PATIENT CONSENT AND AUTHORIZATION
Consent to Treatment:
I hereby consent to receive mental health treatment from Northampton Center for Couples Therapy (hereafter referred to as NCCT). I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option NCCT offers and that I may withdraw my consent at any time.
I accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. I understand that the changes I make will have an impact on my partner and on others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. [This is especially true if dependent children are involved] On the other hand, therapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
I acknowledge that online therapy is therapy done remotely via a computer, Internet and webcam. It is not face-to-face therapy. I understand I must participate in a face-to-face assessment as the initial step of this process to determine if online therapy is an appropriate option for my care. I attest that I am a Massachusetts resident and will only conduct online therapy sessions while in the boundaries of the state of Massachusetts. I also acknowledge that in order to participate in online couples therapy, both members of the couple must be present in the same room during the remote online session.
Online therapy is more easily accessible due to geographic or time constraints, but also has limitations because of the remote aspect and technology used during the session. I understand that video and sound quality is dependent on many factors like hardware, software, Internet connection/speed, external noise, lighting, etc. These factors may cause my online session to be interrupted or terminated. In the event of a technological glitch or interruption, my therapist will attempt to contact me at the alternate number (preferably a landline) I provide, so that we can attempt to resume the online session or reschedule for another date.
Release of Medical Records:
I understand in order for any therapy information or medical records to be released, both members of the couple must provide written authorization. If some individual sessions may help the process of online couples therapy, what I say in those individual sessions will be considered to be a part of the medical record.
I also understand that information discussed in online couples therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the couple. I agree not to subpoena my therapist to testify for or against either party or to provide records in a court action.
Online Therapy Sessions:
I understand that by choosing online therapy, I am agreeing to the following:
I also understand that there are circumstances in which online therapy may not be the best treatment option for me. Such circumstances may include when there is:
I further understand that NCCT may choose at any time to discontinue services in the event that any of these circumstances are present, and at such time all fees paid to NCCT to date (regardless of duration of treatment) are nonrefundable. I understand that in such circumstances NCCT will make a good faith effort to provide me with alternative referrals for treatment, but that ultimately it is my responsibility to seek out and pursue treatment.
I understand that our communications are private and protected by law. Because of laws protecting confidentiality, in most situations my therapist cannot share information about our work without my permission. However, there are certain specific limits to confidentiality. I fully understand these limits below.
Communication and Availability:
Due to my therapist’s work schedule, my therapist is often not immediately available by telephone.
When my therapist is unavailable, an automated voice mail answers his/her telephone. My therapist will make every effort to return my call on the same day I make it, with the exception of weekends and holidays. If I will be difficult to reach, I will inform my therapist of some times when I will be available. In a life-threatening emergency, I will call 911 or go to the nearest Emergency Room.
I understand that email is not a secure medium for communication and my therapist’s preference is that I contact him/her by phone. However, if I choose to contact my therapist using email, I am doing so with the full understanding that my therapist cannot guarantee the safety and security of that communication, despite NCCT taking all possible action to protect my privacy.
I also acknowledge that email occasionally disappears or is delayed and that my therapist may never receive an email that I send. For example, canceling a session via email is not an appropriate method of notification. My therapist recommends that in order to give adequate 24-hour notice of such cancellations, I do so by phone.
I understand that I am responsible for full payment of all fees for my online therapy services provided by NCCT. Payment must be made before my session can begin.
Assignment of Benefits and Release of Information:
I hereby assign and transfer over to NCCT, all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, including medical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain in effect until written notice is given by me revoking this authorization. I certify that the information given is correct. I understand that this assignment and authorization does not relieve me of my obligation to pay any bills not covered by my insurance policy; or of any balance due after payments by my insurance policy. I agree to pay any balance due in full no later than 30 days of statement, unless other arrangements have been made in advance.
Court Action Policy and Fees:
Clients are discouraged from having The Northampton Center for Couples Therapy subpoenaed or requesting records for the purpose of litigation. We are trained as clinical social workers, marriage and family therapists and mental health counselors and our work and therapeutic philosophy comes from non-adversarial positions. We have not been trained forensically or with the expertise to appear in court. We are unable to guarantee that any testimony that we are required by law to give will be solely in your favor. We can only testify to the facts of the case and our professional opinion.
If any clinician at The Northampton Center for Couples Therapy is to receive a subpoena then the attorney or office staff will need to call our office and set up a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice of any Court appearance so that schedule changes for our clients can be made within a reasonable time frame.
Please note: if a subpoena is received without a minimum of 72 hour notice there will be an additional $300 express charge.
Court action fees are as follows:
All fees are doubled if the clinician from The Northampton Center for Couples Therapy is scheduled to go out of town.
If a clinician is subpoenaed and the case is reset with less than 72 hour notice prior to the beginning of the day of the scheduled subpoena and or testimony is not given then the client will be billed $1,000.
Bills for court related actions are presented to clients on a weekly basis and payment is expected upon receipt. A zero balance will need to be kept at all times.
My signature below acknowledge that I understand and accept the terms and conditions of this authorization and agreement. If the patient is a minor child, an appropriate guardian must sign below. Such signature acknowledges that this authorization and agreement applies to the minor child.
Online Cancellation Policy:
If I am unable to keep an appointment, I agree to notify NCCT at least 24 hours in advance of my scheduled visit.
I understand that I will be charged the full session rate for all sessions cancelled with less than 24 hour notice.
I also understand that this fee is not covered by insurance.
Online Attendance Policy:
NCCT recognizes that circumstances arise when I might need to miss more than one appointment during the course of a month. NCCT is able to hold my designated slot as a courtesy for up to 4 weeks.
If I miss more than one appointment within a month for any reason, I will be charged a $150 fee (per week) so that my slot can be held.
Note: This fee will be charged regardless of advanced notice duration. NCCT cannot offer this benefit for more than 4 weeks.
Additionally, a signed credit card release form must be on file OR I will need to pay for the reserved sessions in advance. Failure to do so will result in my slot no longer being held in reserve for me.
My signature below acknowledge that I understand and accept the terms and conditions of this policy. If the patient is a minor child, an appropriate guardian must sign below. Such signature acknowledges that this authorization and agreement applies to the minor child.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures 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:
After you have read this notice you will be asked to sign a form indicating receipt of this notice as well as a separate Consent form to allow me to use and share your PHI. In almost all cases I intend to use your PHI here in my office or share your PHI with other people or organizations to provide treatment to you, arrange for payment for my services, or health care operations.
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:
You may revoke all such authorization (of PHI or Psychotherapy Notes) 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.
Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Patient’s Rights and Therapist’s Duties
On your request, I will discuss with you the details of the accounting process.
Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 413.586.2300 for additional information. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to our Security Officer at 40 Main Street, Suite 206, Florence, MA 01062. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Our Security Officer can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
Other Uses of PHI in Healthcare
The effective date of this notice is April 14, 2003.
The signature below indicates that I have received a copy of the notice of privacy practices from NCCT
The Northampton Center for Couples Therapy is a learning group dedicated exclusively to couples therapy. As part of our commitment to excellence we are requesting your permission to record our therapy session(s) on video file(s). At NCCT, we use video recording for consultation and training in individual and couple therapy and we find it an invaluable tool in Gottman Method for Couples Therapy.
Videos are used for the purposes of professional training, consultation and/or improving service in individual supervision (between your therapist and their supervisor) and/or group supervision (between the therapist, the supervisor, and other clinicians at the Center). The recording of sessions will likely enhance and expand your quality of treatment but is not required. You may decline to have sessions recorded.
Your signature below indicates that you give Northampton Center for Couples Therapy permission to videotape your therapy sessions for training and supervision purposes and that you understand that:
1. You can request that the video recorder be turned off at any time and may request that any portion thereof be erased. You may terminate this permission to record at any time.
2. The purpose of recording is for use in training and supervision. This will allow your therapist to consult with his or her assigned supervisor(s) in an individual or group supervision format, who may view the recording alone or in the presence of other therapists involved in direct supervision.
3. The strictest confidentiality will be maintained, and there will be no sharing of the recorded material beyond the limits of training and supervision. Except for your first name and your voice and/or image on the recording, there will be no information that could identify you. The recording will never knowingly be shared with anyone who knows you. Mental health professionals who may view or hear recorded material of your session are also bound by law and by code of ethics to the same obligation to protect your confidentiality. Except in the context of training and supervision, the existence of this recording will not be discussed with anyone at any time.
4. The video recordings will be stored in a secure location and will not be used for any other purpose without your explicit written permission.
5. The recordings will be erased after they have served their purpose.