Preferred Mode of Contact (Appointments & Scheduling):

Subscriber's Name if other than the client.

(Please complete if client is under 18 years of age)

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the provider with Therapy Sense PLLC. I understand that I am financially responsible for any balance. I also authorize behavioral health professionals/therapists with Therapy Sense PLLC or my insurance company to release any information required to check for eligibility or process my claims.

Client/Legal Guardian Signature

Your health care is completely confidential. No information will be given out about you without your written permission except as required by law or to provide services to you in compliance with federal privacy and security standards.

Please note:

1. We are mandatory reporters of Statutory Sexual Seduction (N.R.S. 200.364).
2. We are also mandatory reporters of Child Abuse and Neglect (N.R.S. 432B.220).
3. We are also mandatory reporters of lewdness (sex) with a child under the age of 14 (N.R.S.201.230).

I have the right to know everything about my care and am encouraged to ask questions.

I understand that in order for us to provide the services I request, I may need to disclose information. 

I understand that in order for us to provide the services I request; I may need to disclose information of a personal nature and regarding my medical history. These may include:

• _Date of birth • _Contact information • _Medications
• _Past/Current medical issues • _Tobacco/alcohol/substance use • _Family dynamics

I have read (or have had read to me) the above information, understand this information, and give my permission for behavioral health professionals/therapists with THERAPY SENSE PLLC to have access to my personal information.

 

State of Nevada

PRIVACY RULE AND HIPAA

Nevada Administrative Code (NAC)

NAC 441A.935, Reporting of additional information to the system upon request by health authority; information of personal nature deemed
confidential medical information.
NAC 441A.940, Provisions do not prohibit health authorities from acquiring information from other sources for inclusion in the system.
Nevada Revised Statutes (NRS)
NRS 441A.167, Investigation: Law enforcement agencies and political subdivisions authorized to share certain information and medical
records with state and local health authorities.
NRS 441A.220, Confidentiality of information; permissible disclosure.
NRS 441A.230, Disclosure of personal information prohibited without consent

CONSENT FOR SERVICES: I hereby consent to and authorize such services as prescribed and fully explained to me by the behavioral health professionals and/or therapists with THERAPY SENSE PLLC.

It is not possible to make guarantees concerning the results of services. I acknowledge no such guarantee has been made to me. I understand I will have the opportunity to discuss any and all care and/or services proposed to me by the provider and I may refuse to consent for care services if I do not want to proceed with such course of services. I will provide the behavioral health professionals and/or therapists with accurate information regarding my medical, sexual, drug, and/or alcohol history, and personal or social concerns which may impact my health or medical care to ensure proper service, care, and referral for needed services.

I understand that if I am more than 15 minutes late for my appointment I may not be seen and will need to reschedule my appointment. I am responsible for notifying the Provider/Therapist – preferably at least 24 hours in advance – if I am unable to keep my scheduled appointment.

 

To the best of my ability, I will be an active participant in my care. I am responsible for reporting any changes in my health status to my Provider/Therapist so that I can receive prompt and appropriate education and referral services.

I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.

I understand that none of the telemental health sessions will be recorded or photographed.

I agree not to make or allow audio or video recordings of any portion of the sessions.

I understand that the laws that protect the privacy and the confidentiality of client information also apply to telemental health and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.

I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access.

I understand that any internet-based communication is not 100% guaranteed to be secure.

I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

I understand that I or my therapist may discontinue the telemental health sessions at any time if it is felt that the video technology is not adequate for the situation.

I understand that if there is an emergency during a telemental health session, then my therapist may call emergency services and/ or my emergency contact.

I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.

I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re-contact.

I understand a “no show” or a late fee will be charged if I miss an appointment or do not cancel within 24 hours of the scheduled appointment.

I understand my therapist will advise me about what telemental health platform to use and the therapist will establish a video conference session.