Columbus Behavioral HealthAn Association of Independent Practitioners
614.360.2600Westerville | Dublin | New Albany
NOTE: For couples therapy, EACH person needs to complete and submit their own New Patient Forms for Couples Counseling.
The focus of couples’ therapy is the relationship. With that in mind, there are some guidelines that we must follow to ensure that I can fulfill my professional responsibility to each of you as individuals as well as to your relationship. I need you to understand and agree to the following:
No Secrets Policy In order to create an atmosphere of trust it is important that I not keep secrets. At times I will meet individually with you to work on individual issues that affect the relationship. Keep in mind that in order for the couples’ therapy to be effective, anything you tell me individually will be used in our couples’ sessions. Our individual sessions are considered part of the couples’ therapy, although both of you will sign in as individual clients. If you revoke consent to my sharing information with your spouse/significant other, then I will have to terminate therapy with you and with the couple. If I terminate therapy with you as a couple, I will not continue with individual therapy with either of you without consent of the other person.
Court Proceedings/Subpoena of Records You agree not to use the information from our sessions against the other person in any kind of judicial setting. Likewise, you agree not to attempt to subpoena me or my records for a deposition or court hearing and if you do, then you agree to pay for all of my time at my standard hourly rate, which will include travel time, time waiting for a hearing/deposition, as well as preparation time.
Documentation I am required to make notes about our session each time we meet. My notes will contain information about both of you. All emails between us are considered part of the therapy record.
Release of Records Both partners must provide their consent to release the complete couples therapy records. If one partner does not provide consent, their portion of the records will be redacted, i.e. it will not be available to the other party.
Voluntary Nature of Treatment Participation in couples’ therapy is voluntary. You are free to stop at any time and I reserve the right, in the event that I don’t feel that I am being effective or that you might benefit with another therapist, to end couples’ therapy.
What to expectCouples therapy is a process of identifying interaction and communication patterns that are negatively impacting the friendship, intimacy, and fulfillment of needs of one or both partners in a relationship. Each partner will be expected to honestly examine their own interaction and communication styles, identify and express their own feelings, and make an attempt at experimenting with alternative methods of communicating and interacting. Each partner will be helped to further clarify their own values and their own level of commitment to the relationship, and the outcome of the therapy may be increased satisfaction with the partnership or increased clarity about the decision to part ways.
Limitations to couples therapyCouple therapy will only be effective in cases where both partners put in a good faith effort to work on their problems and their relationship. Deliberate dishonesty or deceit, unwillingness to introspect and take responsibility for one’s actions, or lack of interest and motivation to engage in the couples therapy process by one or both partners will undermine the therapy
Length of couples therapyA completed couples therapy can take any- where from 5-20 scheduled sessions. Length of time depends on severity level of problems, history of past trauma/ infidelity/ or betrayals, and the presence of co-occurring emotional or psychological issues such as mood disorders, depressive symptoms, substance use problems, or personality disorder traits.
I certify by my signature below that I have read, fully understand, and agree to abide by the stated policies.
GENERAL OFFICE POLICIES
To our clients: We are glad you’re here and we look forward to the opportunity to help you feel better! Below are some of our policies to help familiarize you with our practice.
Locations: Each staff person works in one location only.
Dublin Office6631 Commerce Parkway, Suite R, Dublin OH 43017
Kim Boggs, LISW-SSusan Folger, PhDAsia Place, LPCC Christine Rager, LISW-S Mikel Sinnott, LISW Melaney Thurman, LPCC
New Albany Office5071 Forest Drive, Suite B, New Albany OH 43054
Karen Bretz, Ph.D. Laura Davis, CPN Jaclyn Groh, LISW-S Sarah Vorhis, LISW-SDiana Webb, LISW-SAllie Whittington, LISW-S
Westerville Office635 Park Meadow Road, Suite 101, Westerville OH 43081
Amy Bush, LPCC-S Sarah Grim, LISW-S Jason McCray, PhDErika Stein, LPCC
Appointments: Psychotherapy appointments are scheduled for around 50 minutes. Brief and extended appointments are offered when necessary. If you find it necessary to cancel a scheduled appointment, we request 48 hours-notice in advance (unless due to circumstances beyond your control). We typically have a wait list and if you give us enough time, we can offer that slot to someone else.
Cancellations: We understand the life happens and for this reason, we will give you one free late cancel/ no show per calendar year. If you need to cancel or change an appointment, be sure to give us at least 48 hour notice otherwise you will be charged the full fee for the appointment time reserved. Insurance companies will not pay this fee, so we urge you to give proper notice when canceling, for your benefit and ours. If you are unable to give 48-hour notice, call us as soon as possible. If we are able to fill your appointment on short notice, we may be able to waive the fee.
Emergencies and After Hours: If you or someone you love is experiencing a crisis, call 911 or go to the emergency room or call OSU Harding at 293-9600. In Franklin County you can also call Netcare Access at 276-2273; in Delaware County you can call 684-2324. Emergency messages should not be left on the voice mail system, texted or emailed. If you are feeling suicidal, or that you might hurt someone else, do not hesitate to use one of the emergency resources immediately!
Billing: Payment is expected at the time of service for your portion of the co-pay, deductible, or payment in full if you are not using insurance for services provided. Your prompt payment allows us to keep our fees to you as low as possible. We bill your insurance company as a courtesy service to you, but it is your responsibility to make sure that your bill is paid in full to us. If you anticipate any problems in paying your bill, you should discuss this with us as soon as possible to make a payment plan. Please note that there is a $45 service charge for all returned checks. Also, balances older than 30 days may be subject to a l.5%/ month (18%/year) finance charge, and in cases of payment default, you will be charged for any collection fees we may incur, with a minimum of an additional $25.00 fee. At the bottom of this form is a credit card authorization form. No personal checks or cash will be accepted after August 1, 2018.
Insurance: Please note that it is your responsibility to know your benefits, and that it is your responsibility to pay us. We generally try to verify your insurance before you come in, but occasionally insurance companies give us erroneous information. When this happens, you agree that you are still ultimately responsible for payment in full to us. While we will do all that we can to assist you in filing your claims and seeing that proper payment is made, you are ultimately responsible for knowing your policy and for full payment of your bill. We strongly suggest that you verify your insurance benefits and know if you have any maximum eligible payments per therapy session or per year. Disputes with your insurance company are between you and them.
Confidentiality: Everything that takes place in psychotherapy is confidential, and may not be released without your express written permission. There are two exceptions to this; if you become actively suicidal or are thinking of hurting someone else, and if you are involved in child or elder abuse. We are legally bound to protect you and the other parties, and confidentiality may have to be broken. If you have insurance that uses managed care, treatment information must be released to them in order for your insurance to pay for services rendered to you. We may ask you to sign a release of information form so that we may communicate with your other doctors, previous therapists, or family members. You have the right to refuse to sign these forms if you so choose. Also, confidentiality for minors as well as for couples and families should be discussed with your therapist. Finally, if we see you in public or on social media, we are prohibited from acknowledging you as doing so could be a violation of your confidentiality.
If you do not want contacted at a certain address or phone number, please let your provider know at the first meeting.Ethics and professional standards: As mental health providers licensed by the State of Ohio, we agree to abide by and uphold the most responsible ethical and professional standards possible. We accept responsibility for the consequences of our acts and make every effort to protect the welfare of our clients and to ensure that our services are used appropriately.
If you are unhappy with your services here, it is especially important that you try your best to communicate with us the sources of your dissatisfaction. You may do this in writing if you feel uncomfortable speaking to your therapist, the office manager or Dr. Bretz. If we do not reach an agreeable solution and you need help finding additional or alternate assistance, we will do our best to help you locate a more suitable referral or therapy resource. Our ethics prevent us from seeing a client who is seeing another individual therapist except in extenuating circumstances, should you wish to work with another therapist for services, it is important that you indicate your desire to make a change.
Release of Liability: If you fail to show for an appointment, we will try to contact you during that appt. time at the number you have provided. If we do not hear from you within one week of the missed appointment, you have released us of all liability for your psychological counseling/care. If you cancel an appointment without rescheduling, you release us from liability for your psychological care/counseling. You are welcome to reschedule at any time, provided any past balances, including no show fees, are paid. If you have not been seen for 90 days, the relationship is considered terminated, your chart will be made inactive, and you release us from liability for your psychological care/counseling.Of course there are extenuating circumstances, such as an extended vacation, family emergency, unforeseen business trip, etc. In such cases, please contact us as soon as possible to keep us informed.
Forensic, FMLA, Disability, and Legal Issues: We do not provide reports or recommendations for custody evaluations, a guardian ad litem, disability or FMLA applications/paperwork for clients because the therapeutic relationship will be compromised if there is another agenda. In other words, we cannot be therapists and forensic evaluators at the same time.
Email, Texting, and Electronic Communications: The safest way to communicate is through the patient portal or calling the main number. E-mail, texting, or electronic communications are not secure forms are communication and should only be used if we both agree that is appropriate. If you decide you want to utilize any form of electronic communication you acknowledge that there are confidentiality risks inherent in such communications if they are unencrypted and you agree to accept those risks.
By initializing you agree that you understand the risks involved in unencrypted electronic communications and agree to accept such risks in communications from either me to you or you to me that involve scheduling and/or therapy.
I certify this information is true and correct to the best of my knowledge, and I will notify you of any changes in my health insurance or the above information as soon as possible. I agree to abide by the cancellation policy as well. Your signature below indicates that you have read policies and procedures detailed above and agree to abide by its terms during our professional relationship.
I have read and/or have received a copy of the HIPAA Notice Form.
I understand that my mental health provider, as an independent contractor, is solely legally responsible for my treatment and care.
COLUMBUS BEHAVIORAL HEALTHin DUBLIN/WESTERVILLE/NEW ALBANY
ELECTRONIC SERVICE DELIVERY INFORMED CONSENT
Electronic Service Delivery is defined as mental health therapy in any form offered or rendered primarily by electronic or technology assisted approaches when the mental health therapist and the client are not located in the same place during delivery of services. While working with your therapist you will always have the opportunity to ask any questions that you have about the therapy, electronic communications in general, and other issues involving your therapy. Your therapist will also assess your ability to handle computers and the internet, so that you and he or she may work in this way.As a client receiving mental health services through electronic service deliverymethods, you should understand:
1) This service is provided by technology which at our practice may include telephone or video conferencing platform. There are benefits and limitations to this type of service, which may also include emails and texting. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information may not be direct, and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery. Your therapist will assess whether or not therapy through means of electronic service delivery is appropriate for addressing your issues and whether or not you have the knowledge and skills to use the technology involved.
2) As a therapist licensed in Ohio, your therapist may only deliver services to residents or people located in Ohio. If you plan on leaving Ohio for any length of time in the future, please let your therapist know as soon as possible so that you and he or she can make proper arrangements for future work or referrals, as appropriate. If you are going to be out of state during therapy, then your therapist will have to comply with the licensing laws of the state where you will be located.
3) If a need for direct, face to face services arises, it is your responsibility to contact providers in your area, or to contact this office for a face to face appointment. You understand that an opening may not be immediately available. 4) You may decline any electronic service delivery service at any time without jeopardizing your access to future care, services, and benefits.
5) These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet or through other electronic services that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. Your therapist and you will regularly reassess the appropriateness of continuing to deliver services through the use of technology. When using these services you agree to accept the risks involved with the unencrypted exchange of information, if it is provided in that way.6) Your therapist will need to verify your identity in a face to face meeting, which may be via video/audio electronically and then at subsequent sessions. At the initial session you and your therapist will address imposter concerns. You should be aware that misunderstandings are possible with telephone, text-based modalities (e.g., email), and real-time internet chat, since non-verbal cues are relatively lacking. Even with video chat software, since bandwidth may be limited and images may lack detail, misunderstandings may occur. Your therapist is an observer of human behavior. He or she will gather information from body language, vocal inflection, eye contact, and other non-verbal cues. Cultural differences and how they affect non-verbal cues may also be involved and your therapist will assess whether or not this type of therapy is appropriate for your cultural experiences, your environment and your therapeutic needs. If work is being done with families or groups with different levels of technology competence, power dynamics will be acknowledged. Please let your therapist know if you have any type of audio/visual or cognitive impairment prior to beginning therapy. If you have never engaged in online counseling, you need to have patience with the process and request clarification if you believe that you are not being understood by your therapist or you do not understand something that your therapist says. He or she will regularly review whether or not electronic service delivery is meeting the goals of therapy. Your therapist will also discuss with you how to handle disruptions in services and all methods of delivering services that are compliant with commonly accepted standards of technology safety and security at the time at which services are rendered.7) In emergencies, in the event of disruption of service, or for routine oradministrative reasons, it may be necessary to communicate by other means:
a) In emergency situations: If it is an imminent situation that requires face-to-face contact call 911 or go to the nearest emergency room. If it can be managed over the phone, you can call your therapist but if your therapist does not respond immediately or within a short period of time, you should contact local emergency services (for example, call 911 or go to your local hospital’s emergency room, or call the National Suicide Prevention Hotline number -1-800-273-8255 or Netcare at 1- 614-276-CARE.) Also, other local hotline crisis phone numbers may be available to call, and you can check on the internet to find those.
b) Should service be disrupted: Try to regain contact using the same medium. If that does not work, attempt to make contact using text or e-mail. Your therapist will also make every effort to regain contact. If service is disrupted during a therapy session before the pre-agreed time frame has ended, you will have the opportunity to use the remaining time as soon as contact is made. If contact is not re-established within one hour, you will have the choice to end the session and be charged a pro- rated amount or allowed to schedule an additional session to use the remaining time.
c) For other communications: Your therapist and you may agree to communicate via a phone call, videoconferencing, e-mail, text, fax, or mailed letters.(8) The potential benefits of online counseling include flexibility in scheduling and allowing you to engage in counseling outside of the office, which eliminates issues like transportation and other psycho-social barriers that might make it difficult for you to handle in a traditional office setting. The provision of online counseling may include risks related to the technology used, the distance between you and your therapist, and issues related to timeliness. For example, the potential risk of confidentiality may pertain to your accessing the internet from public locations. You should consider the visibility of your screen and being overheard when in public settings. It is recommended that you be in a private setting when engaging in online counseling. You should also always use strong passwords to protect any information shared with your therapist. Never use a work computer for therapy as your employer may have access to the information shared in electronic communications. Be cautious when using a shared network with others.
(9) Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than it is in person. You are responsible for confidentiality in your own environment, including securing your hardware, internet access points, chat software, email, and passwords. Please develop passwords that are appropriate and strong and not use auto-fill for user names or passwords. Although your therapist will take steps to protect your information, he or she will have policies in effect to notify you of a breach of any of your confidential information which is required to be reported to you.
(10) Your therapist may utilize alternative means of communication in the followingcircumstances: if you do not respond to text, your therapist may call. If you do not respond to a call, your therapist may follow up with text or e-mail. If you do not respond to a call, text, or e-mail, your therapist may follow up with a mailed letter. In case of emergency (or concerns over your welfare), your therapist may contact your emergency contact if you have provided one.
(11) Your therapist will attempt to respond to communications and routine messages within 48 hours if he or she is available.
(12) Most insurance companies in Ohio only currently reimburse for face to face in person therapy sessions, so there may not be insurance coverage for therapy sessions delivered through technology. You should check with your insurance company to determine if they will reimburse you for electronic service delivery sessions. If insurance does not cover reimbursement, then you agree to pay the fee for the service.
(13) You need to take the following precautions to ensure that your communications are directed only to your therapist or other individuals: Ensure that you use the correct e-mail address, telephone number, skype or online name, fax number, and physical address to contact the appropriate individuals. Only leave voice messages after ensuring that the correct phone number was dialed and the voicemail introduction identifies the correct individual.
(14) Your communications exchanged with your therapist, if capable of being put into written form, will be stored in the following manner: e-mails, texts, and other electronic communication relevant to treatment will be printed and kept in your file. Mailed letters and documents will also be kept in your file. Notes outlining electronic service delivery treatment sessions will be written and kept in your file. Your file will be kept in a locked file cabinet or stored electronically and will be accessible only by those who require or are allowed access and will be available to you or someone named by you for the length of time required under Ohio law. Your therapist will not record sessions without first discussing it with you and obtaining your permission to do that. Please see your therapists regular Informed Consent form for information on access to your records, including who will have access to them. (15) The laws, ethics and professional standards that apply to in-person therapeutic services also apply to services delivered by electronic means. This document does not replace other agreements, contracts, or documentation of informed consent covering other issues. If you want licensing information on your therapist, you can find it at one of the licensing board websites. Psychology Board statutes, rules and other helpful information may be found at www.psychology.ohio.gov, and the Counselor, Social Worker & Marriage and Family Therapist Board’s website may be found at www.cswmft.ohio.gov. Acknowledgment of Informed Consent to Treatment via Electronic Service Delivery Means
You voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your therapist to provide such care, treatment or services as are considered necessary and advisable via electronic service delivery means.
By signing this Electronic Service Delivery Informed Consent, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. Ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. If a minor is the client, you are signing on behalf of the minor as the authorized parent/guardian. (Information on Minor rights will be shared with the minor)
You also acknowledge that you have received a copy of the regular Informed Consent and Notice of Privacy Practices for the practice listed at the top of this form.
OHIO NOTICE FORM CONTRACT
I have read and had an opportunity to ask questions about the Notice Form on the Policies and Practices to Protect the Privacy of My Health Information.
My signature below acknowledges my understanding and agreement with this document including that:
1. I give my consent to Columbus Behavioral Health, LLC to use and disclose my protected health information (PHI) for treatment, payment, and health care operations purposes.
2. I may sign an Authorization Form to release my records to others as desired.
3. My PHI may be released without authorization in cases of suspected abuse or threat to safety, by Court order, or Worker’s Compensation claim.
Copies of all documents are available on our website: www.columbusbehavioralhealth.com
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PATIENT FINANCIAL RESPONSIBILITY
I understand and agree that I am financially responsible for all charges for any and all services rendered.
I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any copays, coinsurances or unpaid balances.
I understand and agree that it is my responsibility to know if my insurance has any deductible, co- payment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.
I agree to inform the office of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full.
I understand that if I have a balance over $300, I may be discharged from CBH.
By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and health care operations, and/or as required by law. I authorize CBH to release/exchange treatment information with my family physician and health plan’s utilization reviewers in order to facilitate my treatment at CBH. I have the right to revoke this Consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior Consent. CBH provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
By signing below, I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. If I do not pay this balance within 30 days of being billed, a late fee of $25 may be added to my account each time it is rebilled. If I do not pay this balance or arrange a payment plan, I understand that I may be turned over to a collection agency and I will be billed for any subsequent collection charges, including a minimum charge of $25.00. I understand that returned checks are subject to a $30 return fee.
I certify this information is true and correct to the best of my knowledge, and I will notify you of any changes in my health insurance or the above information as soon as possible.
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GOALS & STRESSORS