Informed Consent to Short Term Treatment Including Teletherapy
Informed Consent Details
Welcome to the Wendt Center for Loss and Healing. This informed consent document is designed to provide you with information about the counseling process, as well as the benefits, and risks associated with it. Please read through this document thoroughly and ask your therapist for clarification if you have any questions.
I. By signing this consent for short-term treatment form:
- I am electing to participate in short-term counseling that is a maximum of 2 sessions.
- I understand that the short-term therapist I meet with will in most cases not be my future, long-term therapist.
- I understand that while this may not be the ideal method of treatment, short-term counseling at the Wendt Center is intended to be a temporary option while remaining on the waiting list for longer-term counseling.
- I understand that after my short-term 2 sessions, I must inform the Wendt Center if I would like to remain on the waiting list for future, long-term services.
- I understand that after my short-term 2 sessions, I am no longer an ‘active’ client of the Center while on the waiting list. I understand that it is my responsibility to acquire other therapy or support during the waiting list time and that my short-term therapist will not be available to support me during this time. The Wendt Center will provide resources and referrals to other providers upon request.
- I understand that the Wendt Center is not a 24 hour, crisis organization. I understand that in the case of an emergency after my 2 short term sessions, and during non-office hours, I will need to contact the District of Columbia’s emergency hotline, Access Help Line (1-888-793-4357), Crisis Link (1-800-784-2433) or dial 9-1-1 in the case of a life-threatening emergency.
- I understand that my therapist will give me clear guidance towards the types of treatment recommended (such as individual counseling, group counseling, family counseling and/or psychiatric services) and the times, dates and session length will be discussed.
- I voluntarily agree to undergo mental health treatment and understand that I may end treatment at any time. I understand that my therapist may want to discuss this with me, and that I reserve the right to end treatment.
- I understand that in certain situations a therapist may decide that it is not in his/her, or in the client’s best interest to continue therapy. While this happens rarely, the therapist also has the right to terminate a therapeutic relationship. If this happens, appropriate referrals will be provided in an effort to ensure client needs are met.
- I understand that my therapist may be required to make a professional diagnosis for reasons of third party billing and may be required to submit that diagnosis to the third party biller.
- I understand that my therapist cannot guarantee results of treatment. However, there will be clearly stated reasons, goals, and objectives for continuing/ending mental health treatment.
- I understand there may be some challenges in participating in mental health treatment. These might include, addressing painful emotional experiences and/or feelings; and being challenged or confronted on a particular issue. I am aware that I can discuss any challenges with my therapist at any time.
- I understand that if I have a grievance with my therapist, I will first attempt to communicate this directly to him/her. In the event that the grievance is not satisfactorily resolved, I understand that I have the right to speak with a supervisor, request a new therapist, and/or speak directly with the Wendt Center’s Executive Director.
- I understand that this Consent is not intended to be “all inclusive” of aspects of my mental health treatment. It is only intended to provide some basic information to assist in making a decision to engage in treatment.
II. By signing this consent for short-term treatment form for telehealth/ teletherapy services:
- I voluntarily agree to undergo mental health treatment via telehealth services and understand that I may opt out at any time.
- I understand that in certain situations a therapist may decide that it is not in his/her, or in the client’s best interest to provide therapy via telehealth.
- I understand that the Wendt Center will be using an approved, HIPAA compliant vendor platform to provide phone and/or video therapy, and that in order to receive teletherapy, I must also use the approved platform. In certain cases, teletherapy may be conducted only using audio with therapist approval.
- I understand that it is my obligation as a client to be in a space where I can openly and privately participate in teletherapy.
- I understand that while the Wendt Center is using a HIPAA compliant platform to conduct our teletherapy session, and values our clients’ security and privacy, the platform is provided by a third party. I understand that in very rare instances, third party security protocols could be hacked, causing a breach of privacy while on the phone or video session.
- I agree to inform my clinician of the address where I am located at the beginning of every teletherapy session.
- I understand that if I am having suicidal or homicidal thoughts, or in a crisis, I will inform my therapist immediately. I understand that if we cannot address my status remotely that I will access emergency services independently.
III. The information that you share with your therapist and/or other Wendt Center staff is considered to be confidential. In most cases, information cannot be released to another party without your written consent. HOWEVER, LOCAL AND FEDERAL LAW AND PROFESSIONAL CODES OF ETHICS REQUIRE THAT IN CERTAIN CIRCUMSTANCES, INFORMATION CAN AND WILL BE SHARED WITHOUT YOUR PERMISSION. These circumstances include:
- Suicide: if you are assessed to be a danger to yourself; cannot guarantee your physical safety against the intention of suicide; and/or have immediate suicidal plans, this information cannot be kept confidential. Actions may be taken to ensure your safety.
- Homicide: if you are assessed to be a danger to others; cannot guarantee their safety; and/or have immediate, specific plans to cause fatal injury/harm to another person, this information cannot be kept confidential. Actions may be taken to protect the safety of others.
- Child Abuse/Neglect: D.C. law requires ALL mental health providers to report any and all suspicions/knowledge of child abuse/neglect to the appropriate authorities.
- Elder Abuse/Neglect: D.C. law requires ALL mental health providers to report any and all suspicions/knowledge of elder abuse/neglect to the appropriate authorities.
- Court order/subpoena: your therapist can be required to relinquish a copy of your written Mental Health Record to the appropriate Courts. Mental health providers can also be subpoenaed to testify in court without your consent.
- Minors can consent to outpatient mental health treatment in the District of Columbia without parental permission or notification provided the minor is knowingly and voluntarily seeking the services and the provision of those services is clinically indicated for the minor’s well-being (DC Code section 7-1231 §7-1231.14) This includes not sharing information with parent(s)/caregiver(s)/case manager(s) without the child’s permission.
- Client medical records are destroyed after the legally required duration.
IV. Confidential mental health information may also be used in a number of ways within the Wendt Center for Loss and Healing without your written permission for the purpose of coordinating services within the agency and delivering high quality care. Examples of this include:
- Consultations and case conferences with other providers at the Wendt Center.
- In supervisory meetings with student interns and associate therapists at the Wendt Center.
- For billing purposes: a diagnosis is given to your insurer for reimbursement purposes. You have the right to review that diagnosis at any point in your care.
V. Client financial records will be kept and maintained with the same level of privacy and security as clinical records.
- Financial records will be kept separate from client’s clinical records
- Financial records will be maintained for ten years and will be appropriately destroyed at the same times as a client’s clinical record
VI. Health Insurance Portability and Accountability Act (HIPAA):
- I understand that I may request a copy of the Wendt Center for Loss and Healing’s HIPAA Notice of Privacy Practices at any time, view it any time, or view it on the Center’s website at www.wendtcenter.org.
- I understand that if I provide my email and phone number to the Center, unless I elect otherwise, this information may be used for appointment reminders, surveys, closure notices, and other appointment related communication. After I am no longer a client, this information may be used for future Wendt Center fundraising efforts. I understand that I may opt out of these options at any time by informing the Center. More details regarding these uses can be found on the above mentioned HIPAA Notice of Privacy Practices.
VII. Billing/fee Information:
- I understand that I am responsible for any co-pays or fees not covered by third parties. I understand that failure to pay for services may result in denial of services. Because payment is expected at the beginning of each session, there should be little to no potential for disputes about payment.
- The same fees that apply for in-person sessions will apply to teletherapy sessions.
- I understand that it is the policy of the Wendt Center to charge a “no show” fee in the event that I do not call or cancel an appointment with 24 hours’ notice. I understand that I will be responsible for the payment of this charge as most insurance companies do not cover such charges. I understand that if a third party payer does cover these charges, I may be depleting my allotted funds.
- More information regarding our billing and fees can be found on the Wendt Center Client Fee Agreement form.
I have read and understand this informed consent. I understand the limits of confidentiality required by law. I consent to the use of a diagnosis in billing, and to the release of that information and other information necessary to complete the billing process. I agree to pay the fee agreed upon at the time of the service provided. I understand my rights and responsibilities as a client and the rights and responsibilities of my therapist. I agree to participate in therapy at the Wendt Center for Loss and Healing and understand that I can end therapy at any time. I understand that this document will be reviewed periodically should issues with its content arise, or should adjustments need to be made.
Client Fee Agreement
Rates and Policies
ASSIGNMENT OF BENEFITS
I authorize and request that payment of benefits by my primary insurance company and my secondary insurance (if any) be made directly to the Wendt Center for Loss and Healing for services furnished to me or my dependent. I understand that my insurance company may only cover a portion of the total bill. I further understand that I may be responsible for all charges not covered by my insurance(s). I authorize the Wendt Center for Loss and Healing or my insurance company to release any information required to process my claims.
If client payment is required, payment is due at the time of service. Payment may be made by cash, check, debit/credit card, or money order. Please make checks payable to the Wendt Center. We charge a $25 fee for any check returned for insufficient funds. Clients will be given a receipt at the time of payment. Insurance clients are responsible for any balance unpaid by insurance including deductibles, co-pays, co-insurance, etc.
Patients may only carry a balance for 2 sessions. Clients will not be eligible for services until the balance is paid in full.
CANCELLATION OF APPOINTMENTS
In order to cancel an appointment, the Center must be notified more than 24 hours prior to the scheduled session. If this notice is not given, the appointment will be marked as ‘missed’ and you will be charged. If private insurance is paying for services and you have a missed appointment, you will be responsible for paying the full contracted rate (copay + insurance’s contribution) for the given session. This does not apply to group services. Clients who have 2 or more ‘missed’ appointments over a 3 month period will be terminated from services. Clients must request to be placed back on the waitlist. Clients are only eligible to be placed back on the waitlist 2 times after being terminated due to missed appointments.
CHANGES IN COVERAGE
If at any time a client’s financial situation or insurance changes significantly, such as changes in employment, please discuss this with the front desk. A new client agreement must be completed as needed. If you are covered under a grant and the grant expires, you will be given notice and an opportunity to change your payment type to continue services. It is your responsibility to notify the Wendt Center immediately of termination of coverage or any other change in coverage. Changes in payment that are not reported will result in client being billed.
I have read, understand, and agree to the above policies. I understand that I am financially responsible for services received from the Wendt Center for Loss and Healing and I agree to pay for any portion of my treatment that my insurance plan or assigned third party payer does not cover.
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