Confidentiality: Federal and state Laws along with professional and ethical standards prohibit the disclosure of any information you provide us unless we have your prior written consent including both Mental Health and Alcohol or Other Drug Services. Thus, if anyone inquires about your receiving services here, we would not be able to disclose any information about you without your written permission.

Even so, there are a few exceptions to the laws and standards of confidentiality wherein your treatment provider is legally obligated to inform proper authorities as well as others in some situations. The limitations to confidentiality are as follows:

• If you provide information indicating abuse of a child or dependent adult.
• If your treatment prodvider is court ordered to disclose information about you.
• If your treatment provider believes you or someone else indentified needs protections from serious and foreseeable harm.

In addition, in accordance with 42 C.F.R and 42 C.F.R. Part 2, the records of clients receiving treatment for a Substance Use Disorder, including those of minors, are subject to federal confidentiality laws as indicated above which prohibits the treatment program or provider from disclosing any information identifying you as an alcohol or other drug treatment participant without your prior written consent. Signature of this Informed Consent document attests to all of the stipulations listed herein. Additional limitations of confidentiality for clients receiving treatment for a Substance Use Disorder, under 42 C.F.R. and 42 C.F.R. Part 2 are as follows.

• If you provide any information about a crime committed or a threat to commit a crime by a client either at the treatment program or against any person who works for the treatment program.
• Disclosures for the purpose of payment and health care operations are permitted.
• Disclosures for research purposes and for audits and/or program evaluation purposes are permitted.
• Declared emergencies resulting from natural disasters that disrupt treatment facilities and services are also considered a "bona fide medical emergency," for the purpose of disclosing SUD records without patient consent.

Rights and Responsibilities: The course of treatment is determined by you and your treatment provider. You are encouraged to ask any questions you have regarding their education and professional background, therapeutic approach, and the specific treatment plan and progress. In addition, you have been provided a copy of the client's rights and grievance policy along with the Notice of Privacy (HIPPA Act).

Referrals and Termination: Should services outside the scope of Community Counseling Center be needed, a referral to a more appropriate resource will be given to better meet your needs and goals. Clients have the right to terminate treatment at any point during the process and can refuse any and all treatments. However, your service provider may also decline to provide clients treatment if the client refuses or cannot comply with the necessary requirements of that treatment.

Consultation and Supervision: In order to provide you with the best services possible your treatment provider may choose to consult with other Community Counseling Center treatment providers. In addition, graduate level interns providing counseling services are supervised by licensed clinician or a team that includes a licensed clinician. Colleagues who provide consultation and/or supersvision are subject to the same confidentialtiy restraints as your clinician.

Communication and Technology: Community Counseling Center cannot ensure your email, text or any other electronic communications are confidential, are received or are addressed in a timely manner. You are encouraged to call 440-998-4210 if you have treatement related needs.

Treatment of Minors: Upon the request of a minor fourteen years of age or older, a mental health professional may provide outpatient mental services, excluding the use of medication, without the consent or knowledge of  the minor's parent or guardian. A minor age 14 or older is entitled to six sessions or 30 days unitl parental notification is required.

Risk and Benefits: Each treatment service that you receive has risks and benefits associated with it. Research indicates that most people who engage in treatment can benefit from the experience, even so, it's possible for things to get worse before they get better. Your initials indicate that you wish to receive this treatment and that you have recieved a copy of the risks and benefits and they have been explained to you.

 

By checking Telehealth Services box above, I agree the use of Telehealth services in my behavorial health and/or substance use treatment. This may include telephone calls, text messages, electronic mail, and images transmitted via fax machine. They also include real-time, interactive videoconferencing, better known as telemedicine or telehealth. Interactive videoconferencing will be used when required by service type/licensure, or payer. Community Counseling Center services utilizing telehealth will be provided in accordance with O.A.C Rule 5122-29-31. There are many potential benefits to use of this resource in treatment, including increased accessibility, efficiency, availability of specialty care, and convenience. As with all forms of treatment, there are also risks associated with Telehealth services. These potential risks include barrieres to clinical insight, technoligy issues, and increased risk of breach of  security of confidentiality. Community Counseling Center does everything possible to minimize these risks and maximize results through training of staff, use of secure locations to provide services. Community Counseling Center cannot be held responsibleif a client's chosen location to receive services (i.e. their home) is not confidential. As with all forms of treatment, Clients are encouraged to discuss any concerns, needs, and preferences with their treatment providers.

Furthermore, I understand that participation in treatment at Community Counseling Center is strictly voluntary. I have asked for any needed clarification of the conditions mentioned above, and I am satisfied with the explanations and I agree to abide by these conditions. I consent or consent for my minor child named above t participate in treatement services at Community Counseling Center and I understand that I may withdraw consent at any time.

Ohio State Reporting Requirements: OBHIS is mandatory for all clients covered by Medicaid, Board funding or OhioMAS dollars. CCC will not enter records for clients covered by FEMA grants unless asked by the Board to do so using an ID number for the Board payment system (e.g. SHARES, GOSH, etc.). The same would be true for foundation money that passes through the Board.

CCC participates in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. CCC, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying [the EHR System administrator/Medical Records Department] OR [the office administrator].

Signing the Informed Consent for Treatment Services, which will be located in your electronic client record, affirms that you have been provided an orientation to the agency, its programs, services, staff and facilities, as well as have been made aware of restrictions of privileges that may be imposed due to violation of program rules: and that the information listed above has been reviewed in a way that is understandable, and that you have been given the opportunity to ask questions.

Supervision Notification: The Counseling staff of Community Counseling Center is trained and qualified to be of assistance to you. Providers who are not licensed to practice independently, are required to operate under the supervision of a licensed provider with supervisory credentials, as per requirements of the provider’s licensing board. Community Counseling Center ensures that the necessary supervision requirements are met for all practitioners.