CLIENT CONSENT TO TREATMENT

  • I have read the informed consent packet and had sufficient time to consider it carefully and I know I can ask questions about treatment or information at any time. I know all information disclosed or in written records is confidential, except where required by law. I know my provider is legally required to contact the proper authorities if they believe I will harm myself or others, including children being abused or witnessing abuse.
  • I am over age 14 and consent to treatment or treatment of my child and know that children must have both parents signature on this form if the child parents have joint custody or are in an ongoing custody arrangement.
  • I understand the risk of using online/telephonic methods to discuss treatment, and do not hold Serenity or its providers responsible for the security of any information that is sent by me or to me electronically or via email.
  • I consent to the use of a diagnosis, and the release of information needed to complete the billing and or collections process. I agree to pay any and all fees my insurance doesn’t cover, including co-pays at the start of my session or when notified by Serenity. I also agree to pay a 20% add on fee should any debt go to collections.
  • I agree to pay a fee of $20.00 for speaking with my therapist outside appointments for every 15 minutes.
  • If I miss an appointment or cancel without 24hr notice, I will pay a $100 NO SHOW/Cancellation Fee.
  • I understand if I fail to show/call or reschedule within 7 days of my last appointment, my therapy case will be closed. If on a repeating schedule, and I do not show up for a scheduled SECOND session thereafter, I will be charged and agree to pay an extra $100.00 NO SHOW/Cancellation Fee prior to my case being closed.
  • Serenity therapists default policy is to NOT keep secrets from spouses seeking relationship help and I will not hold my provider or Serenity liable for any information that is revealed in individual or in joint sessions.
  • I agree not to disparage Serenity or its providers on any platform or electronic media as this could do irreparable harm to providers at Serenity not involved in anyway with my care.
  • I agree to allow counseling related students to join in my session and understand that they too are to keep my information confidential and that I can deny a student/s into my session at any time for any reason.
  • I agree that my provider may consult with or refer to other professionals and exchange information within Serenity as part of a treatment team to maximize my treatment for individual, couples or family therapy.
  • I agree that I am ultimately responsible for my appointments and may or may not get a phone call/text reminder prior to my appointment. And I agree if I am not called back to make an appointment within 24hrs of my last attempted contact I WILL email Serenity at Info@scshawaii.net to arrange the appointment electronically.
  • I know I can end treatment at any time or ask for a different provider and that I can refuse any requests or suggestions made by Serenity or any other professional.
  • I will pay a fee for any documents I request my provider to fill out or provide to me. I will speak to each provider/s directly when requesting any documents and understand processing my request may take up to 72hrs.
  • Life coaching is a cash pay service. Records of my visits will be kept. No medical records or Dx are given.
  • Active Duty Military Service Members: I know my diagnosis may not be honored by the military and that if my condition interferes with my duties/mission and I did not disclose this to my command I may face UMCJ action and release my provider to inform my command if they feel I could place myself or my duties at jeopardy.

TELEMENTAL HEALTH SERVICES INFORMATION

What is Telemental health services and when are they used?

Telemental health services are used when mental health staff cannot be physically present with you to evaluate your mental health needs and, if appropriate, prescribe medications. Mental health staff may be present at another location and available to serve you through newly available technology.

Instead of talking to someone on the phone at another location, Telemental health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better evaluation of your needs.

How do Telemental health services work?

There are several was to access Telemental Health Services within our network.

  1. You will be in a personal safe space at your personal computer with webcam or on your smartphone.   You will be either by yourself, with a friend, or family member.  Anyone in attendance will be required to sign a consent form and confidentiality agreement.
  2. You will be in a private room either by yourself, with a friend, family member, or staff person. The room will have a computer with a video camera.
  3. The mental health staff will also be in a private room but at another location with the same type of equipment.

When the session is ready to begin, clinic staff will start the session and this will allow you or center staff to connect with your or the centers computer and camera or by your sell phone so that you and mental health staff can see each other and talk together.

When the session is over, clinic staff will shut off the equipment.

How is it different than a regular session with mental health staff?

Other than you and mental health staff not being in a room together, there is very little difference in the session. Mental health staff will ask and document clinical information that you share with him/her and they will document the service that is provided, and ensure that documentation is included in your clinical record for future reference..

If the practitioner is able to prescribe medications, at the end of the session, they will send any prescriptions that are ordered to the pharmacy for you to pick up.

What happens if I choose not to consent to Telemental health services?

If you choose not to consent to Telemental health services, we will be unable to provide you with convenient and readily available services and your services will be rescheduled for a later date and/or a different site.

This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions code, Civil Code and HIPAA Privacy Standards. This and any other documented service notes will become a permanent and legal part of your medical record.

CONSENT FOR TELEMENTAL HEALTH SERVICES

I, {PatientName}  understand that:

  1. I have the option to withhold consent at this time or to withdraw this consent at any time, including any time during a session, without affecting the right to future care, treatment, or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  2. The potential benefit of Telemental health services is that I will be able to talk with mental health staff today from a local setting for an evaluation of my needs. When appropriate, I will be able to participate in mental health services today.
  3. The potential risk of Telemental health services is that there could be a partial or complete failure of the equipment being used which could result in mental health staff’s inability to complete the evaluation or mental health services and may require scheduling an additional session once the internet issues have resolved. .
  4. There is no permanent video or voice recording kept of the Telemental health service’s session.
  5. All existing confidentiality protections apply.
  6. All existing laws regarding client access to mental health information and copies of mental health records apply.
  7. Dissemination of client identifiable images or information from the Telemental health interaction to researchers or other entities shall not occur.

I, {PatientName}, {PatientDOB},  by submitting this form I am providing expressed acknowledgement that I have read, understand and agree to the Informed Consent Policy, the Consent for Telehealth Services, HIPAA Privacy Practices Policy, and the Notice of Privacy Practices Policy, provided here or on the patient portal and that I agree to all terms herein and on this form and that information provided is true and accurate.   I further understand that if face to face services are deemed necessary, a referral for on-site services will be scheduled or you may be referred to a practitioner that provides in -person services if not offered by your current counselor.   In circumstances in which mental health staff appropriate to my needs is not immediately available at my location, I will be provided with local, state, or community services.   My mental health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I understand the written information provided above or on my patient portal.