Consent for Treatment & Authorization Form

 

Evergreen staff looks forward to helping you reach your goals. This form requests information to better serve you. All information between provider and patient is held strictly confidential unless you authorize release of confidential information; you present physical danger to yourself or other(s); or child/elder abuse or neglect is suspected. I am required by law to inform potential victims and legal authorities so that protective measures can be taken.

 

I.         Receipt of Required Notices: I hereby acknowledge that I have received a copy of Evergreen Youth & Family Services’  (EYS) Notice of Privacy Practices and a copy of your Additional Rights (Equal Access, Quality Treatment and Privacy, etc.).

II.       Consent for treatment and use of personal health information (PHI): I acknowledge that I have consented to receive mental health and related services from the staff of EYS which will be described in full in the treatment planning process. I understand that I must consent to receive services or I will not be served. I further acknowledge that I consent that my PHI, including information regarding chemical dependency, may be used for treatment, payment, or service referrals, subject to the uses and limitations set forth in state and federal law. Any additional uses of my PHI beyond those which are provided for in state and federal law shall require my authorization.

 

In some instances, counseling services may be covered by grant sources but if you do have insurance, we are required to use that source first and request that you please present that information. If applicable, upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and EYS will be paid directly by the carrier.   Please note that Evergreen has a policy that we will cover costs not paid by insurance companies for mental health services.

authorize the release of information regarding my care to my health plan for the payment of claims, certifications/ case management decisions, and other purposes related to the administration of benefits for my health plan.

I further authorize and request that my treating provider carry out mental health examinations, treatments, and/or diagnostic procedures, which now or during the course of my care are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

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INFORMED CONSENT FOR TELETHERAPY

This Informed Consent for Teletherapy contains important information focusing on providing psychotherapy remotely (can include phone, video, or other electronic communications). Please read this policy carefully. When you sign this document, it will represent an agreement between you and Evergreen Youth & Family Services.  

Benefits and Risks of Teletherapy

Teletherapy refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone.  Benefits of teletherapy is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to meet in person. It can often be more convenient and take less time. Teletherapy, however, requires technical competence to be successful. Although there are benefits of teletherapy, there are some differences between in-person psychotherapy and teletherapy, as well as some risks. For example:

- Risks to confidentiality. Because teletherapy sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On behalf of Evergreen providers, it is the therapist responsibility to take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session, where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where others are not present and cannot overhear the conversation.

 

- Issues related to technology. There are many ways technology issues might impact teletherapy. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

 

- Crisis management and intervention. Usually, the therapist will not engage in teletherapy with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in teletherapy, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our teletherapy work.

- Efficacy. Most research shows that teletherapy is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

Electronic Communications
Therapist and clients will decide together which kind of teletherapy service to use. You may have to have access to certain computer or cell phone systems to use teletherapy services effectively. You are solely responsible for any cost to you in obtaining the necessary equipment, accessories, or software to participate in teletherapy.

For communication between sessions, your Therapist may use email, social media communication and text messaging with your permission and only for administrative purposes, unless we have made another agreement. This means that email exchanges and text messages with the therapist or therapy staff should be limited to administrative matters, and should be directed to the administrative team. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that the Therapist cannot guarantee the confidentiality of any information communicated by email or text. Therefore, Therapists will not discuss any clinical information by email or text and prefer that you do not either. Also, Therapists do check e-mail and text at their convenience, however this may result in a delayed response due to work load, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach the therapist by phone. The Therapist will try to return your call within 48 hours, except on weekends and holidays. If you are unable to reach your Therapist and feel that you cannot wait for the Therapist to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If the Therapist will be unavailable for an extended time, they will provide you with the name of a colleague to contact in their absence if requested and necessary.

Confidentiality

Therapists have a legal and ethical responsibility to make every effort to protect all communications that are a part of our teletherapy. However, the nature of electronic communications technologies is such that Therapists cannot guarantee that communications will be kept confidential or that others, outside of the agency, may not gain access to our communications. The Therapist will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is always a risk that electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for teletherapy sessions and having passwords to protect the device you use for teletherapy).

 

The extent of confidentiality, and the exceptions to confidentiality, that the Therapist outlined in the Informed Consent still apply in teletherapy. Please let us know if you have any questions about exceptions to confidentiality.

Appropriateness of Teletherapy

Therapists will let you know if they decide that teletherapy is no longer the most appropriate form of treatment for you.  Therapists will discuss alternate options of engaging in in-person counseling or referrals to another professional in your location, who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when using teletherapy, as opposed to in-person therapy. To address some of these difficulties, the Therapists and client will create an emergency plan before engaging in teletherapy services. The therapist will ask you to identify an emergency contact person who is near your location and who they can contact in the event of a crisis or emergency to assist in addressing the situation. The therapist will ask that you sign a separate authorization form allowing them to contact your emergency contact person as needed during a crisis or emergency.

 

I understand and agree to all of the above information.

Please complete as much information as possible.

INSURANCE INFORMATION

Please indicate how the services requested are to be paid?