information my provider would ordinarily get in face-to-face consultation may not be available in teleconsultation. I understand such missing information could in some situations make it more difficult for my provider to understand my problems and to help me get better. My provider will be unable to touch me or to render any emergency assistance.
7. I understand telehealth consultation(s) are a new form of treatment, in an area not yet fully validated by research, and they have potential risks, possibly including some not yet recognized. Among the risks that are presently recognized are the possibility the technology will fail before or during the consultation, the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and the information may be intercepted by an unauthorized person or persons.
8. I authorize the release of information pertaining to me determined by my provider, my other health care providers or by my insurance carrier to be relevant to the consultation(s) or processing of insurance claims, including but not limited to my name, Social Security number, birth date, and clinical or medical record information.
9. I understand at any time, the consultation(s) can be discontinued by me. I further understand I do not have to answer any question I feel is inappropriate or whose answer I do not wish persons present to hear, that any refusal to participate in the consultation(s) will not affect my continued treatment, and that no action will be taken against me. I acknowledge, however, that diagnosis depends on information, and treatment depends on diagnosis, so if I withhold information, I assume the risk a diagnosis might not be made or might be made incorrectly. Were that to happen, my treatment might be less successful than it otherwise would be, or it could fail entirely.
10. I also understand, under the law, and regardless of what form of communication I use in working with my provider, my provider may be required to report to the authorities information suggesting that I have engaged in behaviors that endanger others.
11. The alternatives to the consultation(s) have been explained to me, including their risks and benefits, as well as the risks and benefits of doing without treatment. I understand that I can pursue in-person consultations. I understand that the telehealth consultation(s) does not necessarily eliminate my need to see a specialist in person, and I have received no guarantee as to the consultation’s effectiveness.
12. I understand my telehealth consultation(s) may be recorded and stored electronically as part of my medical records. I understand consultations, test results, and disclosures will be held in confidence subject to state and/or federal law. I understand I am ordinarily guaranteed access to my medical records and copies of records of consultation(s) are available to me on my written request. I also understand, however, if my provider, in the exercise of professional judgment, concludes that providing my records to me could threaten the safety of a human being, myself or another person, he or she may rightfully decline to provide them. If such a request is made and honored, I understand that I retain sole responsibility for the confidentiality of the records released to me and I may have to pay a fee to get a copy.
13. I have received a copy of my provider’s contact information, including his or her name, telephone number, voice mail number, business address, mailing address, and e-mail address. I am aware my provider may contact the proper authorities in case of an emergency. I acknowledge, however, if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person, I am not to seek a telehealth consultation. Instead, I will seek care immediately through my own local health care provider or at the nearest hospital emergency department or by calling 911.