Consent for Treatment Contract Page 4
turning point counseling Services
To My Clients:
The following information is to familiarize you with who I am, my policies and my practice. If you have any questions, I will be pleased to answer them.
ABOUT MYSELF:
I am a Licensed Professional Counselor (License #499) in the state of Alaska, a Master Addiction Counselor (#507427) by the NAADAC Certification Commission, a National Certified Counselor (# 82380) by the National Board for Certified Counselors (NBCC), and a Board Certified Counselor (#12546) by the American Psychotherapy Association (APA). I have worked in the field of addictions since 1998, and have been a practicing clinician for Mental Health and Addictions since 2003. My experience includes working in a residential Substance Abuse treatment center as a Chemical Dependency Clinician, as a Senior Mental Health Counselor and Crisis Stabilization Unit Coordinator for a private corporation, as a Licensed Social Service Provider at Community Behavioral Health, and as a Mental Health Clinician and Clinical Supervisor for an Alaska nonprofit health corporation. I have extensive postgraduate training in both Mental Health and Substance Abuse treatments including Individual and Group Critical Incident Stress Management, Co-Occurring Disorders, Personality Disorders, Mindfulness Therapy, Child Parent Relationship Therapy (Filial Therapy), Sexual Trauma, Solution Focused Therapy, and Dialectical Behavioral Therapy, and have attended the Annual School on Addictions. I have over 3 years supervisory experience in Mental Health and Substance Abuse. I obtained my Bachelors Degree in 2000 in Psychology from the University of Southern Mississippi. I hold two Masters Degrees, a Master of Science in Counseling Psychology and a Master of Education in Adult Education, both also received from the University of Southern Mississippi. My Counseling Psychology Masters program training provided me with strong foundations in Client Centered, Cognitive Behavioral, Rational Emotive Behavioral, Solution Focused, and Family Systems therapies. I consider myself as a solution-oriented therapist, but I will draw from my wide training experience to match what works best with each individual.
CONFIDENTIALITY:
The maintenance of strict confidentiality is essential to the practice of clinical and counseling psychology. Your informed written consent is required for the release of any information about you (or you child) except in the following circumstances:
1. I am legally obligated to inform the police if I have reason to believe a client is likely to inflict bodily harm on another person.
2. If I assess a client to be at high risk of suicide or gravely disabled due to a mental illness I am legally obligated to arrange for protective hospitalization.
3. I am legally obligated to report suspected child abuse to the State Office of Children’s Services (OCS). I am also required by law to report suspected abuse of handicapped or elderly persons.
4. In certain legal situations, my treatment records may be ordered to be released by a court of law. Please discuss with me any concerns in this regard.
5. When an insurance claim is filed for my services the client (or legal guardian) gives their health insurance carrier the right to make inquires regarding their mental condition. In certain cases, I may be asked to provide details concerning a client’s presenting problem(s) and treatment needs. Insurance companies usually require a signed release from clients in order to pay benefits directly to a health service provider.
6. If necessary, I may release a client’s name to a collection agency. In these cases, no treatment related content would be disclosed.
In releasing confidential information, I will only disclose those details of a case that are legally or clinically necessary.
If you see someone leaving my office area that you recognize, please respect his or her confidentiality, as you would want them to do the same for you.
YOUR HEALTH INFORMATION RIGHTS:
Your treatment file will be kept for seven years after your last date of service. After that time, it will be destroyed. Although your health record is the physical property of my practice, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) you have the right to:
· Obtain a paper copy of this notice of information on request.
· Inspect and receive a copy of your health record.
· Amend or supplement certain information in your health record.
· Request communications of your health information by alternative means or at an alternative location.
· Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
MY RESPONSIBILITIES:
My practice is required to:
· Maintain the privacy of your health information.
· Provide you with this notice as to my legal duties and privacy practices with respect to the information I collect and maintain about you.
· Abide by terms of this notice.
· Notify you if I am unable to agree to a requested restriction.
· Accommodate reasonable requests you may have to communicate health information by alternative means or at an alternative location.
I reserve that right to change my practices and to make new provisions effective for all protected health information I maintain. Should my information or practices change, I will mail a revised notice to the address you’ve supplied. I will not use or disclose your health information without your written authorization, except as described in this notice. I will also discontinue to use or disclose your health information after I have received a written revocation of the authorization.
FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions or would like additional information you may speak with me. If you believe your privacy rights have been violated, you can file a complaint with me or with the Office for Civil Rights, US Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Office of Civil Rights or myself.
FEES:
Initial assessment fee is $280.00 and usually takes 1.5 to 2 hours to complete.
Individual and Family therapy sessions are billed at $140.00 per 50-minute hour.
PAYMENT METHOD AND INSURANCE:
Payment is expected in full at the time of your initial assessment, except in cases where an advance arrangement with outside state and other agencies has been contracted. Your insurance will be billed for you as a courtesy unless you request otherwise.
Co-Pays & deductibles for subsequent sessions must also be paid at the time of service. As a courtesy, your insurance will be billed for the balance; however, you are ultimately responsible for the amount owed regardless of what the insurance pays.
COURT TESTIMONY AND REPORTS:
Court testimony, depositions, and written reports to the court will be charged at a rate of $175.00 per hour. Travel and waiting time will be included in the hourly rate. Please discuss with me in advance any court related services you may require.
BROKEN APPOINTMENTS:
Appointment that are not kept or not canceled in advance will be billed at half the normal session rate.
PHONE CALLS:
If you need to call me, please call: 978-4576. During weekend, after hours, and other times when I may be unavailable, I have an answering service that will take your call and assist you.
If you have a crisis and need immediate help after hours, call Fairbanks Community Behavioral Health Center at 452-1575 and they will be able to assist you. They have masters level clinicians who you will be able to talk to.
INSPECTION OF RECORDS:
Federal law grants you the right to review any notes, psychological assessment reports, or other documents that are part of your treatment record. If you would like to review these records, please let me know. Your treatment file will be kept for seven years after your last date of service. After that time it will be destroyed.
MISCELLANEOUS:
If you are obtaining services for your child and the child is in an individual therapy session with me, I ask that a parent or guardian remain close and leave me your cell phone.
I take one or more vacations, and regularly attend training seminars. I will inform you in advance of those times when I will be away from my office. I will continue to check my messages and call you within 24 hours of you leaving me a message. Also, when I am out of town, I will make arrangements with another therapist in Fairbanks to cover any emergencies. The answering service will have this information for you.
Please keep me informed of any changes in your address or phone number so I may contact you in case any changes need to be made in scheduling.
By signing below you stated that you have received a copy of the above material. Additionally, your signature gives your consent to receive treatment and states that you agree to abide by the terms outlined above.
______
Client’s Signature Date
______
Parent/Legal Guardian’s Signature Date
(if client is under 18)
______
Joseph Nowell, LPC, MAC, NCC, BCPC Date
Licensed Professional Counselor
Master Addiction Counselor
National Certified Counselor
Board Certified Professional Counselor