Consent for Treatment

NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or legal guardian must complete and sign this form.

Acknowledgment of receipt and understanding: 

I acknowledge that Serenity-BHS has provided me with a copy of the Client Welcome Packet which informs me of Serenity-BHS' Cost of Services policy, Client Rights policy, and HIPAA policy.  I have read and understand the information presented in the Client Welcome Packet and acknowledge that I have the ability to make decisions in regard to my own healthcare needs.

Note: the Client Welcome Packet can also be found on our website, www.serenity-bhs.org.

Communication Policy:

I consent to communications between myself and my therapist through the use of phone calls, emails, and/or cell phone texting in order to schedule or re-schedule appointments.  I understand that I should only communicate non-confidential information via email and texting with my therapist and that email and texting is not a form of treatment. 

Cost of Services Policy: 

Serenity-BHS aims to provide effective counseling services to you and your family. Our Cost of Services Policy is designed to utilize your health insurance as much as possible to cover the fees associated with seeing a Serenity-BHS therapist. Clients are responsible for the cost of services provided by their therapist that their insurance doesn't cover, for example: copays, deductibles, etc. I also understand that the cost to participate in group therapy is set by my insurance company and will be at least $50 per session.

• I agree to check my personal health insurance coverages to understand my copays and deductibles.
• I agree to provide Serenity-BHS with up-to-date primary health insurance and secondary health insurance information and to indicate who is listed as the "primary insured" for each insurance.
• I agree to notify Serenity-BHS when my health insurance changes, so that treatment can continue without interruption.
• I agree to pay the fees associated with my treatment services.

Late Notice Cancellation Policy:

I understand that I must give at least a 24-hour-notice if I intend to cancel my therapy session to avoid paying a $50.00 late notice cancellation fee.  I understand that I have a right to terminate treatment at any time.  I understand that if I miss or cancel my appointment more than twice in a row, that Serenity-BHS has the right to terminate my services. 

Informed Consent for Treatment:

I give consent for my Serenity-BHS therapist to complete a Diagnostic Assessment (DA) of me. I understand that this DA will include completing paperwork during the first two sessions with my therapist. I also consent for treatment as outlined in the treatment plan developed with by my therapist and me during our first two sessions together. I understand that this consent is for the duration of the services being provided to me. I understand that treatment will involve talking about my personal thoughts, feelings, and experiences. I understand that therapy may cause additional stress or emotional difficulty during the course of learning how to resolve and address my presenting problems. I understand that if a crisis occurs, as it relates to my mental health treatment, I can contact Netcare Access or call 911 for assistance. I also understand that my therapist may ask to refer me to external medical services if they feel it is necessary to meet my therapeutic needs. Such referrals may include a medical or psychiatric assessment and will require my signature on a Release of Information form before my therapist can make a referral or release my records. 

Consent to Intern Observation:

Throughout the year, Serenity-BHS has master’s level interns placed with us who are completing their internship program, as a college and board requirement, to become licensed mental health therapists. I understand that my therapist is required to obtain my verbal permission for an intern to observe my counseling session in order for the intern to learn how to become a therapist. I understand that I have the right to say no. I understand that an intern may join my therapy session either by being in the room with us or by watching my session remotely, via a camera. I understand that I will be asked prior to my session if I consent to an intern observing my therapy session. 

Tele-Therapy Consent:

Tele-therapy is a way of providing Outpatient Mental Health Counseling sessions via Microsoft Teams or www.Doxy.me.com, both of which are HIPAA-compliant teleconferencing systems. Tele-therapy psychotherapy includes the practice of diagnosis, treatment, psychotherapy care, consultation, coaching, and/or counseling. A Tele-therapy session occurs primarily through the internet via interactive audio, video, and telephone communications.

 

It is the policy of Serenity-BHS to try to complete the cleint's first session in person and in the office, whenever possible, and then utilize tele-therapy for on-going sessions, especially during a crisis, when a client is sick/contagious, on bad weather days, or when a client is out of town.  

 

Substantial steps have been taken to ensure the confidentiality and privacy of therapy provided online, but there are risks related to tele-therapy services; there can be technological failure such as unclear video, loss of sound, poor connection, or loss of connection.  

 

All existing laws regarding client access to mental health information and copies of mental health records apply.  No permanent video or voice recordings are kept from tele-therapy sessions. Clients may not record or store video conference sessions or face-to-face sessions.

 

Tele-therapy may not be the most effective form of treatment for certain individuals or presenting problems.  Arrangements to meet via tele-therapy must be made in advance and therapists reserve the right to reject requests to meet via tele-therapy if they do not think the situation is appropriate.

 

To participate in a tele-therapy session, the client and therapist must be in a private location that is away from distractions such as other people, a television that is on, outdoor/traffic noise, or anywhere that a person could overhear the conversation being had between the therapist and the client. The client must be dressed appropriately and should be mentally and physically ready for the tele-therapy session. The client and therapist should have the same session expectations as if attending the counseling session in-person.

 

Serenity-BHS cannot guarantee the security of any internet transmissions or communications. The Client agrees to take full responsibility for the security of any communications or treatment on their computer and at their physical location. I agree to release and indemnify Serenity Behavioral Health Services from all suits, claims and other actions originating from any tele-therapy services provided by Serenity Behavioral Health Services. 

 

Please refer to our Client Welcome Packet for more details regarding our tele-therapy policy 

Sick Policy (COVID/Flu/Virus): 
 
I understand that Serenity-BHS follows CDC guidelines when cleaning offices and common areas to decrease the risk of spreading a virus. I also understand that Serenity-BHS therapists and staff monitor their own health to ensure that they do not provide in-person office counseling if they have any COVID/Flu/Virus symptoms or have been exposed to anyone who has COVID. 
 
I understand that carriers of COVID/Flu or other infectious viruses may not show symptoms but may still be highly contagious. I understand that if I have any of the following symptoms listed below, I should cancel my session or request that my session be conducted via tele-therapy:

• Fever/feverish chills
• Severe headache
• Sore throat
• Dry cough
• Shortness of breath or difficulty breathing
• Loss of taste or smell
• Extreme fatigue
• Runny nose
• Muscle or body aches 

I agree that I will not proceed with an in-person therapy session if I exhibit any COVID/Flu/Virus symptoms which may spread to others through close contact.

I agree to cancel my in-person therapy session and request a tele-therapy session if someone from my household, or someone I have had recent close physical contact with, has COVID/Flu/Virus symptoms or are in isolation or quarantine.

Confidentiality Policy:

I understand that all Serenity-BHS therapists and staff are committed to maintaining confidentiality. However, confidentiality will not not maintained where Serenity-BHS is legally required to notify others in situations such as the following:

• Any threat to harm self or others, including murder, suicide, and assault
• Any reports of actual or suspected child abuse, endangerment, or neglect
• Any reports, actual or suspected, of abuse of the elderly or dependent adult
• Any reports of actual or suspected animal abuse
• A clinician (therapist) is court ordered to testify, or a subpoena requires the release of such records to an attorney or investigator
• A guardian or legal custodial parent requests information by signing a Release of Information (ROI) form and are legally allowed to do so

HIPAA Policy:

Your therapist may discuss cases with professional colleagues, without use of names and only when necessary, and will abide by all HIPPA laws as outlined in our agency’s policies and as required by the Ohio State Licensing Board.

I agree to these Consent for Treatment policies and procedures as outlined above.

I give consent for Serenity-BHS to bill me and/or my health insurance for the cost of my services.

I consent for Serenity-BHS to use the credit card I have on file to process my copays after each session or after the insurance company has processed my claims and made known to Serenity-BHS my exact costs.

I also give consent to Serenity-BHS to send me a confidential Client Survey to get my feedback about the services I receive.