Client-Counselor Service Agreement
This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. Please be aware that when using our website and submitting any correspondence like submitting forms or sending emails, you are digitally agreeing to the Terms and Service of maternalwell.com and/or any providers associated with the practice maternalwell.com. It also represents an agreement between us. We can discuss any questions you have once you agree to all of the policies of the practice.
Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. Our clinic/providers have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Goals of Counseling
There can be many goals for the counseling relationship. Some of these will be long term goals such as improving the quality of your life, learning to live with mindfulness and self-actualization. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will be set by the clients according to what they want to work on in counseling. The counselor may make suggestions on how to reach that goal but you decide where you want to go.
Risks/Benefits of Counseling
Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.
Clinical Interview Appointments
We will work with patients to arrange the easiest time for their schedule in regards to Clinical Interview Appointments. We ask that you try your best to keep the scheduled time that you book so that our providers and you the patient can have the most efficient process. Clinical Interview will ordinarily be 60 minutes in duration, although some sessions may be longer or shorter depending on the need of the patient. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with 24 hour notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you may be responsible for a cancelation fee if needed. In addition, you are responsible for attending your session on time; if you are late, your appointment may still need to end on time.
Our providers will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Your counselor may consult with a supervisor or other professional counselor in order to give you the best service. In the event that your counselor consults with another counselor, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If your counselor receives a court order or subpoena, they may be required to release some information. In such a case, your counselor will consult with other professionals and limit the release to only what is necessary by law.
Confidentiality and Technology
Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Skype, video conferencing, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Your counselor will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone, voice mail or other technology used in your counseling sessions. Should a client have concerns about the safety of their email, your counselor can arrange to encrypt email communication with you.
Your counselor may keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically on a USB flash drive or in a paper file and stored in a locked cabinet in the practice office.
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card, check or cash. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment.
If you anticipate becoming involved in a court case, we recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.
Payment plan options may be available to receive sliding scale fees. Fees are subject to change at counselor’s discretion.
We accept all insurance providers and in-network providers for most insurance providers. We cannot guarrentee that we are in network with health insurance provider. If you have a health insurance policy, it will may or not provide coverage for mental health treatment. You are responsible for knowing your coverage and for letting us know if/when your coverage changes.
You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information which will become part of the insurance company files. By agreeing to the Terms and Service of maternalwell.com you are essentially agreeing digitally and agree that I can provide requested information to your carrier if you plan to pay with insurance.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover counseling fees. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services.
A receipt will be furnished for any fees you pay to the clinic. If we are not participating provider for your insurance plan, we will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, we can assist with referring your to a colleague or other provider.
I hereby instruct and direct my insurance company to pay by check made payable to: MaternalWell or any providers associated with the clinic to be reimbursed for medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS FROM THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assigned, and I agree to pay any balance of said professional services charges over and above this insurance payment at the time service is rendered.
I also authorize the release of any information pertinent to my case to any insurance company. A photocopy or facsimile of this Assignment shall be considered as effective and valid as the original.
Please contact us by email or by phone 24 hours a day 7 days a week. We may be with a clients or otherwise be unavailable and may not be available immediately. At these times, you may leave a message on our confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.
Email Opt In
Our providers may request client’s email address. Client has the right to refuse to divulge email address. Our providers may use email addresses to periodically check in with clients or coordinate sessions. Our providers may also use email addresses to valuable therapeutic information such as tips. Our providers also has a blog and if this is appropriate for the client, counselor may send information through email about subscribing to the blog or information related to mental health and wellness. If you would like to opt out of email correspondence, please contact us so we can mark it in your chart.
Text Messaging Opt In
Normally we do not text message patients. By agreeing to these Terms and Service you understand that we may utilize text messaging with process like to appointment reminders. By texting to maternalwell.com, you are automatically opting in and authorizing us to respond back with a text message.
Standard text messaging rates and data charges may apply. Contact your carrier for details. stop please contact the clinic directly. Other terms and conditions may apply. We will not share your information with any other person or entity.
We will use secure systems to safeguard your cell number and privacy. There is no connection to the mobile marketing and your account details. Also all text messages from will include the word We will not send any specific account information using this system.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
By using our services, website, or using any correspondence between you and our practice/clinic/providers associated with our clinic, you fully AGREE and indicate that you have READ AND FULLY UNDERSTAND the entire Terms and Service of maternalwell.com and AGREE to its terms.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and/or indirectly;
- Obtain payment from third-party payers; and
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge I understand your Notice of Privacy Practices uses and disclosures of your health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time, and I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
I understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.