By submitting this form, I agree that: I have been provided a copy of the Consent Disclosure (Displayed below). I have read the Consent Disclosure, and wish to partake in Chosen's Services with my assigned Care Manager.
I acknowledge that I have read and understand the above Electronic Records Disclosure and have been given the opportunity to ask questions about it.
By signing this informed consent for services form, you agree that you have reviewed this informed consent for services form, and acknowledge you have read and understood all the terms and information contained in it and that ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. Furthermore, you agree to abide by all policies outlined herein. I understand the Research Consent explained above and consent to allowing the assessment results to be used in Chosen's Outcomes Research Project.
Client Consent to the Use of Telehealth- I have read and understand the information provided above regarding telehealth, have discussed it with my Care Manager, and all my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.
Consent Disclosure
CHOSEN SERVICE OVERVIEW
Services Available:
• Caregiver Coaching
• Caregiver Education
• Counseling
• Targeted Case Management
• Peer Support
• Therapeutic Referral
Hours: Normal office hours are Monday – Friday; 8:30 – 5:30 pm.
Accommodations outside of these hours may be made if needed.
Fees are calculated based on a sliding scale of income and family size. Service fees will be
discussed following application submission and two complimentary sessions.
INFORMED CONSENT
MISSION: Chosen’s Mission is to help children heal from trauma by strengthening their families.
VISION: Our vision is to see every child thriving in a family.
RATIONALE FOR SERVICES: We believe that offering our trauma-informed model of care to
families impacted by the child welfare system will serve our mission of helping children heal
from trauma by strengthening their families. With our attachment as the foundation, we
approach the family as a system so that everyone in the home can heal and thrive.
EDUCATION: All Chosen Care Managers possess a bachelor’s degree in social work/related
field or have a minimum of a decade of lived experience. All Care Managers have been trained
in trauma-informed interventions and techniques. Chosen does provide counseling and social
work internships to assist students actively pursuing degrees and licensing with necessary
opportunities to gain valuable experience in this area of practice. We will always consult with
client/parent first and receive permission before allowing/inviting interns into sessions. Allowing
an intern in a session is optional.
LICENSES: All Chosen Care Managers who provide counseling possess an unrestricted
license (LMSW, LBSW, LPC, etc.) to practice in the state where they are located. Care
Managers who do not possess a license only provide parent coaching and personalized case
management.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE:
• Participation in Chosen’s Model of Care can result in several benefits to the client, including
improving interpersonal relationships and resolution of the specific concerns that led them to
seek services. Working toward these benefits, however, requires effort on the Parent/Legal
Guardian’s part, including active involvement, honesty, and openness in order to change
thoughts, feelings, and/or behavior to bring healing. During the course of service delivery,
the Care Manager is likely to draw on various approaches according, in part, to the problem
that is being treated and their assessment of what will best benefit the client. These
approaches include but are not limited to using various assessment instruments, and best
practiced/trauma-informed interventions such as Trust-Based Relational Intervention ™,
Trauma Competent Caregiver Curriculum, Motivational Interviewing, Making Sense of Your
Worth, and various curricula created by Chosen staff.
• There is an inherent risk that during the service delivery, the client may experience painful
feelings, caused by making sense of difficult memories and experiences, and in the process
of resolving problems with relating to others. Additionally, there is no guarantee that
Chosen’s model of care will meet any expected or desired outcomes for the client or
parent/legal guardian.
• Typical scheduled sessions will normally be 60 minutes, although sometimes longer
sessions are appropriate. Care Manager and Parent/Legal Guardian will decide together
how often the sessions should occur. Sessions are scheduled either at the end of each
session, by scheduling online, by calling Chosen’s main office number at (830) 455-0101, or
by calling the client’s assigned Care Manager’s phone number. Parent/Legal Guardian is
permitted to contact their assigned Care Manager outside of the scheduled sessions when
necessary and within appropriate boundaries.
CLIENT RELATIONSHIPS: The relationship between Care Manager and client is the vehicle
through which change can take place. As a result, the relationship is often one in which close
emotional bonds develop. It is also a professional relationship, in which appropriate boundaries
must be maintained. Because the care manager-client relationship is so important, Chosen
Care Managers cannot be involved in a social relationship or friendship that exists outside of the
client home/virtual platform. Limiting the relationship to the office/client home/virtual platform
keeps the service environment safe, secure, and free of outside complications that could
interfere with the therapeutic work.
TRAUMA-INFORMED ACTION PLAN®: Within a reasonable period of time (usually 2-3
sessions) after the initiation of service delivery, the Care Manager will discuss with client(s)
working understanding of the problems, strengths, goals, and their view of the desired outcomes
of treatment using a written Trauma-informed Action Plan® (TAP®), signed and agreed upon by
all Care Managers and client(s). If there are any unanswered questions about any of the
procedures used in the course of service delivery or about the treatment plan, they may be
asked and will be answered. The client also has the right to ask about other
interventions/approaches for client’s concerns.
CONFIDENTIALITY: Our core values at Chosen compel that all information disclosed within
sessions and the written records pertaining to those sessions are confidential and may not be
revealed to anyone without clients’ written permission except where disclosure is required by
law. In all but a few rare situations, the confidential information of the client is protected by state
law. Texas state law requires Chosen to inform the parent/legal guardian that in certain cases,
confidentiality is not protected, and the information may be disclosed to the appropriate
authorities/agencies. These cases include:
• If we have reason to believe that the client may harm self or others;
• In the event that the Care Manager reasonably believes that the client is in physical
danger, either to themselves or another person, consent is given for the Care Manager
to warn the person in danger and to contact any person in a position to prevent harm to
themselves or another person, including law enforcement and medical personnel;
• If we have reason to believe that client is involved in or has knowledge of abuse or
neglect of a child, or abuse, neglect, or exploitation of a person who is elderly or has a
disability;
• If we are ordered to disclose by a state or federal court; or
• Additionally, we may disclose information if there is a signed Release of Information form
granting permission to designated third parties to receive information that we are
requested to share. If any of the situations listed above arise, Chosen will make every
effort to discuss it with you in advance and to limit our disclosure to what is necessary.
RECORDS: All of our communications become a part of your clinical record. Adult client records
are disposed of 7 years after the file is closed. Minor client records are disposed of 7 years after
the client’s 18th birthday.
CONSULTATION: In order to provide the best care possible, Chosen Care Managers consult
regularly with other professionals regarding approaches and techniques; however, each client's
identity will remain completely anonymous, and confidentiality will be fully maintained.
E–MAILS, CELL PHONES AND COMPUTERS: Client/Parent/Legal Guardian consents for
Chosen to communicate by mail, text, email, and phone at the addresses and phone numbers
provided by the family at time of intake, and the Client/Parent/Legal Guardian will immediately
advise Chosen if there is a change. This communication will ONLY pertain to the
scheduling/rescheduling or cancelling of appointments outside of sessions. During office hours,
Chosen can be reached at (830) 455-0101. You may contact your Care Manager outside of a
scheduled session and Care Managers will make every effort to return the call/text/email as
soon as possible. Please ensure that you secure your computer and emails against
unauthorized viewing by third parties. This may include adopting the use of password protection
for all personal email accounts and documents etc. It is recommended that you do not engage
in online counseling using a public computer, where the content of exchanges could be viewed
by others in the close proximity. For security reasons we would not advise that you send any
content in an “open email.” We would also recommend that you send it as a Word document
attachment to your email using a password for further protection.
SOCIAL NETWORKING: Our Care Managers do not accept friend requests from current
clients, nor do they request connections to current clients on social networking sites, such as
Facebook, Instagram, etc. We believe that adding clients on these sites and/or communicating
via such sites can compromise their privacy and confidentiality. For this same reason, we
request that current clients not communicate with Care Managers via any interactive or social
networking sites. Should a current client communicate with Care Managers over a social
networking site, Care Managers will not respond.
AUDIO OR VIDEO RECORDING: By signing this consent, you agree that there will not be
recording of audio or visual content of sessions without the permission from all involved parties,
and that any sessions’ content will not be posted or forwarded for others to see or hear without
the expressed permission of all involved parties.
EMERGENCIES:
In case of an emergency (an urgent issue requiring immediate action), immediately contact 911,
the client’s physician, the local emergency room, or your local Mental Health Crisis Hotline. It is
the Client/Parent/Legal Guardian’s responsibility to seek appropriate resources in emergency
situations where the client presents a serious and imminent risk to themselves or others.
Chosen is not a crisis center; neither its Care Managers nor Chosen will be held responsible for
any damages occurring as a result of unmet crisis or acute care. In case of emergency, Chosen
is authorized (but not required) to discuss the emergency with the emergency contact listed in
electronic client file information form.
LEGAL PROCEEDINGS:
Chosen Care Managers are legally required to respond to court subpoenas, either for written
records, or to testify on particular cases. We will only share the information specifically
requested of us, and nothing more. We are more than willing to provide written summaries of
assessment, treatment plans, and closing summaries as applicable for a fee. If Chosen Care
Managers are subpoenaed to be physically present in court as fact witnesses or as expert
witness, Chosen Care Managers will require compensation for their time, as is usual and
customary when professionals are requested to testify in court. We request at least 7 business
days’ notice so that calendars can be cleared and adequate preparations can be made. As we
would be required to cancel other client sessions for a substantial block of time, our policy is to
receive payment for that time in advance for all preparation time and all time required out of the
office, including travel time. Should our presence be desired in court, the fee structure is as
follows:
• All preparatory time (e.g., reviewing the file, court preparation with attorney,
communication relation to preparation) is charged at $75 per hour.
• All time required offsite (including drive time), whether spent testifying or not, is charged
at $75 per hour.
FINANCIAL RESPONSIBILITIES: Client (or Parent/Legal Guardian) may be subject to paying
for missed or cancelled sessions unless they call at least 24 hours in advance to cancel or
reschedule the session. (Exceptions may be made in emergency situations.) Chosen’s fees are
set on a sliding scale and prompt payment is appreciated. You are responsible to pay all fees in
accordance with the Fee Schedule you are provided. We do not accept cash at this time.
Chosen will not file insurance claims for clients at this time.
CANCELLATION/LATE AND NO-SHOW POLICY: Sessions with Care Managers are an
integral part of the work we do at Chosen and in pursuit of our goal to bring hope to families and
healing to children. Having a cancellation/no/late show policy in place is important in serving our
families with excellence. Regular attendance at appointments is shown to help with progress,
skills practice, and improved outcomes. This requires commitment from everyone involved in
the process. Chosen will work closely with clients to remind them of upcoming
appointments, using calendar invites and text confirmations. However, it is ultimately the
responsibility of the Client/Parent/Legal Guardian to be aware of their upcoming
appointment dates and times.
1. Cancellation Policy: Chosen’s Care Managers desire to be available for all the clients we
serve. However, we are limited in the amount of therapy appointments we can offer at this
time. When a client cancels a scheduled appointment without adequate notice, another
client loses an opportunity to be seen.
a. Cancellation: Chosen requires at least a 24-hour cancellation notice for therapy
appointments, by phone call (text messages/e-mails can have delays, depending on
the locations and connectivity of each person). If there is no answer, or it is after
business hours, client must leave a message.
b. Late cancellation: A cancellation is considered late when the appointment is
cancelled without 24-hour advance notice, or a client is more than 15 minutes
late. If a Client/Parent/Legal Guardian late-cancels on 3 or more occasions, we
reserve the right to discharge from services.
c. Emergencies: Chosen is aware that “life happens,” and desires to be sensitive to
the unforeseen circumstances that may arise for the families we serve. Emergency
late cancellations are accepted only for personal illness, hospitalization, illness of a
family member (Client/Parent/Legal Guardian), or death in the family.
2. Late Show Policy: Chosen understands that delays can happen, however, it is important to
keep everyone on time. If a client is late, the session will still end at the scheduled time.
a. The Care Manager will wait 15 minutes before ending the session.
b. If a client is more than 15 minutes late on 3 or more occasions, we reserve the right
to discharge services.
3. No-Show Policy: A “no-show” is a client who misses an appointment without cancelling or
notifying us within the proper 24-hour time frame.
a. After 3 no show/missed appointments, a client may be discharged from services.
TERMINATION OF SERVICES: Each client is in a different place of healing, but it is our goal
that each client will finish services in a timely manner, without unnecessary expenditure of time
or money. Progress is more likely when the client practices the skills learned between sessions.
Normally, services will be terminated by mutual agreement. The Client/Parent/Legal Guardian
has the right to terminate services at any time. If there is not an appointment scheduled within
90 days of the last session, Chosen and its Care Managers have the right at any time thereafter
to deem services terminated. If the previously indicated Cancellation/Late and No-Show policy
is not followed, it provides grounds for termination as well. As services proceed, we will assess
the continued benefit of your sessions with us. Our Care Managers do not continue to treat
clients who are not benefitting from sessions with us or those who believe we are not equipped
to help. We will discuss this with the involved parties and, if appropriate, terminate sessions. In
the case of termination, we will provide referrals to other providers who may be of help to the
client. If it is requested and authorized in writing, we will consult with the provider selected to
assist in transition.
CARE MANAGER'S INCAPACITY OR DEATH: If the assigned Chosen Care Manager
becomes incapacitated, dies or ceases to practice parent coaching, it will become necessary for
another Care Manager to take possession of client files and records. By signing this Informed
Consent for Services form, you consent to allow Chosen to select another Care Manager to
provide services if necessary. Chosen will consult with you to ensure as smooth a transition as
possible.
COMPLAINTS: If you have a complaint or concern, please speak first to the Chosen Care
Manager or their supervisor.
AMENDMENTS: Chosen may amend this Informed Consent for Services form with prior notice
to you.
CONSENT TO SERVICES: You have voluntarily agreed to receive mental health assessment,
care, case management, parent coaching or counseling, and you consent to and authorize
Chosen Care Managers to provide such assessment, care, case management, parent coaching
or counseling in the manner they consider necessary and advisable. You agree to participate in
the planning of the model of care; and you may stop services at any time.
FINANCIAL DRAFT AUTHORIZATION: By signing this Informed Consent for Services, you
authorize Chosen to charge you all fees in accordance with the Fee Sheet we provided to you
after your second session. Additionally, by signing this Informed Consent, you agree to pay the
fee incurred within 30 days of receipt of invoice.
BEHAVIOR SUPPORT MANAGEMENT POLICY
Chosen does not use restrictive behavior management interventions and are not authorized to
use it. We promote respect, healing, and positive behavior of the client and prevent the need for
crisis interventions. Further, Chosen monitors potential harassment or violence towards others,
including other service recipients or personnel, and utilizes the below levels to mediate any
circumstances.
Chosen staff is trained in the Trauma Competent Caregiver Curriculum by Back2Back Ministries
as well as Trust-Based Relational Intervention (TBRI®) developed by Dr. Karyn Purvis and Dr.
David Cross at the Karyn Purvis Institute of Child Development, both of which utilize TBRI®
Levels of Response™. The level system is used to de-escalate situations.
Level 1: Playful Engagement
Level 2: Structured Engagement
Level 3: Calming Engagement
Level 4: Protective Engagement
Chosen advises clients to seek formal training during Level 4 Response. This would come from
the agency through which the child was placed in their home. The organization does not escort
individuals or use or advise locked seclusion. The organization is not qualified to authorize a
restrictive intervention. Personnel will not be involved in any restrictive behavior management
interventions while in the home. If staff is a witness to the incident, they will debrief with client to
identify possible injuries and emotional reactions. The organization is not responsible for
incidents and advise clients to report to their agency immediately. If a client discloses
information about using a restrictive behavior management intervention, Chosen will document
it in the client’s file, including justification, use, circumstances, and length of application. All
attempts made prior to use of the restrictive behavior management intervention will also be
identified and documented. Staff will review the incident and talk through de-escalation
strategies for future scenarios. The organization supports the safest environment possible and
wants to further reduce the use of restrictive interventions.
CLIENT RIGHTS
SERVICE DELIVERY
Services are generally delivered through various forms of technology, included but not limited to
Zoom meetings, phone calls, emails, and more. When technology-based services are
unavailable to clients, location of meetings will be determined with your assigned Care
Manager. Chosen’s staff respects the privacy of clients in every manner of service delivery.
Employees demonstrate competency in the security and general resources of any technological
service used before leading client services. Employees monitor confidentiality issues and other
areas of concern, ensuring that clients are consistently protected.
RESPONSIBILITIES
Clients are responsible for various expectations during services with Chosen. Clients
understand that services are provided during the hours of 8:00a-5:00p CST, and any requests
for services provided at other times may be declined. Clients are also expected to provide
proper notice, per the agreements signed at intake, for any changes in information, client status,
or need for services.
LEGAL DUTIES
State and Federal laws require that we keep your health records private. Such laws require that
we provide you with this notice informing you of our privacy of information policies, your rights,
and our duties. We are required to abide these policies until replaced or revised. We have the
right to revise our privacy policies for all medical records, including records kept before policy
changes were made. Any changes in this notice will be made available upon request before
changes take place. The contents of material disclosed to us in an evaluation, intake, or
counseling session are covered by the law as private information. We abide by ethical and legal
requirements of confidentiality and privacy of records.
USE OF INFORMATION
Information about you may be used by the personnel associated with this organization for
diagnosis, treatment planning, treatment, and continuity of care. Both verbal information and
written records about a client cannot be shared with another party without the written consent of
the client or the client’s legal guardian or personal representative. We may ask for permission to
disclose information to health care providers who provide you with treatment, such as doctors,
nurses, mental health professionals, and mental health students and mental health
professionals or business associates affiliated with this clinic such as billing, quality
enhancement, training, audits, and accreditation. It is the client’s responsibility to provide
necessary information for services to be provided as accurately and effectively as possible. It is
the policy of this organization not to release any information about a client without a signed
release of information except in certain emergency situations or exceptions in which client
information can be disclosed to others without written consent. Some of these situations are
noted below, and there may be other provisions provided by legal requirements.
DUTY TO WARN AND PROTECT
When a client discloses intentions or a plan to harm another person or persons, the health care
professional is required to warn the intended victim and report this information to legal
authorities. In cases in which the client discloses or implies a plan for suicide, the health care
professional is required to notify legal authorities and make reasonable attempts to notify the
family of the client.
PUBLIC SAFETY
Health records may be released for the public interest and safety for public health activities,
judicial and administrative proceedings, law enforcement purposes, serious threats to public
safety, essential government functions, military, and when complying with worker’s
compensation laws.
ABUSE
If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently
abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the
health care professional is required to report this information to the appropriate social service
and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and
their safety appears to be at risk, we may share this information with law enforcement officials.
GRIEVANCES
You have the right to express and resolve grievances regarding denial of services or service
conduct. There will be no retaliation or interference with any grievance reported. Grievances
should be submitted to the Chief Programs Officer at staci@chosen.care. This should address
the specific concerns, the employee involved, and requested action taken. This can be in the
form of a written complaint or through email and should be signed and dated.
The Chief Program Officer will re-assign you to a different Care Manager immediately after the
grievance is filed. All future meetings will occur between the newly assigned Care Manager. The
Chief Program Officer will send a notification within 24 hours that the grievance was received
and will communicate that the complaint is taken seriously and is being reviewed.
The Chief Program Officer will review the grievance allegations, notify the employee involved
and, if necessary, include the CEO and Board. The review process will include factual research
on the complaints made and interviews with any involved staff members. Next steps should be
decided within one week of the grievance submittal. The steps will be initiated immediately and
completed within one month. If one month is not reasonable, this will be communicated with all
parties involved. A final follow up will be conducted to ensure that the filer has agreed to the
terms decided and remains in good standing with Chosen.
IN THE EVENT OF A CLIENT’S DEATH
In the event of a client’s death, the spouse or parents of a deceased client has a right to access
his/her child’s or spouse’s records, upon request.
PROFESSIONAL MISCONDUCT
Professional misconduct by a health care professional must be reported by other health care
professionals. In cases in which a disciplinary meeting is being held regarding the health care
professional’s actions, related records may be released in order to substantiate disciplinary
concerns.
JUDICIAL OR ADMINISTRATIVE PROCEEDINGS
Health care professionals are required to release records of clients when a court order has been
placed.
OTHER PROVISIONS
When payment for services are the responsibility of the client, or a person who has agreed to
providing payment, and payment has not been made in a timely manner, collection agencies
may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis,
treatment plan, progress notes, testing) is not disclosed. Insurance companies, managed care,
and other third-party payers are given information that they request regarding services to the
client. Information which may be requested to include type of services, dates/times of services,
diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.
Redacted information about clients may be disclosed in consultations with other professionals in
order to provide the best possible treatment. Progress notes and reports are dictated/typed
within the clinic or by outside sources specializing in (and held accountable for) such
procedures. In the event in which the clinic or mental health professional must telephone the
client for purposes such as appointment cancellations or reminders, or to give/receive other
information, efforts are made to preserve confidentiality. Please notify us in writing where we
may reach you by phone and how you would like us to identify ourselves. If this information is
not provided to us (below), we will adhere to the following procedure when making phone calls:
first we will ask to speak to the client without identifying the name of the agency. If the person
answering the phone asks for more identifying information, we will say that it is a personal call.
We will not identify the agency. If we reach an answering machine or voice mail, we will follow
the same guidelines.
CASE RECORD RIGHTS
You have the right to request to review or receive your health files. The procedures for obtaining
a copy of your information is as follows. You may request a copy of your records in writing with
an original (not photocopied) signature. You have the right to cancel a release of information by
providing us a written notice. If you desire to have your information sent to a location different
than our address on file, you must provide this information in writing. You have the right to
restrict which information might be disclosed to others. You have the right to request that
information about you be communicated by other means or to another location. This request
must be made to us in writing. You have the right to disagree with the records in our files. You
may request that this information be changed. Although we might deny changing the record, you
have the right to make a statement of disagreement, which will be placed in your file. You have
the right to know what information in your record has been provided to whom. Request this in
writing. If you desire a written copy of this notice you may obtain it by requesting, it from the
Chief Program Officer of Chosen.
SELF-DETERMINATION RIGHTS
All clients have the right to provide feedback and input into service delivery and service content.
All services received will be non-coercive to allow clients the ability to self-determine their needs
with the guidance of their Care Manager. Any decisions made regarding treatment will include
the input and acceptance of clients. Clients have the choice to consent to services and be
informed of benefits, risks, and alternatives to planned services. Clients have the right to refuse
any service.
FAIR AND EQUIPABLE TREATMENT
All clients have the right to fair and equitable treatment in a non-discriminatory manner. Chosen
does not discriminate based on gender, age, religion, ethnicity, culture, language, sexual
preference or any other factors. Chosen agrees to provide all services consistently and
respectfully in accordance with company policy and expectations.
COMPLAINTS
If you have any complaints or questions regarding these procedures, please contact Chosen at
(830) 455-0101. We will respond in a timely manner. You may also submit a complaint to the
U.S. Dept. of Health and Human Services. If you file a complaint, Chosen will not retaliate in any
way. The Health Insurance Portability and Accountability Act (HIPAA) has created new patient
protections surrounding the use of protected health information. Commonly referred to as the
“medical records privacy law,” HIPAA provides patient protections related to the electronic
transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy
rules”), and storage and access to health care records (“security rules”). HIPAA requires
providers and health care agencies throughout the country to provide patients a notification of
their privacy rights as it relates to their records. You may have already received similar notices
such as this one from your other health care providers. This Patient Notification of Privacy
Rights is our attempt to inform you of your rights. Please read this document, as it is
important you know what patient protections HIPAA affords all of us. If you have any
questions about any of the matters discussed in this document, please do not hesitate to
ask for further clarification. Please understand that you are responsible for your own
understanding of these regulations and rights.
ELECTRONIC RECORDS DISCLOSURE
Chosen keeps and stores records for each client in a record-keeping system produced and
maintained by Salesforce.com, Inc. (“Salesforce”). This system is “cloud-based,” meaning the
records are stored on servers which are connected to the Internet. To help prevent the loss or
damage of records, we keep backups of the records using an online backup service produced
and maintained by Salesforce. Here are the ways in which the security of these records is
maintained:
• Salesforce has certain obligations under federal law to protect records from
unauthorized use or disclosure;
• Chosen employs various technical security measures to maintain the protection of these
records from unauthorized use or disclosure; and,
• Chosen has specific cyber-security measures for protecting the electronic devices that
Chosen uses to access these records, including:
o On computers, we employ firewalls, antivirus software, and passwords to protect
the computer from unauthorized access and thus to protect the records from
unauthorized access; or,
o On mobile devices, we use passwords and remote cloud wipe to maintain the
security of the device and prevent unauthorized persons from using it to access
any records.
Here are things to keep in mind about our record-keeping system:
• While both our record-keeping company and Chosen use reasonable security measures
to protect these records from unauthorized access or disclosure, no cyber-security
measure can be guaranteed to prevent all instances of unauthorized access or
disclosure;
• Some staff at Chosen, such as administrators, may have the ability to access these
records for the purpose of maintaining our IT systems. As a HIPAA Business Associate,
Chosen has certain obligation under federal and Texas law to train its staff on the proper
maintenance of confidential records, and to prevent misuse or unauthorized disclosure
of these records. Chosen takes its privacy obligations seriously, however no personnel
management or training system is foolproof.
• Our record-keeping company keeps a log of our transactions with the IT system for
various purposes, including maintaining the integrity of the records and allowing for
security audits. These transactions are kept for seven years from the date of the last
service to Chosen.
CONSENT TO PARTICIPATE IN RESEARCH
Privacy laws, including the Health Insurance Portability and Accountability Act ("HIPAA"),
protect the use and disclosure of health information about you, also known as Protected Health
Information (“PHI”). Under these laws, Chosen cannot release PHI about you for research
purposes unless you give your consent. If you wish to participate in this research, you must give
Chosen permission to collect “PHI” about you and use and share that information with others by
signing this Authorization. You have a right to see and make copies of the PHI collected about
you for the study. However, by signing this Authorization, you understand and agree that you
may not be able to see or copy some or all of this information until Chosen has completed all
work related to this study.
By signing this consent, I agree to allow outcomes from Chosen’s work with me and the
members of my household (including the minor children of whom this PHI is being used) to be
included in a confidentiality manor for research purposes. My confidentiality rights will not be
waived, and all identifying factors will remain confidential throughout the project. By signing this
consent, I understand that I am only consenting to the Outcomes Research Project. Should
Chosen participate in any other research, a separate Research Consent will be provided.
Chosen may use and disclose PHI about you, including the PHI they collect for the study. This
information may include, but is not necessarily limited to:
• Your initials, age, gender, and race;
• The dates that you receive care as part of the study;
• Current or past medications or therapies that you receive or have received;
• Results of all assessments, tests, and procedures conducted as part of the study.
I understand that I am not required to sign this Authorization and that Chosen’s services will
continue, regardless of my decision to participate.
This authorization is effective for a period of 24 months from the signature date and will expire
after that time. I understand that I have the right to revoke this Authorization, in writing, at any
time by sending such written notification to Chosen, located at 144 Clemens Avenue, New
Braunfels, Texas 78130. If you revoke this Authorization, the information collected before you
withdrew your permission may still be used or disclosed as needed for the study.
RELEASE FOR TELEHEALTH SERVICES
By signing this release, I am granting permission to receive Chosen's services with
Telehealth, which includes using a secure online video platform or phone calls instead of
meeting in person when circumstances are appropriate for doing so. Please know that
sometimes there are technology issues that can prove challenging, and there is a slight risk
that someone who isn't supposed to listen to our call or meeting could listen in. My signature
acknowledges this risk.
Telehealth involves the use of electronic communications to enable mental health professionals
to connect with individuals using interactive video and audio communications. Telehealth
includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral
to resources, education, and the transfer of medical and clinical data.
I understand that I have the rights with respect to telehealth:
1. The laws that protect the confidentiality of my personal information also apply to telehealth.
As such, I understand that the information disclosed by me during my sessions is generally
confidential. However, there are both mandatory and permissive exceptions to confidentiality,
including, but not limited to, reporting child, elder, and dependent adult abuse; expressed
threats of violence toward an ascertainable victim; and where I make my mental or emotional
state an issue in a legal proceeding. I also understand that the dissemination of any personally
identifiable images or information from the telehealth interaction to other entities shall not occur
without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth
during my care at any time, without affecting my right to future care or treatment.
3. I understand that there are risks and consequences from telehealth, including, but not limited
to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission
of my personal information could be disrupted or distorted by technical failures, the transmission
of my personal information could be interrupted by unauthorized persons, and/or the electronic
storage of my personal information could be unintentionally lost or accessed by unauthorized
persons. Chosen utilizes secure, encrypted audio/video transmission software to deliver
telehealth.
4. I understand that if my counselor believes I would be better served by another form of
intervention (e.g., face-to-face services), I will be referred to a different mental health
professional, or we will discuss the possibility of face to face sessions.
5. I understand the alternatives to counseling through telehealth as they have been explained to
me, and in choosing to participate in telehealth, I am agreeing to participate using video
conferencing technology. I also understand that at my request or at the direction of my
counselor, I may be directed to “face-to-face” psychotherapy.
6. I understand that I may expect the anticipated benefits such as improved access to care and
more efficient evaluation and management from the use of telehealth in my care, but that no
results can be guaranteed or assured.
7. I understand that my healthcare information may be shared with other individuals for
scheduling and billing purposes. Others may also be present during the consultation other than
my counselor in order to operate the video equipment. The above-mentioned people will all
maintain confidentiality of the information obtained. I further understand that I will be informed of
their presence in the consultation and thus will have the right to request the following: (1) omit
specific details of my medical history that are personally sensitive to me, (2) ask non-clinical
personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.
8. I understand that my express consent is required to forward my personally identifiable
information for billing purposes only.
9. I understand that I have a right to access my medical information and copies of my medical
records in accordance with the laws pertaining to the state in which I reside.
10. By signing this document, I agree that certain situations, including emergencies and crises,
are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in
an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented
health care facility in my immediate area.
11. I understand that different states have different regulations for the use of telehealth.
12. Provider will bill client for telehealth services in accordance with client’s Fee Sheet. Payment
within 30 days is requested.