Informed Consent For Counseling Services
I have been given or have been directed to the website of Shoreline Counseling Services LLC and have read the materials provided regarding the practice of therapy.
Confidentiality laws in regard to reporting: 07.01.07.08
.08 Reporting Crimes, Child Abuse, and Neglect.
The following prevail over the confidentiality provisions of this chapter:
A. Suspected child abuse or neglect, or abuse, neglect, self-neglect, or exploitation of a vulnerable adult, shall be reported in accordance with the provisions of Family Law Article, Annotated Code of Maryland;
B. Suspected fraud in the administration of a Department program shall be reported as required by the regulations for that program;
C. Any ongoing or imminent criminal conduct of an applicant or customer may be reported to appropriate law enforcement personnel.
When the custodian of the record discloses confidential information to an individual other than an employee of the Department or a law enforcement agency in accordance with this chapter and COMAR 07.01.02, the custodian shall inform the individual to whom the disclosure is made of the obligation to keep the information confidential, in accordance with Article 88A, §6, Annotated Code of Maryland.
· Doctors and mental health professionals are responsible for maintaining confidentiality of patient information based on the ethical standards of their profession. In an effort to protect potential victims from a patient’s violent behavior, however, many states have passed "duty to warn" laws. These laws impose a duty on psychotherapists to warn third parties of potential threats to their safety.
Health Care Operations is defined by the HIPAA regulations under 45 C.F.R. § 164.501 and is incorporated herein by reference, and includes the following:
1. Quality assessment and improvement, including outcomes evaluation and development of clinical guidelines; population-based activities relating to improving health or reducing health care costs, protocol development, case management and case coordination, contacting providers and patients with information about treatment alternatives; and related functions that do not include treatment.
2. Accreditation, certification, licensing or credentialing activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals.
3. Conducting or arranging for medical review, legal services and auditing.
4. Business planning and development related to managing and operating the entity.
5. Business management and general administrative activities, such as fundraising and marketing of services to the extent permitted without Authorization, disclosure of PHI in a due diligence review or to resolve internal grievances, and customer service.
I understand that ANY missed appointments, OR cancellations (without 24 hour notice), will be charged the full amount, and another scheduled appointment will not be made until the payment is received, unless there are extenuation circumstances, which you would have to have permission by your therapist to waive the fee.
As a parent, I understand that I we have the right to information regarding my minor child, however I we understand that my child has the right to privacy, and a safe environment to disclose himself/herself to the therapist. I would permit my child’s therapist to use their discretion, in accordance with professional ethics and state federal laws, in deciding what information revealed by my child is to be shared with me.
I understand and accept the term as outlined in the material provided regarding confidentially, policies, procedures, fees, and the HIPPA policy.
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Signature / Date
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Signature of Therapist/ Date