INFORMED CONSENT FOR COUNSELING SERVICES Each treatment service that I receive has risks and benefits associated with it. The risks and benefits are outlined below and have been explained to me. My signature indicate that I wish to receive this treatment, and that I have had these benefits and risks explained to me as well as any others that may apply. 

Counseling / Psychotherapy: I understand that therapy is a collaborative effort, and that success or failure is a function of the efforts of both the therapist and myself. Specific benefits of an effective therapy for me are outlined in my individual service plan. General benefits of therapy may include relief of symptoms, increased insight and confidence, improvement in interpersonal relationships, decreased anxiety, and a general improvement in daily functioning. The professional literature suggests that approximately 10% of therapy clients become more dysfunctional because of the stress of treatment.  

Confidentiality has been explained to me and I understand this concept. 

As a minor 14 years of age or older, I understand I am entitled to receive counseling services for not more than six sessions or thirty (30) days, whichever comes first, without the consent of my parent / guardian and without that person being informed. If services extend beyond that point, I will work with my therapist to involve my parent / guardian in my treatment.  

I understand that I have the right to refuse all treatment. 

I also understand that my therapist may decline to provide services to me if I refuse or cannot comply with the necessary requirements of therapy. 

I understand that I have the right to withdraw my consent for all treatments at any time. If I refuse or withdraw consent for treatment, my therapist will try to develop input or an alternative approach to therapy.  

CLIENT POLICIES As a client at Ageless Counseling, you can expect that the following rights will be met: 

-The right to service in a humane setting which is the least feasible restrictive environment  

-The right to be informed of one's own condition, of proposed or current services, treatment, or therapies, and of the alternatives. 

-The right to consent to or refuse any service, treatment, or therapy upon full explanation of the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service, treatment, or therapy on behalf of a minor client. 

-The right to confidentiality of communications and of all personally identifying information within the limitations and requirements for disclosure of various funding and/or certifying sources, state of federal statutes, unless release of information is specifically authorized by the client or parent or legal guardian of a minor client or court-appointed guardian of the person of an adult client in accordance with Rule 5122":2-3-11 of the State of Ohio Administrative Code. 

-The right to have access to one's own treatment records unless access to identified items of information is specifically restricted for that individual client for clear treatment reasons in the client's treatment plan. "Clear treatment reasons" shall be understood to mean only severe emotional damage to the client such that dangerous or self-injurious behavior is an imminent risk. The person restricting the information shall explain to the client and other persons authorized by the client the information about the individual client that necessitates the restriction. Any person authorized by the client has unrestricted access to all information. Clients shall be informed in writing of agency policies and procedures for viewing or obtaining copies of personal records. 

-The right to be informed in advance of the reason(s) for discontinuance for service provision, and to be involved in planning for the consequences of that event. 

-The right to receive an explanation of the reasons for denial of service. 

-The right to know the cost of services. 

-The right to be fully informed of all rights. 

As a client of Ageless Counseling, we expect the following from you as our client: 

-To be motivated for change. By contacting and scheduling appointments with us, we assume that you are prepared to make positive and transformative changes in your life on this journey to inner peace. 

-We expect that you will make the commitment to attend your scheduled appointments. Our time is valuable, and we are here to work with you as you walk down this path of change. Repeated cancellations call into question your commitment to this process. 

-You will be charged a minimum amount of $30.00 for late cancellations or appointments cancelled without 24 hour notice. 

-We use a variety of communication to stay in contact with you including phone, text messaging, and email. If you choose to communicate with us through these methods, you acknowledge that there are limits to what can be kept confidential over the Internet. We are often not immediately available by telephone or outside of business hours. We encourage the use of your support system and coping strategies to manage stress outside of scheduled appointment times. 

-If at any time you feel that you cannot wait for a return phone call or keep yourself safe, please contact 1) Netcare Access at 614-276-2273 or 740/687-TALK, 2) call 988, call 911, or 3) attend your nearest emergency department. 

-We provide appointment reminders for counseling appointments; this service is a courtesy provided to you but you are ultimately responsible for your own appointment time. 

-For counseling services, we schedule typically, hourly appointments for 50 minutes to allow us to have ample time to prepare in advance for our appointment with you. If you arrive late to your appointment, you will still have the same allotted time your appointment will end at ten minutes to the hour. We want to be respectful of everyone's time and make our best effort to keep our appointments on time. 

-We use a variety of treatment modalities at Ageless Counseling that are evidence-based practices to help facilitate your process of change. We will provide you with as much as information as you would like about these modalities and the evidence that supports our decision to utilize these in your treatment process. We recognize that every person is different, and we will develop a treatment plan appropriate to your needs and desired changes. 

-We expect that you will participate in these treatments to the best of your ability and as appropriate by our recommendations.

HIPPA NOTICES OF PRIVACY PRACTICES 

This notice describes how medical/mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This information is effective as of January 1, 2016 Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes. All information released will be in accordance with state and federal laws and the ethics of the counseling profession. This notice describes our policies related to the use and disclosure of client health care information. For the purposes of treatment, we use and disclose health information to provide, manage and coordinate care. This may include case consultation. To obtain payment we use and disclose health information to verify insurance coverage and to process claims and collect fees. We use and disclose health information for healthcare operations such as reviews of treatment and business activities. We will disclose client information to report child abuse, medical emergency and as required by law. 

This includes: - Report of suspected physical, sexual or emotional abuse of a minor to appropriate authorities. - Report homicidal ideation to the identified victim(s) and local police department. - Report suicidal intentions if treatment recommendations are not followed.

Consent for Telehealth Consultation 

This is a telehealth consent form, by signing this form, I understand and agree with the following: 

-Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.  

-Providers may include this provider, other psychotherapists, community representatives and family members, caregivers, or other legal representatives or guardians may join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives, or guardians. The information may be used for diagnosis, therapy, follow-up and/or education. 

-Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include: Progress reports, assessments, or other intervention-related documents. 

-Bio-physiological data transmitted electronically, videos, pictures, text messages, audio, and any digital form of data. 

-The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing, and healthcare operations. 

-By agreeing to the use telehealth/telemedicine services, I am consenting to Ageless Counseling, LLC sharing of my protected health information with certain third parties as more fully described in their Privacy Policy. 

-I understand, agree, and expressly consent to Ageless Counseling, LLC obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services. 

-As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 

-Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies. 

-Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet's infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team. 

-I hereby release and hold harmless Ageless Counseling, LLC and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.  

-I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at Ageless Counseling, LLC. (Telehealth Consent v.08.30.2021) 

-I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit. 

-I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert to traditional in-person clinic services. 

-I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled. 

-All my questions have been answered to my satisfaction. 

-I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions. 

-By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. 

-I have carefully read and understand the above statements. I understand that this informed consent will become a part of my medical record.

Initial Evaluation | Service code 90791  

Quantity (# of sessions or units): 1 per Year | $175 per unit 

Psychotherapy: 60 minutes | Service code 90837 | Quantity: Up to 52 a year | $135 per unit 

Psychotherapy: 45 minutes | Service code 90834 | Quantity: Up to 52 a year | $135 per unit 

Total estimated cost 

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