New Client Intake Forms - Aura Counseling

CANCELLATION POLICY
CLIENT NAME:
Cancellation Policy
In the event you are unable to keep your scheduled appointment, it is your responsibility to notify Aura Counseling and Wellness 24 hours in advance. Frequent Cancellations could result in the loss of services. *

I ACKNOWLEDGE
We require a 24-hour notice on any cancellation as a courtesy to our Clinicians and other clients that are waiting to be scheduled. You may not see a charge to your account for sessions cancelled with less than 24-hour notice however, three (3) or more sessions cancelled with less than 24-hour notice may put you at risk of being removed from your Clinician’s schedule. *

I ACKNOWLEDGE
No Show Policy
You are allotted (3) excused absences and (2) unexcused absences during your treatment episode. In the event you reach your maximum allotted excuses, the staff will determine whether to discharge you from the program and refer you elsewhere that may provide more appropriate treatment schedule and/or flexibility. If you have more than 3 consecutive no shows or 5 or more unexcused absences in a 3-month time frame, you will automatically be removed from your Provider’s schedule and you may be discharged from services. *

I ACKNOWLEDGE
By signing this document, you are acknowledging that you understand and agree to abide by the policy as a recipient of services at Aura Counseling and Wellness.
Client Signature: *

Clear
CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date
Parent or Guardian *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date

CLIENT RIGHTS
CLIENT NAME:
CLIENT RIGHTS

As a behavioral mental health treatment facility that offers substance abus e treatment, we are required to protect the fundamental human, civil, constitutional and statutory rights of each client receiving services with us. The following is a listing of your rights while receiving service s here.
- You have the right to impartial access to treatment, regardless of race, religion, gender, ethnicity, age or handicap.
- You have the right to respect for personal dignity in the provision of all care and treatment.
- You have the right to adequate and humane services , regardless of the source of financial support.
- You have the right to receive services within the least restrictive environment possible.
- You have the right to an individualized treatment plan, based on assessment of current ne eds.
- You have the right to p articipate in your treatment planning.
- You have the right to request Department of Health and Welfare staff review the treatment plan or the services provided.
- You have the right to personal privacy when residing at a treatment facility including: Visits f rom family and significant others, regardless of their age, unless such visits are clinically contraindicated. Suitable areas for private visits, unless such privacy is contraindicated by your treatment plan.
- Ability to send and receive mail without hindra nce.
- Ability to conduct private telephone conversations with family and friends, unless clinically contraindicated.
If individual therapeutic indications necessitate restrictions on visitors, telephone calls or other commu nications, those restrictions sh all be evaluated for therapeutic effectiveness by a qualified professional at least every three (3) days. Any restrictions to communication will be fully expl ained to you and your family.

You have the right to privacy with r espect to visitors including but not limited to:
- You shall be informed in advance of educational or other individual or group visitations available through this program.
- Visitations to this facility will be conducted in a manner limiting the disruption of your usual activities and treatment process.
- You have the right to request the opinion of a consultant, at your own expense, or to request an in-house review of your individualized treatment plan.
You and, where there is a valid release of information, your family and significant others have the right to be fully informed regarding:
- Client’s rights;
- The name, professional status and position of staff members responsible for your care;
- The nature of care, treatment and procedure s that you will receive;
- The current and future use and disposition of products of special observation and audiovisual techniques, such as one - way mirrors, tape recorders, video recorders, television, movies or photographs;
- The risks, side effects and bene fits of all treatment procedures used;
- Alternative t reatment procedures that are available;
- The right to refuse to participate in any research project without compromising your access to program services;
- The right to refuse specific treatment procedures;
- As appropriate, the cost, itemized when possible, of services rendered;
- The source of this facilities reimbursement and any limitations placed on duration of services;
- The reasons for any proposed change in the professional staff responsible for you or for any transfer of care within or outside this agency;
- The rules and policies of this program applicable to client conduct.
- The right to initiate a complaint or grievance procedure and the means to request a hearing or review of the complaint.
- The discharge plan and the plans for recover y support activities following discharge.
In accordance with the requirements of any applicable law or any applicable standard for substance abuse treatment, a written, dated and signed informed consent form shall be obtained from you or your family or your legal guardian, as appropriate, for participation in any research project or other procedures or activities where consent is required by law.

Client work shall be permitted only under certain conditions. These conditions include the following:
- The work is part of the individualized treatmen t plan o r the therapeutic community environment.
- The work performed voluntarily.
- If paid, the client receives wages commensurate with the economic value of the work.
- The work project complies with applicable laws and rules.
Client Responsibilities
- Supply i nformation (to the extent possible), that Optum, your insurance provider, BPA and/or its personnel in order to provide care
- Follow plans and instructions for care that you have agreed on with your treatment provider
- Understand your health problems and parti cipate in developing mutually agreed upon treatment goals to the degree possible
- Keep scheduled appointments and actively participate in treatment
Signature *

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CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date
Parent or Guardian *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date

EMAIL/TEXT MESSAGING CONSENT
CLIENT NAME:
EMAIL/TEXT MESSAGING CONSENT: In order to communicate with you by email, we need to be sure you are aware of the privacy issues that could arise when we communicate this way, and to document that you are aware of these issues and agree to them. If you want to communicate with your care provider through email or text messaging, please read and sign the form below.
Potential Risks of Using Email and/or Text Messaging:

Aura Counseling and Wellness may offer clients the ability to stay in touch via email and/or text messaging if you, the client or legal guardian, chooses to do so. In the case of children under 18 years old, the parent or legal guardian must approve of email/text communication and sign this consent. Emailing and Text Messaging has a number of risks that consumers should consider before making a final decision about using email or text messaging. These include, but are not limited to , the following:
1. Email and Text Messaging messages may not be received.
2. Email and Text Messaging can be circulated, forwarded, and/or stored in numerous paper and electronic files, in intended and unintended ways.
3. Senders can easily misaddress an email or Text Message.
4. Email and Text Messages can be immediately broadcast worldwide and received by many intended and unintended recipients.
5. Email and Text Messaging can be easier to falsify than handwritten or signed documents.
6. Back-up copies of email and text messages may exist even after the sender or the recipient has deleted their copy.
7. Email and Text Messaging can be used as evidence in court.
8. Email and Text Messaging can be intercepted, altered, forwarded or used without authorization or detection.
9. Email and Text Messaging messages can be lost in transmission.
Aura Counseling and Wellness will use reasonable methods to protect the security and confidentiality of email information sent and received. However, because of the risks listed above, ACW cannot email or text any Protected Health Information unless you specifically request him/her to do so.

Conditions for the Use of Text Messaging and/or Email:
- Email and/or text message correspondence must be specifically requested and initiated by the consumer or the minor consumer’s parent/guardian.
- Aura Counseling and Wellness, agency staff, or your care provider, shall not email nor guarantee the security and confidentiality of a text or email communication, and is not responsible for improper disclosure of confidential information that is not caused by ACW’s intentional misconduct .
Consent to the use of texting or email includes agreement with the following terms:
- Any email and text message that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted.
- Emails and/or text messages containing clinical content will become a part of your medical record.
Although ACW staff will endeavor to read and respond promptly to an email or text message, ACW cannot guarantee that any particular text or email will be read and responded to within any particular period of time. Thus, you should not use text messaging or email for medical emergencies or other time-sensitive matters.
- You are responsible for informing the provider of any types of information that you do not want sent by text message and/or email.
- Your email/text will not be forwarded to a third party without your expressed permission, (or as required by law) unless you have already signed a release for ACW to communicate with a third party.
- You may withdraw consent to communicate by text or email via written communication to the provider at any time.
- If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room immediately.
- You are responsible for protecting your password and access to your phone and/or email account and any text or email you send or receive from ACW to ensure your confidentiality.
Aura Counseling and Wellness, agency staff, or your care provider, cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
Consumer Acknowledgment and Agreement *

By checking the box indicated, I acknowledge that I have read and fully understand this consent form. I understand the risks associated with email and/or text communication and consent to the conditions herein. Any questions I may have had, were answered.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Client Signature: *

Clear
CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date
Parent or Guardian Signature *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date

NOTICE OF PRIVACY PRACTICES
CLIENT NAME:
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Aura Counseling and Wellness LLC, can change the terms of this Notice, and such changes will apply to all information we have about you. Should a change to this Notice occur, the new Notice will be available upon request, in the agency office, and on our website.

1 - OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from all agency staff. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental/ behavioral health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

Our agency is required by law to:
1. Make sure that protected health information (“PHI”) that identifies you is kept private.
2. Give you this notice of my legal duties and privacy practices with respect to health information.
3. Follow the terms of the notice that is currently in effect.
2 - HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
1. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations.
2. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
3. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
4. Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
3 - CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. Our agency may keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As a psychotherapist, behavioral health agency, SUD agency, mental health counseling agency and/or provider, we will not use or disclose your PHI for marketing purposes.

Sale of PHI. As a psychotherapist, behavioral health agency, SUD agency, mental health counseling agency and/or provider, we will not sell your PHI in the regular course of our business.

4 - CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although our policy and preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on agency premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although agency preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment at our agency or with an agency staff member. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
5 - CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations and/or in accordance with the law.

6 - YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask our agency not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and may say “no” if we believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and our agency and its staff will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable and cost-based fee for doing so.

The Right to Get a List of the Disclosures That Are Made. You have the right to request a list of instances in which our agency or its staff have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list given to you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable and cost-based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that our agency or its staff correct the existing information or add the missing information. We may say “no” to your request, but you will be told why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

This notice went into effect on October 1, 2016
By checking the box indicated, I acknowledge that I have read and fully understand this form. Any questions I may have had, were answered. *

I AGREE

Acknowledgement of Receipt of Privacy Notice
CLIENT NAME:
Acknowledgement of Receipt of Privacy Notice

I hereby acknowledge that I have received a copy of the Aura Counseling and Wellness Notice of Privacy Practices (“Notice”):
- The information contained in this Notice has been explained to me, and I understand that I may ask questions about the Notice, and my rights, at any time.
- The Notice tells me how Aura Counseling and Wellness will use my health information for the purposes of my treatment, payment for my treatment, and Aura Counseling and Wellness’ health care operations.
- The Notices explain in more detail how Aura Counseling and Wellness may use and share my health information for other than treatment, payment, and health care operations.
- Aura Counseling and Wellness will also use and share my health information as required/permitted by law. A copy of the Privacy Practices is available to you at any time and is posted in the lobby of the office. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. You are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
- Aura Counseling and Wellness, hereinafter referred to as “Provider”, is a state approved service provider contracted with Business Psychology Associates to provide substance abuse treatment or recovery support services to individuals qualifying for state administered funding. Provider has approved access to Web Infrastructures for Treatment Services, hereinafter referred to as “WITS”, in accordance with Provider’s status as a state approved provider contracted with Business Psychology Associates. WITS is a certified Complete EHR Technology administered by the Idaho Department of Health and Welfare to collect and store electronic health records for qualified individuals in Idaho.
- Pursuant to IDAPA 16.05.01 et seq., the Idaho Department of Health and Welfare maintains the confidentiality of information collected in WITS. Strict physical, electronic and managerial procedures safeguard and secure information. All users are educated to avoid unauthorized access to or disclosure of information. Providers and all users must agree to maintain the security and confidentiality of all information in WITS before access to WITS is granted. All signed WITS User Agreements are on file with the Idaho Department of Health and Welfare. Any Provider or user that is found to violate the WITS User Agreement, or applicable privacy laws, may have their access to WITS terminated and may be subject to further penalties.
USE OF INFORMATION: Provider intends to utilize WITS to record your health and financial Information. This information usually includes a record of your condition, the treatment provided, and payment for your treatment. By allowing the Provider to utilize WITS for your information, you are granting use of your information as follows:

1. Information may be used for reporting, research or functions related to payment or reimbursement of services. Information used for reporting or research purposes is de-identified to maintain the anonymity of the individuals.

2. Service providers are audited periodically to ensure they are meeting the standards required by IDAPA for client care. Health and financial information may be reviewed during an audit.

3. The WITS Help Desk may access health and financial information to provide technical assistance to Provider.

DISCLOSURE OF INFORM ATION: Information collected in WITS will only be disclosed to third parties to the extent required by law or authorized by you. If you have concerns about your Protected Health Information, please discuss your options with Provider.

ACKNOWLEDGMENT AND CONSENT: I hereby acknowledge and consent to the storage of health and financial information by Provider in the electronic systems of the State of Idaho, also known as WITS. I hereby acknowledge that I am entitled to a copy of this notice upon request. I acknowledge that I have the right to file a complaint if I believe my privacy rights have been violated.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Client Signature: *

Clear
CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date
Parent or Guardian Signature *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date

PRACTICE POLICIES
CLIENT NAME:
TELEPHONE ACCESSIBILITY

If you need to contact a staff member between sessions, please leave a message on our voice mail or with the front desk staff. Often our staff may not immediately be available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situatio n arises, please call 911 or any local emergency room.
By checking the box indicated, I acknowledge that I have read and fully understand the above policy. Any questions I may have had, were answered. *

I AGREE
SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Our Staff does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you meet with your primary therapist and we will be happy to talk more about it.
By checking the box indicated, I acknowledge that I have read and fully understand the above policy. Any questions I may have had, were answered. *

I AGREE
ELECTRONIC COMMUNICATION

Aura Counseling and Wellness and their staff cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, our agency will do so. While our agency may try to return messages in a timely manner, our agency cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Idaho. Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

(2) All existing confidentiality protections are equally applicable.

(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.

(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.

Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client.

Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences.

When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression.

Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
By checking the box indicated, I acknowledge that I have read and fully understand the above policy. Any questions I may have had, were answered. *

I AGREE
MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
By checking the box indicated, I acknowledge that I have read and fully understand the above policy. Any questions I may have had, were answered. *

I AGREE
TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment.

Our agency may terminate treatment after appropriate discussion with you and a termination process if your therapist determines that the psychotherapy is not being effectively used or if you are in default on payment.

Our agency and therapists will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating unless you are in violation of the SUD Treatment Rules and/or a behavior contract.

If therapy is terminated for any reason or you request another therapist, you be provided with a list of qualified psychotherapists and/or agencies to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, our agency must consider the professional relationship discontinued.
By checking the box indicated, I acknowledge that I have read and fully understand the above policy. Any questions I may have had, were answered. *

I AGREE
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Client Signature: *

Clear
CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date: *

Month Day Year
Date
Parent or Guardian Signature *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date:

Month Day Year
Date

Idaho Substance Abuse Treatment and Recovery Support Services

Direct any and all questions or concerns to: Amy Kappel, LCPC, Clinical Director – 208-463-4639
Consent for Release of Information

- SUD Funding (BPA, IDJC)
I, {clientName321} , am requesting substance abuse services from Idaho's publicly funded substance abuse system of care.

As such I voluntarily authorize BPA Health, those Substance Abuse Treatment and Recovery Support Services (RSS) providers who are contracted to provide Treatment and RSS under Idaho's publicly funded substance abuse system of care, and the Department of Health and Welfare (Department) to disclose my name, all necessary treatment information and my social security number to each other and the Department.

This information will be disclosed for the following purposes: 1) To assist with referring me to appropriate types of care and guiding my treatment and recovery support; 2) To be entered into the Department's common client database so that I will have one client number for any services received from the Department; 3) To process payment of costs for my treatment and recovery support services; 4) For monitoring compliance in the program; 5) For program audit and research including independent peer reviewers, contract monitors or researchers appointment by the Department; 6) For investigations related to fraud.

Furthermore, I authorize the disclosure of personal substance abuse treatment and recovery outcomes data collected by contracted Substance Abuse Treatment and RSS Providers, BPA Health and the Department to the Federal Center for Substance Abuse Treatment and its contracted data collection Agents.
ACKNOWLEDGEMENT *

I AGREE
Informed and Voluntary Consent for Treatment

The purpose of my participation, as a client, in the Idaho publicly funded substance abuse treatment program is to acquire knowledge, skills and attitudes supportive of a sober and more satisfying lifestyle. In addition to the potential positive outcomes likely to occur as a result of my participation, the following reasonably foreseen risks may occur, as they would in any other alcohol and drug treatment program: breach of confidentiality; negative reactions of group members; emotional stress from requirements of group interaction, self-disclosure; stress to relationships resulting from open discussion of issues, past traumas; and, stress to relationships resulting from participant behavioral changes, positive or negative, need to attend recovery support meetings, spend time in group and doing assignments. Providers will take steps to minimize or protect participants against potential risks by adhering to standards of confidentiality found both in Federal and State Code, and by informing and verifying client group rules. And, by intervening in and guiding appropriate disclosure, confrontation and understanding of resolution self-help groups in group and in family conflict. Providers will assist clients in accessing sober support services and where acceptance and stress reducing support is available.
ACKNOWLEDGEMENT *

I AGREE
Revocation Clause

This release may be revoked at any time either orally or in writing, except to the extent that action has already been taken in reliance on the release. I acknowledge that some information may include material that is protected by State and Federal regulations including Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Information Portability and Accountability Act (HIPAA). Unless revoked as stated above, this consent expires automatically on:

ONE YEAR FROM DATE OF DISCHARGE
ACKNOWLEDGEMENT *

I AGREE
I have read the above Consent to Release of Information, Informed and Voluntary Consent for treatment and the Revocation Clause. I agree I have been given the opportunity to question the above disclosures and consent for care and hereby do agree to the above identified Disclosures and Consent to Treatment.
Client Name
Client Signature *

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CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date

Month Day Year
Date
Parent/ Guardian Name *
Parent/ Guardian Signature *

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DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date

Month Day Year
Date
AGENCY STAFF VERIFICATION:

*All documents signed & submitted electronically.

ICANS Informed Consent
Date of Form Submission

Month Day Year
Do not change date of form submission
I am the parent or legal guardian of the minor child indicated below.
Name of Parent/ Guardian
Name of Minor Client
I have received a brochure explaining how ICANS is a secure electronic health system used to administer the ICANS assessment, and make the results available to providers who participate in the ICANS system.

I authorize the following Agency: AURA COUNSELING & WELLNESS LLC to release, use, receive, mutually exchange, communicate with and disclose information to the ICANS system, and with Agencies/Authorized Users with access to ICANS.

WHO MAY DISCLOSE INFORMATION. The agency I have named at the top of this form may disclose protected health information to ICANS.

WHAT MAY BE DISCLOSED. By signing this consent, I specifically understand that protected health information or records will be released, used, disclosed, received, mutually exchanged or communicated to, by, among, or between any person, entity, or agency named in this authorization. I understand this information may include material protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 C.F.R. Part 2; the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 & 164; and the Medicaid Act, 42 CFR Part 431, Subpart F. Federal rules restrict any use of the information to criminally investigate or prosecute and to redisclose records relating to any alcohol or drug abuse patient.

PURPOSES. I understand this authorization will allow my treatment team to plan and coordinate services I need and allows any person, entity, or agency named in this authorization to be actively involved in my case coordination, evaluation, treatment, planning, or legal proceedings. I hereby request and give my permission for an open exchange of information to, by, among, or between, any person, entity, or agency named in this authorization.
REVOCATION. I also understand that I may revoke this Informed Consent at any time, except to the extent that action has been taken in reliance on it and that in any event this authorization expires automatically as indicated with each disclosure item identified above. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as this original.

EXPIRATION. This authorization shall expire one (1) year from the date the Minor Client and Parent or Legal Guardian signs below.

CONSENT. I understand that my information cannot be disclosed without my written consent, except as otherwise provided by law, and that federal and Idaho law will be followed for using and disclosing my ICANS information.

By signing this form, I am authorizing providers assessing or treating my child/ward to provide my child/ward’s information to ICANS. I understand that failure to sign this authorization may limit determine of eligibility, enrollment, or treatment for my child/ward.

I have read this Informed Consent/had this Informed Consent read/explained to me and I acknowledge an understanding of the purpose for the release of information. I am signing this authorization of my own free will.
Full Legal Signatures
Full Legal Signature of Minor (or Authorized Personal Representative) *

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CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Relationship to Client
You may change above text, if applicable.
Date

Month Day Year
Date
Full Legal Signature of Parent or Legal Guardian – Required if Client is under 16 years of age, but only after signed by client. *

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DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Relationship of Parent/Legal Guardian to the Client *
Date

Month Day Year
Date

Therapy Meets Technology

Aura Counseling & Wellness
How Our Therapy Meets Technology

Evidence-Based Therapy Services offer the most effective forms of therapy and treatment services to anyone using or participating in such programs and curriculum. At Aura Counseling and Wellness, we firmly believe in the use of these practices as a way to bring you the most up-to-date, effective, and client-focused therapy techniques.
The OQ system aids therapy in two primary ways:
1. The OQ Measures provides performance feedback that therapists too often lack because many clients would prefer to report worsening symptoms to a computer—even if they know that their therapist will see the results—rather than disappoint therapists face-to-face.
2. The second benefit comes from metrics: Risk alerts allow therapists to adjust treatment plans, and can help them compensate for natural overconfidence and clinical blind spots.
Why We Use It:
The OQ Measures provides a quick but comprehensive snapshot of the client’s current functioning across a wide variety of disorders. Initial (beginning) Intake scores can help identify areas of immediate clinical concern and aid in treatment planning. The quality of the relationship between the client and therapist has been found to have a direct impact on how well the client does in treatment and your success after treatment. The OQ-Analyst system is designed for repeated measurement of client progress throughout therapy. The OQ Measures system can detect suicide, substance abuse, and workplace/school violence.
The OQ Measures is sensitive to change over short periods of time, making it useful for evaluating client progress at any point during treatment.
Information from the OQ Measures may be helpful in treatment/discharge planning and could lead to more effective therapy meaning that services could be shorter in duration than at other agencies.
How It Works:
The Youth/Teen version is for children ages 12-18 and there is a version for the parents/guardian of a child ages 4-17, if it is determined the parent report would be more effective. The Adult version is for anyone over the age of 18.
Clients are encouraged to answer openly and honestly and the questions should be answered according to how true each statement is during the past 7 days. The survey will be completed before each individual counseling session and at every significant clinical event (treatment plan/goal updates, new assessment, etc.) but no more than once a week.
Your Answers and The Results:
You’ll be asked to complete it several times so you and your therapist can track how things are going for you over time. Each and every time, our clinical staff will review the report and talk further about how things are going and how things change over time.
I authorize the following Agency: AURA COUNSELING & WELLNESS LLC to release, use, receive, mutually exchange, communicate with and disclose information to the OQ-A Measures system.
WHO MAY DISCLOSE INFORMATION. The agency I have named at the top of this form may disclose protected health information to OQ-A Measures.
WHAT MAY BE DISCLOSED. By signing this consent, I specifically understand that protected health information or records will be released, used, disclosed, received, mutually exchanged or communicated to, by, among, or between any person, entity, or agency named in this authorization.
I understand this information may include material protected under federal regulations governing confidentiality of alcohol and drug abuse patient records, 42 C.F.R. Part 2; the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 & 164; and the Medicaid Act, 42 CFR Part 431, Subpart F. Federal rules restrict any use of the information to criminally investigate or prosecute and to redisclose records relating to any alcohol or drug abuse patient.
PURPOSES. I understand this authorization will allow my treatment team to plan and coordinate services I need and allows any person, entity, or agency named in this authorization to be actively involved in my case coordination, evaluation, treatment, planning, or legal proceedings. I hereby request and give my permission for an open exchange of information to, by, among, or between, any person, entity, or agency named in this authorization.
REVOCATION. I also understand that I may revoke this Informed Consent at any time, except to the extent that action has been taken in reliance on it and that in any event this authorization expires automatically as indicated with each disclosure item identified above. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as this original.
I understand that my information cannot be disclosed without my written consent, except as otherwise provided by law, and that federal and Idaho law will be followed for using and disclosing my information.
By signing this form and regularly completing the OQ-A questionnaire, I am authorizing providers assessing or treating the Client Name Below (myself or my minor child) to use the OQ-A Measures system as a form of my services with Aura Counseling and Wellness LLC. I have read this Informed Consent/had this Informed Consent read/explained to me and I acknowledge an understanding of the purpose for the release of information. I am signing this authorization of my own free will.
Name of Client
Client Signature *

Clear
CLIENT DIGITAL SIGNATURE
Digital Signature Approval *

Accept Signature
Date *

Month Day Year
Date
Parent/ Guardian Signature *

Clear
DIGITAL SIGNATURE - Parent/ Guardian
Digital Signature Approval *

Accept Signature
Date

Month Day Year
Date
THANK YOU!

We understand that this process may seem like a lot but we appreciate your time and patience in completing these forms.

If you have any questions, comments, or concerns please contact our office directly.

Aura Counseling and Wellness

3050 12th Ave Rd, Nampa, ID 83686

P: 208-463-4639

E: newclient@auracounseling.com

Use the SUBMIT button below to finish and submit your forms.
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NEW CLIENT INTAKE

Authorization & Consent to Treat

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

CANCELLATION POLICY

Cancellation Policy

No Show Policy

By signing this document, you are acknowledging that you understand and agree to abide by the policy as a recipient of services at Aura Counseling and Wellness.

CLIENT RIGHTS

EMAIL/TEXT MESSAGING CONSENT

INFORMED CONSENT & MEMORANDUM OF UNDERSTANDING

NOTICE OF PRIVACY PRACTICES

Acknowledgement of Receipt of Privacy Notice

PRACTICE POLICIES

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Idaho Substance Abuse Treatment and Recovery Support Services

Consent for Release of Information

ICANS Informed Consent

Full Legal Signatures

CUSTODY DISCLOSURE FOR MINOR CHILDREN

PLEASE PROVIDE THE FOLLOWING INFORMATION, IF APPLICABLE:

Therapy Meets Technology