The UAY Counseling Program is a voluntary program that provides therapy and support services to youth and families.  Program participants have the right to end services at any time.  As a participant in the Counseling Program you have the following rights and responsibilities:
 
Participant’s Rights:
· You and your belongings will be treated with unconditional positive regard (respect) by United Action for Youth staff.
· You will be treated fairly, honestly, ethically and responsibly without regard to race, color, creed, religion, gender, age, national origin or disability.
· You will be notified if your Therapist is unable to attend your scheduled appointment.
· You will have your information kept confidential unless you have provided written permission for information to be shared, or in the case of imminent harm or danger to you or a member of your family, or in the case of suspected child abuse or neglect.
· You may review your case file upon written request to UAY or your Therapist.
·Meetings will be scheduled at times that are convenient for you and your Therapist
 
Participant’s Responsibilities:
· Treat UAY Therapist with unconditional positive regard (respect).
· Contact your UAY Therapist at 319-338-7518 if you are unable to keep an appointment.
 
Communication:
Therapists are often not immediately available by telephone. While usually in the office between 9 AM and 5 PM, Monday through Friday, your call may go to voicemail if your therapist is with a client or otherwise engaged. Please suggest some times when you will be available in your message. If you are unable to wait for a return call and are experiencing a mental health emergency, please contact or go to the nearest emergency room, or call 911.
 
· In some cases, electronic communications, such as email and text messaging, may be used to communicate with your therapist. These are not to be considered emergency contacts or crisis lines. In-depth conversations about your mental health and wellbeing should be avoided when communicating electronically to protect your confidentiality. 
 
· Electronic communications will not be responded to after hours, on weekends, or during holidays. All messages sent during these times will be answered during the next business day.
 
·A voice messaging service is available for after hour calls. If you have a non-life threatening emergency, call 319-338-7518, dial 1 when prompted and you will be connected to an On-Call Counselor, available 24/7.
 
Benefits and Risks of Therapy
Engaging in therapy can have many benefits. Your therapist can help you identify your strengths and find ways to use them to cope with your life, or develop new coping skills. You may find that you learn more about your reactions, relationships, and emotions. Your therapist can also help you to make desired choices and changes. You may experience a reduction of negative feelings (anger, guilt, shame, etc) or a reduced impact on your daily life from these feelings.
 
Therapy has potential emotional risks as well. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with your therapist to be a source of strong feelings, some of them painful at times. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful, and your therapist will always act in your best interest.
 
Client-Therapist Relationship Expectations
With the exception of their work at the youth center or at community events, your therapist will not engage in any relationship with you outside of the context of your therapy together. This means that you will not see each other socially or have a relationship on social media. You and your therapist can decide together how to manage situations where you may unintentionally see each other outside of therapy, including the youth center, in a way that acknowledges your right to confidentiality and your therapist’s ethics.
 
Counseling Program Grievance Procedure
If you believe your rights have been denied, or you would like to express complaints, suggestions, grievances or concerns regarding services you have received through your participation in the Counseling Program, you may do so without the fear of punishment or discrimination.  We encourage you to share your concerns directly with staff.  If you feel the issue has not been resolved please contact:

Talia Medlinger, LISW
Counseling Program Coordinator
United Action for Youth
1700 S 1st Ave, Ste 14, Iowa City, IA 52240                                                                               
If you are unable to resolve the issue with the Counseling Director, an appeal may be sent to the Executive Director at the same address.

 
What is shared with a UAY staff person or UAY volunteer is confidential, whether you are an adult or a young person.  It is important that everyone has someone with whom they can share a concern, tell something private or get ideas on a troublesome situation.  Young people and their families can do so at UAY without information being shared with the rest of their family, their school, or others in the community, unless written permission is given.
 
There are exceptions to this policy:
 
1.)   CHILD ABUSE: UAY Staff and Volunteers must report all forms of child abuse.
2.)   SUICIDE: UAY Staff and Volunteers will do everything possible to keep people from hurting themselves.  That may mean calling parents, the police or getting someone to the hospital.
3.)   DANGER TO OTHERS: If a UAY staff or Volunteer believes there is clear and immediate danger to another person, they will make a report.
4.)   COURT ORDERED: UAY will have to disclose information pertinent in any open child abuse case or when required by a Court of Law.
5.)   CASE PROCESSING: UAY Staff will consult with other staff for case processing and supervision purposes only.
6.)   MEDICAL EMERGENCY: UAY Staff will seek medical assistance in the event of a program participant’s medical emergency.
7.)   WAIVER: The program participant waives the privilege of confidentiality by bringing charges against UAY.
 
I understand that UAY staff will be contacting me via letter, email, phone, or text messaging and that my personal information will be confidential.
 
 
I have read and understood UAY’s Confidentiality Policy.  I know that UAY will report child abuse, suicide risk, and danger to others.  I also understand that UAY provides information to funding sources, which may include age, gender, race, income and other statistical information, but does not include my family members’ names. I willingly agree to accept services from United Action for Youth.

I hereby consent to participate in telemental health with my United Action for Youth Therapist as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to telemental health:
1)  I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2)  I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3)  I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4)  I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
5)  I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
6)  I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, my therapist will call me to reschedule.
 I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

In case of emergency, I need to know your location. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency. 

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

Medical Insurance Coverage: You are responsible for payment of services. You may have insurance that pays some or all of our charges, but that is a matter solely between you and your insurance company.
 
If you have medical insurance, we are eager to help you receive your maximum allowable benefits. You must realize, however, that your insurance is a contract between you and your insurance company. Not all services are covered by every insurance policy. While the filing of insurance claims is a courtesy we extend to our clients, all charges are your responsibility from the date the services are rendered. All charges are assessed a 3% service fee after 60 days. We require that your copayment be paid at the time of services rendered. If you do not know what your copayment may be, check with your insurance company. Be sure to specifically ask about benefits for outpatient mental health counseling.  Full payment at the time of service is required if you do not want your insurance billed.
 
Payment Policy: We accept cash, check, money-order, Visa or Mastercard. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact our office staff as promptly as you can for assistance in management of your account. If we do not hear from you within 90 days of service, your account may be turned over to a 3rd party for collection or continuing services may be reduced or denied.
 
Missed Appointments: Once an appointment is scheduled, you may cancel for any reason. Since we can accept only a limited number of clients, our time is precious. A late cancellation or missed appointment is a loss to us and to those waiting for appointments. If you need to cancel an appointment, we ask that call at least 24 yours in advance. If you miss an appointment you may be charged a no-show fee. We do understand circumstances may arise that are beyond your control, and we will consider each situation on a case by case basis. Please understand that your insurance benefits do not apply for missed sessions and you will be responsible for the no-show fee as an out of pocket expense.

Please upload a clear front and back copy of your current insurance card

I hereby authorize payment directly to the above named facility of the payments otherwise directly payable to me.