Here is a sample of the documents that new incoming clients are required to sign. To receive them via the Client Portal through Simple Practice, reach out via email, then you will be sent a request to create a portal account and complete these documents.
Document 1:
Informed Consent
Forward Thinking Mental Wellness: 201-419-5308, info@ftmwellness.comGeneral Information
Hello and welcome to Forward Thinking Mental Wellness! Beginning therapy is an exciting step in life and the purpose of this document is to outline information you need to make the decision to proceed with treatment, including policies, procedures, and legal aspects of care. It is important that you have an understanding of the information below, and you can ask questions at any time to make sure you’re comfortable with this information.
Clearly defined rights and responsibilities held by each person in the therapeutic relationship are important to help our work together. As a client in psychotherapy, 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. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
Risks and Benefits
The purpose of psychotherapy is to assist individuals in coping with life's problems and resolving conflicts in order to thrive, achieved by increasing awareness, acceptance, coping abilities, and modifying behaviors.
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But there are no guarantees about what will happen. Psychotherapy 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.
The Process
Our first few sessions will involve lots of questions as I get to know you and evaluate your needs. Please try to be open and forthcoming with the information you share; the therapy process is non-judgemental and limiting information may hinder your progress. We will discuss your treatment goals and create a plan to meet them. It is important for you to have input in creating these goals and we will work together to establish priorities that are achievable and relevant.
Therapy may be short-term (i.e., between 5 and 20 sessions) or longer-term (ongoing) depending on the type of problem or issues. For example, when one basic problem of recent onset is identified and is the sole focus of therapy, short-term therapy is likely to be sufficient. When there are multiple problems or difficulties which have persisted over a long period of time, therapy is likely to be longer in duration. Furthermore, many individuals switch the course of therapy as situations change and new challenges arise.
When our work together is reaching its end, the appropriate length of the termination depends on the length and intensity of the treatment. If I determine that the psychotherapy is not being effectively used or if you are in default on payment, treatment may have to be terminated. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. When therapy is terminated for any reason, or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
Appointments & Cancellations
Sessions last approximately 45-53 minutes. Please arrive on time, as we must end on time. We may schedule on a weekly, biweekly, or monthly basis at a mutually agreed upon day and time. You can reach out if you require additional sessions during a specific time of moderate crisis (although I am not always available and cannot be relied upon in an urgent situation) or may wish to adjust the frequency to more or less often as we progress. In the event of a medical or psychiatric emergency, or in any event in which you feel unsafe, please contact 911 or 988 or go to your nearest hospital’s Emergency Room. Do not rely on communicating with your therapist in the event of an emergency.
If you must miss a scheduled appointment, we can try our best to reschedule for another time during that week. I try to accommodate changes as best as I can within reason, and sometimes I may also ask you to be flexible as well. Cancellations made within 24 hours of the appointment will incur a fee of $100. Insurance does not reimburse for cancellations.
Fees
The fee per session will be determined on a case-by-case basis before you begin your first session. You are responsible to pay in full via credit card, Venmo, or Zelle for each appointment. I utilize a platform called Reimbursify which will issue you a “superbill”, or an invoice for the services you received, and you will be able to submit that to your insurance company to potentially obtain reimbursement of a portion of the cost. I am unable to make any guarantees about reimbursement; some people have zero out-of-network benefits while others receive reimbursement for all or most of their session fees–this is determined by the insurance company and not the provider. Regardless of reimbursement, you are required to pay in full for sessions at the time they occur. You are encouraged to set up automatic payments through our client portal, which you can access and make changes to at any time. If you become delinquent in payment, we may need to pause sessions until you are able to rectify the matter. I reserve the right to use an attorney or collection agency to secure past due payments.
In addition to our weekly appointments, you may request additional services from me, such as report or letter- writing, phone conversations longer than 15 minutes, or consultations or meetings with other providers, schools, etc. The fee for these actions will be prorated according to the standard session rate (for example, an ESA letter may take me 30 minutes to write, and therefore would cost ½ of your normal session fee).
If you anticipate becoming involved with a court case, I recommend we have a discussion about your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
Insurance & Payment
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. Forward Thinking Mental Wellness is not in-network with any insurance providers. If you have a health insurance policy with out-of-network benefits, it will usually provide some coverage for mental health treatment. With your permission, my billing service and I will assist you to the extent possible in filing claims for reimbursement (through the superbills mentioned above) and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. I will be glad to share information with you to learn more about your diagnosis, if applicable.
Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information database. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your insurance carrier for payment purposes.
Records
I am required to keep appropriate records of the psychological services that I provide. Your records are digital and maintained securely. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records.
Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional , which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
Confidentiality
Session content and all relevant materials to your treatment are confidential, as per the Health Insurance Portability and Accountability Act (HIPAA). You may, at any time, request in writing to have all or portions of such content released to a specifically named person/persons (you must request a specific form to do so). Limitations of client privilege exist and are itemized below:
If you/the client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If you/ the client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Additionally, I may occasionally need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office. Further, due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients or their family members on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Parents and Minors
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless the child agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. [See Consent for Treatment of Minors Form, to be signed by both youth and parent(s).]
Communication
You may sign up for appointment reminders through the Client Portal, and you may also reach out to me to alert me of a cancellation or request to reschedule an appointment, or with any questions regarding your bill, account, etc. Communication through email or text message is very convenient, however it is not considered secure and your private information may be at risk of being viewed by third parties, as is other information stored on a cell phone or computer. You are welcome to communicate through those channels, however you do so with the understanding of that risk. I strive to reply to all communication within 24-48 business hours. Forward Thinking Mental Wellness operates in the state of New Jersey and all communications regarding time will be in Eastern Standard Time (EST). I am often not immediately available as I do not answer my phone when I am with clients or during my personal time. I will make every attempt to inform you in advance of planned absences and, when possible, provide you with the name and phone number of the mental health professional covering my practice.
In the event of a medical or psychiatric emergency, or in any event in which you feel unsafe, please contact 911 or 988 or go to your nearest hospital’s Emergency Room.
Telehealth
Services by electronic means, including but not limited to video chat, telephone communication, the internet, facsimiles, and e-mail are considered telemedicine/telehealth. Telehealth therapy appointments are considered to take place in the state where the client is located at the time. Forward Thinking Mental Wellness is licensed to operate in New Jersey (and Keith Brouca is licensed in Pennsylvania); please notify me in advance of any out-of-state travel plans that may impact our sessions. I am required to note your location at the start of each session so that I may assist however possible in any type of emergency.
There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.
Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
Social Media
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients or their family members on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. I will not look you up on any social media service or search engine. If there is something you wish to show me that will benefit the therapeutic process, you may do so of your own volition and share a screenshot of the relevant information it via email. Please remember that I have no control over the data and privacy information, contact suggestions, or anything outside of Forward Thinking Mental Wellness. If you have questions about this, please bring them up when we meet and we can talk more about it.
Other Rights
If you are unhappy with what is happening in therapy, I hope you will talk with me and/or the practice owner (Nicole J. Rossetti, LCSW, LCADC –info@ftmwellness.com) so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.
BY ELECTRONICALLY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
EFFECTIVE JUNE 6, 2023
UPDATED JULY 26, 2024
Your signature/checkbox below indicates that you have read, understand, and accept the terms of this Agreement.
Document 2: Contact & Emergency Contacts
Client Contact Information
Client name: _______________________________________________________________
Client date of birth: _________________________________________________________
Cell phone: ________________________________________________________________
Other phone: ______________________________________________________________
Email: ____________________________________________________________________
Home address: _____________________________________________________________
Work address: ______________________________________________________________
Insurance Provider/ID #/Group #/Insurer Phone # for Provers: ______________________________________________________________
Emergency Contacts
Please provide the information for 1-2 trusted contacts in case of an emergency.
Name: ____________________________________________________________________
Relationship to you: _________________________________________________________
Cell phone: ________________________________________________________________
Other contact method: _______________________________________________________
Name: ____________________________________________________________________
Relationship to you: _________________________________________________________
Cell phone: ________________________________________________________________
Other contact method: _______________________________________________________
Document 3: Credit Card Authorization
Credit Card Authorization
Forward Thinking Mental Wellness holds a credit card (Visa, Mastercard, American Express, or Discover) on file to collect payments, cancellation fees, and any past due balances within 30 days of the date of service or less. Payments should be automatically made on the date of service in most cases. If you wish to establish an alternative method of payment (Venmo, Zelle, etc.), your credit card will be stored as a last resort in the event of an outstanding unpaid balance. If a payment is rejected, a second attempt will be made to charge the card after 24 hours. By your electronic signature of this form, you authorize charges to your credit card for services rendered. These charges will appear on your bank/credit card statement as “50 minute psychotherapy appointment”. The rate of therapy services is $185 per 50-minute session (unless you have a different agreement with Forward Thinking Mental Wellness). You have the right to request a paper copy of this document. You certify that you are an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. You acknowledge that credit card transactions could be linked to Protected Health Information. You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Forward Thinking Mental Wellness in writing of any changes to your account information or termination of this authorization.
Client name: _______________________________________________________________
Client date of birth: __________________________________________________________
Credit Card Information
Card type:
Visa
Mastercard
American Express
Discover
Other:__________
FSA/HSA?
Debit
Credit
Cardholder name (as it appears on the card):_____________________________________
Card #: ___________________________________________________________________
Expiration date (mm/yy): _____________________________________________________
CCV (code on back of card): ___________________________________________________
Billing zip code: _____________________________________________________________
I, ____________________________, authorize Forward Thinking Mental Wellness to charge my credit or debit card above for agreed upon purchases. I understand that my information will be stored on file for future transactions on my account.
____________________________________________ _________________________
Cardholder Signature Date
Document 4: Notice of Privacy Practices (HIPAA)
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Confidentiality
As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent. My formal Electronic Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis/progress, and any psychological testing reports. As allowed by law, I may use or disclose records or information for treatment, payment, and health care operations purposes and require you to complete a HIPAA release of information form (attached) for any other disclosures.
II. Limits of Confidentiality
Possible Uses and Disclosures of Electronic Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by New Jersey State Law to report the matter immediately to 1-800-NJ-ABUSE.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, I am required by New Jersey State Law to immediately make a report and provide relevant information to 1-800-NJ-ABUSE
· Health Oversight: New Jersey State Law requires that licensed mental health professionals report misconduct by a health care provider of their own profession. I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. The State of New Jersey has the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to block the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. Confidentiality may be broken in court cases related to allegations of child, adult, or elder abuse or neglect, or when you present a risk of harm to yourself or others, including direct threats of violence. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: Under New Jersey State Law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
· Records of Minors: Individuals under the age of 18 require parental signatures for informed consent and HIPAA-related documents. An exception to this is when minors are authorized to consent for their own health care and do so, the HIPAA Privacy Rule treats them as “individuals” who are able to exercise rights over their own protected health information (PHI). Also, when parents have acceded to a confidentiality agreement between a minor and a health professional, the minor is considered an “individual” under the Rule. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. [This sentence is now required under the HIPAA “Final Rule.”]
III. Patient’s Rights and Provider’s Duties
· Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure, or both; and 3) to whom you want the limits to apply.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voicemail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
· Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process
. · Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
· Right to Amend: If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
· Right to a copy of this notice: You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time.
IV. Changes to This Notice
I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted. I will have copies of the current notice available on request.
V. Complaints
If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
EFFECTIVE JUNE 6, 2023
Document 5: Release of Information (HIPAA)
Client’s Name: ____________________________________________________
Address: ___________________________________________________________ City: _______________________ State: __________ Zip: ________________
Phone: _________________________ DOB: ______/______/_____________
I, ____________________________(name) , authorize Forward Thinking Mental Wellness to:
Receive information from
Send information to
Speak to
Name (individual and/or agency): __________________________________________ Address: ___________________________________________________________ City: _______________________ State: __________ Zip: ________________
Phone: _________________________ DOB: ______/______/_____________
The above information will be used for the following purposes: any/all information necessary for treatment. I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.
I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after 1 year this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.
Your relationship to client:
Self
Parent/legal guardian
Other: _________________
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.
_______________________________________________________________
Signature (self or parent/guardian/representative if applicable) Date signed
_______________________________________________________________
Signature of witness Date signed
Document 6: External Referral Waiver/Release of Liability
I, ______________________________________________________(full name), am requesting a referral from Forward Thinking Mental Wellness to a provider outside of that organization. I understand that Forward Thinking Mental Wellness and its employees are in no way responsible for the actions of such providers and this referral is not a recommendation or endorsement of the quality of their services, expertise, knowledge, or skills. I agree to hold Forward Thinking Mental Wellness and its employees harmless for any harm, injury, loss, damages, malpractice, or other claims against other practitioners, facilities, clinics, agencies, etc.
Document 7: Telehealth Policy
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
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.
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.
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.
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.
CONSENT TO USE TELEHEALTH
Telehealth by SimplePractice, Doxy, or Google meet are the technology services we likely will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:
Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Document 8: Treatment of Minors (optional)
The involvement of children and adolescents in therapy can be highly beneficial to their overall development. Very often, it is best to see them with parents and other family members; sometimes, they are best seen alone. I will assess which might be best for your child and make recommendations to you. Obviously the support of all the child’s caregivers is essential, as well as their understanding of the basic procedures involved in counseling children.
The general goal of involving children in therapy is to foster their development at all levels. At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information. Although those objectives may be part of overall development, they may not be the best goals for therapy. Again, I will evaluate and discuss these goals with you.
Because my role is that of the child’s helper, I will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law. Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child’s therapist.
The issue of confidentiality is critical in treating children. When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right. However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost. Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information. This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy.
· Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible.
· Minors may independently enter into therapy and claim the privilege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases, and when they are on active military duty, married, or officially emancipated. They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child. (These circumstances may vary from state to state, and the specific laws of each state must be followed.)
· Any evaluation, treatment, or reports ordered by, or done for submission to a third party such as a court or a school is not entirely confidential and will be shared with that agency with your specific written permission. Please also note that I do not have control over information once it is released to a third party.
I, (name) ____________________________________ (relationship to child)
& I, (name) ____________________________________ (relationship to child)
agree that my/our child (name) _____________________ should have privacy in his/her/their therapy sessions, and I agree to allow this privacy except in extreme situations, which I will discuss with the therapist. At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information.
I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions. If my child prefers not to volunteer information about the sessions, I will respect his/her/their right not to disclose details. Basically, unless my child has been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following:
· whether sessions are attended
· whether or not my child is/children are generally participating
· whether or not progress is generally being made
The normal procedure for discussing issues that are in my child’s therapy will be joint sessions including my child, the therapist, and me, and perhaps other appropriate adults. If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child present. Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child. I understand that if information becomes known to the therapist and has a significant bearing on the child’s/children’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.
EFFECTIVE JUNE 6, 2023
Signature: _______________________________________ Date: / /
Signature: _______________________________________ Date: / /