BHTS
Behavioral Health Treatment Solutions, LLC
7000 Peachtree Dunwoody Road; Bldg 6 – Suite 302; Atlanta, GA 30328
Phone: (678) 234-6089 Fax: (678) 579-9664
Welcome
It is a pleasure to work with you at Behavioral Health Treatment Solutions, LLC (BHTS). The information in this packet pertains to the treatment and financial policies of BHTS. Please read the packet in its entirety and be sure to sign the agreement at the end of the packet so that we know you understand and acknowledge all guidelines and policies.
Informed Consent
Client Rights and Informed Consent
Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. This framework helps to create the safety to take risks and the support to become empowered to changes. As a client in counseling, you have certain rights that are important for you to know. There are also certain legal limitations to those rights. As your counselor, I have corresponding responsibilities to you.
Confidentiality
With the exception of certain specific described below, you have the absolute right to the confidentiality of all communications and I may only release information about the sessions to others with your written permission.
Privacy/Confidentiality
Communication between you and your therapist is considered privileged and confidential. No information will be released without your written release. The only exception to these conditions may occur in situations such as child abuse, danger to life, Disability or Worker’s Compensation where by law other action is permitted.
Uses and disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
- Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you and/or others.
- Child or Adult Abuse – If there is reasonable cause to believe that a child, disabled adult or elder person has had a physical or sexual harm inflicted upon to a child, disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that to the appropriate authority.
- Judicial or Administrative Proceedings – if you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information, without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
- Disability Claims or Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to disability or worker’s compensation or other similar programs, established by law without regard to fault.
GEORGIA HIPAA NOTICE
Notice of Policies and Practices to Protect the Privacy of Your Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Georgia State Laws.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION UNDER THE NEW HIPAA LAWS. PLEASE REVIEW IT CAREFULLY.
- Use and Disclosure for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
- “PHI” refers to information in your health record that could identify you.
- “Treatment, Payment and Health Care Operations” is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another therapist.
- “Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- “Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operation are quality assessment and improvements activities, business-related matters such as audits and administrative services, and case management and care coordination.
- “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of my office such as releasing, transferring, or providing access to information about you to other parties.
- Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversations during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater of protection than PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization: or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
- Appointment Length and Phone Calls
Individual, couple, and family therapy are billed on the basis of 45-50 minutes. If an appointment runs longer, you will be charged for the additional time. The charge will be determined and prorated on the basis of each additional 15 minutes of time. If there are phone calls between appointments that are other than scheduling appointments, there may be a charge assessed on a prorated basis of 15 minutes for the additional time.
- Cancellations
Any cancelation of an appointment need to be made at least 24 hours prior to your scheduled appointment. If you miss an appointment or fail to cancel your appointment within 24 hours for non-urgent issues, you will be charged a non-refundable fee of $50.00. If it is an EAP session you forfeit the session.
INFORMATION, AUTHORIZATION, & CONSENT TO TELEMENTAL HEALTH
This is designed to inform you about what you can expect from us regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to TeleMental Health. TeleMental Health is defined as follows:
“TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.”
Telephone via Landline:
It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If this is not an acceptable way to contact you, please let your therapist know. Telephone conversations (other than just setting up appointments) are billed at the hourly rate.
Cell phones:
In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, we realize that most people have and utilize a cell phone. Use by cell phone for contact is typically only for purposes of setting up an appointment if needed. Additionally, your therapist may keep your phone number in his/her cell phone, but it will be listed by your initials only and his/her phone is password protected. If this is a problem, please let your therapist know, and you he/she will be glad to discuss other options. Telephone conversations (other than just setting up appointments) are billed at the hourly rate.
Text Messaging:
Text messaging is not a secure means of communication and may compromise your confidentiality. Furthermore, sometimes people misinterpret the meaning of a text message and/or the emotion behind it.
Email:
Email is not a secure means of communication and may compromise your confidentiality. However, realize that many people prefer to email because it is a quick way to convey information. Nonetheless, please know that it is the policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that it is required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy.
Limitations of TeleMental Health Therapy Services
TeleMental Health services should not be viewed as a complete substitute for therapy conducted in our office, unless there are extreme circumstances that prevent you from attending therapy in person. It is an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, your therapist might not see a tear in your eye. Or, if audio quality is lacking, he or she might not hear the crack in your voice that he or she could have easily picked up if you were in our office.
There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Please know that BHTS has the utmost respect and positive regard for you and your wellbeing.
Consent to TeleMental Health Services
Please check the TeleMental Health services you are authorizing to utilize for your treatment or administrative purposes. You will ultimately determine which modes of communication are best for you. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying in writing.
Texting
Video Conferencing
Electronic IM Forum
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Feel free to ask questions, about these and other modalities of communication and treatment.
Client Information and Consent for Services and the Georgia HIPAA Notice
Signature Page
I have read, understand, agree to abide by the terms and conditions set forth in the Client Information and Consent for Services, and do hereby consent to participation in the treatment as described in the consent agreement. I also understand that my participation is entirely voluntary, and that I may withdraw my consent and terminate treatment at any time.
I have been provided with the Georgia HIPAA Notice and I understand.
HIPAA is a federal law that provides privacy protection and assured patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a complete printed copy of the Georgia HIPAA Notice for use and disclosure of PHI for treatment, payment, and health information in great detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. We can discuss any questions that you may have about the procedures outlined in the Georgia HIPAA Notice
______
Client (or Guardian) Signature Date
BHTS
Behavioral Health Treatment Solutions, LLC
Name:Today’s Date:
Address:
City:State:Zip:
Source of Referral:Type(s) of Service
Phone Number:Work Phone:Date of Birth: / /
Email Address:
I give permission to communicate by email YesNo
I give permission to communicate by texting YesNo
Primary Insurance Company:
Address: City:St: Zip:
Phone Number:
Subscriber:Policy Number:
Group Number:Subscriber’s DOB://
Emergency Contact:Relationship:
Phone Number:
If you need more space for any of the questions, please use back of the sheet.
Primary reason(s) for seeking services:
Anger management / Anxiety / Coping / DepressionEating Disorder / Fear/phobias / Mental Confusion / Sexual Concerns
Sleeping problem / Addictive behaviors / Alcohol/drugs
Other mental health concerns (specify):
Family Information
Living Living with you
RelationshipName Age Yes No Yes No____
MotherFather
Spouse
Children
Marital Status (more than one answer may apply)
Single / Divorce in process / Unmarried, living togetherLength in time / Length in time
Legally Married / Separated / Divorced
Length in time / Length in time / Length in time
Widowed / Annulment
Length in time / Length in time / Total # of marriages
Assessment of current relationship (if applicable) / Good / Fair / Poor
Special circumstances (e.g. raised by person other than parents, information about spouse/children not living with you, etc.):
Development
Are there special, unusual, or traumatic circumstances that affected your development? Yes No
If Yes, please describe:Has there been history of child abuse? / Yes / No
If Yes, which type(s)? / Sexual / Physical / Verbal
If Yes, the abuse was as a: / Victim / Physical / Verbal
Other childhood issues: / Neglect / Inadequate nutrition / Other (please specify
Comments re: childhood development:
Social Relationships
Check how you generally get along with other people: (check all that apply)
Affectionate / Aggressive / Avoidant / Fight/argue often / FollowerFriendly / Leader / Outgoing / Shy/withdrawn / Submissive
Other (specify):
Sexual orientation: / Comments:
Sexual dysfunctions? / Yes / No
If Yes, describe:
Any current or history of being a sexual perpetrator / Yes / No
If Yes, describe:
Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)? / Yes / NoIf Yes, please describe and indicate the court and hearing/trail dates and charges:
Are you presently on probation or parole? / Yes / No
If Yes, describe
Past History
Traffic violations: / Yes / No / DWI/DUI: / Yes / NoCriminal involvement: / Yes / No / Civil involvement: / Yes / No
If you responded Yes to any of the above, please fill in the following information.
Charges / Date / Where (city) / ResultsEducation
Fill in all that apply: / Years of education: / Currently enrolled in school? / Yes / NoHigh school grad/GED
Vocational: / Number of years: / Graduated: / Yes / No / Major:
College: / Number of years: / Graduated: / Yes / No / Major:
Graduate: / Number of years: / Graduated: / Yes / No / Major:
Special circumstances(e.g. learning disabilities, gifted):
Employment
Begin with most recent job, list job history:
Employer / Dates / Title / Reason left the job / How often miss work?Currently: / FT / PT / Temp / Laid-off / Disabled / Retired
Social Security / Student / Other (describe):
Military
Military Experiences? / Yes / No / Combat Experience? / Yes / NoWhere:
Branch: / Discharge date:
Date drafted: / Type of discharge:
Date enlisted: / Rank at discharge:
Medical/Physical Health
AIDS / Dizziness / Nose bleedsAlcoholism / Drug abuse / Pneumonia
Abdominal pain / Epilepsy / Rheumatic Fever
Abortion / Ear infections / Sexually transmitted Diseases
Allergies / Eating problems / Sleeping disorders
Anemia / Fainting / Sore throat
Appendicitis / Fatigue / Scarlet Fever
Arthritis / Frequent urination / Sinusitis
Asthma / Headaches / Small Pox
Bronchitis / Hearing problems / Stroke
Bed wetting / Hepatitis / Sexual Problems
Cancer / High blood pressure / Tonsillitis
Chest pain / Kidney problems / Tuberculosis
Chronic pain / Measles / Toothache
Colds/Coughs / Mononucleosis / Thyroid problems
Constipation / Mumps / Vision problems
Chicken Pox / Menstrual pain / Vomiting
Dental problems / Miscarriages / Whooping cough
Diabetes / Neurological disorders / Other: (describe):
Diarrhea / Nausea
List any current health concerns:
List any recent health or physical changes:
Current prescribed medications / Doses / Dates / Purpose / Side effects / Who Prescribed
Are you allergic to any medications or drugs? / Yes / No
If Yes, describe
Date / Reason / Results
Last physical exam
Last doctor’s visit
Last dental exam
Most recent surgery
Other surgery
Upcoming surgery
Family history of medical problems:
Please check if there have been any recent changes in the following:
Sleep Patterns / Eating patterns / Behavior / Energy levelPhysical activity level / General disposition / Weight / Nervousness/tension
Describe changes in areas in which you checked above:
Chemical Use History
Method of use and amount / Frequency of use / Age of first use / Age of last use / Used in last 48 hours / Used in Last 30 DaysYes / No / Yes / No
Alcohol
Barbiturates
Valium/Librium
Cocaine/Crack
Heroin/Opiates
Marijuana
PCP/LSD/Mescaline
Inhalants
Caffeine
Nicotine
Over the counter
Prescription drugs
Other drugs
Counseling/Prior Treatment History