Acknowledgment of receipt and understanding:

I certify that Serenity-BHS has provided me with a copy of the Client Welcome Packet which includes the cost of services, Client Rights and HIPAA policy.  I have read and understand the following items.  I have the ability to make decisions in regards to my own healthcare needs.

Cost of Services Policy:

Serenity-BHS Fee Policy is designed to ensure that you can utilize your health insurance as much as possible to cover the cost of services.  Serenity BHS aims to provide adequate and effective counseling services to you and your family.  Clients are responsible for the cost of all services provided by their therapist when insurance does not pay for such services due to deductible or other issues that may arise.  I understand the cost of group therapy is set by my insurance company and will be at least $40 per session.  I agree to pay for the fees associated to my treatment services.    

Informed Consent for Treatment:

I give my consent for a diagnostic assessment.  I understand that an assessment will include doing some paperwork during the first two sessions with my therapist.  I also consent for treatment as outlined in my treatment plan that I will develop with my therapist within the first two sessions with my therapist.  I understand that this consent is for the duration of the services to be provided.  I understand that treatment will involve talking about my personal thoughts, feelings, and experiences.  I understand that therapy may cause some additional stress or emotional difficulty during the course of learning how to resolve and address presenting problems.  I understand that if a crisis occurs as it relates to my mental health treatment, that 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 before my therapist can release records or make a referral.

Consent to Intern Observation:

Serenity-BHS has Master’s level interns placed with us whom are completing their internship in order to become a licensed therapist.  I understand that my therapist may request permission for an intern to observe my counseling session in order for the intern to learn how to be a therapist.  I understand that I have the right to say no.  I understand that the intern may join my therapy session via in the room with us or by watching the session from a different room via a camera.  I understand that I will be asked prior to my session if I consent to the intern observing my therapy session.

Tele-Therapy Consent:

Tele-Therapy is a modality of providing Outpatient Mental Health Counseling via www.SecureVideo.com, www.Doxy.me.com, Microsoft TEAMS, or TherapyNotes, all of which are HIPAA Compliant tele-conferencing systems. The policy of Serenity Behavioral Health Services is to try to complete the first session in person, in the office, if and whenever possible.  Then utilizing E-Therapy via the internet for on-going counseling services, especially for crisis sessions, sick days, bad weather days and when clients are out of town on personal matters. 

Serenity Behavioral Health Services has taken substantial steps to ensure the confidentiality and privacy of therapy provided online.  Serenity Behavioral Health Services cannot guarantee the security of any internet transmissions or communications. Client agree to take full responsibility for the security of any communications or treatment on my own computer and in my physical location.

Client understand that therapy conducted online is technical in nature and that problems may occur with internet connectivity. Internet availability may be limited or disrupted by things such as server maintenance, upgrades or other problems (such as software or hardware malfunction). Any problems with internet availability or connectivity are outside the control of Serenity-BHS, and Serenity-BHS makes no guarantees that such services will be available. If something occurs to prevent or disrupt any tele-therapy session due to technical complications, Serenity-BHS therapist may resume the session by telephone with the client.

Cancellation Policy:

I understand that I need to give at least a 24-hour notice if I intend to cancel my therapy session in order to avoid paying the cancellation fee of $50.00. I understand that I have a right to terminate treatment at any time.

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 therapists and that email and texting is not a form of treatment.

Confidentiality Policy:

I understand that my therapist and the staff of Serenity-BHS are committed to maintaining confidentiality. Please note that confidentiality will not be maintained in the event of the following:

1. Any threat to harm self or others, including murder, suicide, and assault
2. Any reports of actual or suspected child abuse, endangerment or neglect
3. Any reports, actual or suspected, of abuse of the elderly or dependent adult
4. Any reports of actual or suspected animal abuse
5. Clinician is court ordered to testify or a subpoena requires the release of such records to an attorney or investigator.
6. Guardian or legal custodial parent requests information.

HIPAA Policy:

 

Your clinician may discuss cases with professional colleagues, without use of names, as deemed necessary. However, your therapist will always abide by the rules as outlined in our agency’s policies, Ohio State Licensing Board rules, and will be compliant with HIPPA.

I agree to these policies and fees. I give consent for Serenity-BHS to bill me and/or my health insurance for the cost of my services. I also give consent to Serenity-BHS to send me a confidential Client Survey to get my feedback about the services I receive.