• ONLINE THERAPY NEW CLIENT FORM

  • OVERVIEW

    Thank you for choosing Genesis Counseling Center.  We are honored you have entrusted us to walk with you through this journey. As with any medical appointment, there are a few documents to complete and sign:

    Informed Consent for Online Therapy Services:  This form is intended to review and inform you of your rights regarding Online Therapy mental health services and provides your consent to participate.

    Professional Services Agreement:  This outlines our Privacy Policy and how we protect you and your records. It gives us authorization to bill your insurance on your behalf, if applicable, outlines our Cancellation Policy (please call to cancel appointments at least 24 hours in advance or there is a $65 fee not covered by insurance), and allows us to securely store your payment information for copays and any portion of your bill that is your responsibility.

    For Online Therapy services, it is our policy that a payment method be saved in the secure vault, so we can collect payment remotely each time you check in for your appointment. This payment method was saved during your account setup.

    Please call our office at 929-GENESIS (929-436-3747) or your local office (Genesis Offices) for assistance or questions about payment.

    Clinical History Form:  This is provided through our Patient Portal and needs to be completed ahead of your first appointment so that our therapist can better serve you.

    Notice of Privacy Practices:  This is provided at the bottom of this form for your review.  You can obtain a copy of this from the link below.

    Genesis Counseling Center Notice of Privacy Practices

    As an Online Therapy client, you will not check in at a physical office location, so you will not be interacting directly with a Client Care Coordinator at each appointment. Please know we have Client Care Coordinators in our multiple office locations that can schedule appointments, assist with payments, and answer any questions you may have.  Please connect through chat from our website or call us between 9 a.m. and 5 p.m. Monday through Friday for all your administrative needs at 929-GENESIS (929-436-3747) or your local office (Genesis Offices). We also encourage you to leave a message at any time, and one of our Client Care Coordinators will return your call.

    Please note: These forms must be completed and submitted online before your first Online Therapy session is held. See the Online Info page of our website for more information and Online Check-in to select your therapist’s name and connect to their Online Therapy Virtual Lobby.

  • INFORMED CONSENT FOR ONLINE THERAPY SERVICES

  • DEFINITION OF ONLINE THERAPY

    Online therapy involves the use of electronic communications to enable Genesis Counseling Center’s mental health professionals to connect with individuals using interactive video and audio communications.

    Online therapy includes the practice of psychological 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 Online Therapy:

    1. The laws that protect the confidentiality of my personal information also apply to online therapy. As such, I understand that the information disclosed by me during the course of 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 online therapy 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 online therapy in the course of my care at any time, without affecting my right to future care or treatment.

    3. I understand that there are risks and consequences from online therapy, 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. Genesis Counseling Center utilizes secure, encrypted audio/video transmission software to deliver online therapy.

    4. I understand that online counseling sessions are not recorded, and I agree that I will not record counseling sessions on a mobile or other recording device.

    5. 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 mental health professional that can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.

    6. I understand the alternatives to counseling through online therapy as they have been explained to me, and in choosing to participate in online therapy, 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.

    7. 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 online therapy in my care, but that no results can be guaranteed or assured.

    8. 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 online therapy room, and/or (3) terminate the consultation at any time.

    9. I understand that my express consent is required to forward my personally identifiable information to a third party.

    10. 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 of my legal residence.

    11. 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.

    PAYMENT FOR ONLINE THERAPY SERVICES

    Payment for online therapy services is due at time of service and must be paid by credit card.  Credit cards will be stored in our secure electronic vault that is PCI-DSS compliant. Card will automatically be charged at the time of appointment for payments due.

    PATIENT CONSENT TO THE USE OF ONLINE THERAPY I have read and understand the information provided above regarding online therapy, have discussed it with my counselor, and all of 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 online therapy services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of online therapy 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.

  • Professional Services Agreement

    Receipt of Notice of Privacy Practices, Informed Consent, Confidentiality Release to Contact Payor(s), and Payment Agreement Form
  • Notice of Privacy Practices: I understand that the Genesis Notice of Privacy Practices provides information about how Genesis may use and disclose protected health information about me. Please initial on each line below.

    Informed Consent: This agreement indicates my commitment to enter treatment for psychiatric and/or counseling services, and my understanding of the basic ideas and personal growth goals of treatment and/or counseling. I agree to keep my physician and/or therapist up to date about any changes in my symptoms or any situation that may impact the success of treatment. I understand that effective counseling is a process which unfolds cyclically, from exploration to understanding, and finally, to action. The process may necessitate periodic evaluation of goals and new goals may be agreed upon to serve my long-term best interest. At times, counseling may arouse unpleasant feelings and emotional experiences, particularly in the initial phase of treatment. I understand that my therapy may include periodic case consultation with Genesis’ clinical staff when necessary.  I acknowledge I give informed consent to begin psychiatric and/or counseling services.

    Financial Agreement:  If the office is closed, voicemail is available to give notice of cancellation. I am responsible for remembering my appointment. Although reminders are sent, I understand they are a courtesy and I am ultimately responsible for remembering my appointments. Returned checks are subject to a $50.00 service charge.  Genesis will not accept any more personal checks for the duration of therapy.  Unpaid balances that are more than 60 days past due are subject to a 1.5% per month service charge.  I understand that I am responsible for all charges incurred during the course of my treatment, including any portion of charges not covered by insurance, case management fees as explained and/or court related fees should a Genesis employee be subpoenaed on my behalf.  Case management activities such as written consultations or phone calls will be prorated at the therapist’s hourly rate. There will be a fee of $50 for any letters that are requested of the therapist.  Failure to make payment on an amount owed may necessitate at the discretion of Genesis Counseling Center, PC the initiation of collections procedures, including possible legal action to recover the amount owed.  The undersigned shall be responsible for any fees, including reasonable attorney fees and collection agency fees, pursuant to this course of action.  My signature represents my understanding of this payment agreement. 

    Credit Card on File Policy: We require keeping your credit card or debit card on file as a convenient method of payment for services that your insurance doesn’t cover, but for which you are liable. Your credit card information is kept confidential and secure according to PCI standards.

    For More Information: I understand if I desire more detailed information regarding Genesis’ policies related to privacy, informed consent, professional services, and payment, I may request more information from the Client Care Coordinator.

  • Clinical History Form

  • Signature and Information Upload

  • By entering your initials below you confirm the following statements:

    • Privacy Practices - I acknowledge that I have received a copy of Genesis Counseling Center, PC’s Notice of Privacy Practices (see below) and that an additional copy is available upon request.
    • Benefit Information - Benefit Information is given to Genesis by the insurance company and only represents an estimate. Genesis Counseling Center, PC is not responsible for co-pays and/or deductibles that may differ from what Genesis is told when verifying benefits. The Client/Guarantor gives permission to Genesis to contact any third-party payer for payment.
    • Insurance Claims - I understand that Genesis will submit claims to my insurance company, if I have insurance which Genesis is contracted with.
    • Payment Due at Time of Service - I understand that my payment is due at the time services are rendered.
    • Cancellation Fee - I understand that I will be billed a fee of $65 for appointments not canceled 24 hours prior to the scheduled appointment time, except in cases of true emergencies.
    • Credit Card Authorization - I authorized Genesis to save my credit card information in a secure vault and charge my credit card the portion of my bill that is my responsibility.
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  • Read the Notice of Privacy Practices & Scroll Down to Submit

  • Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. PLEASE REVIEW IT CAREFULLY.
  • Genesis Counseling Center is committed to maintaining the privacy of all client information and adheres to the requirements of the Health Insurance Portability and Accountability Act (HIPAA). The Notice of Privacy Practices explains the ways in which Genesis Counseling Center safeguards each client’s protected health information. If you have questions or comments please contact the Vice-President of Operations, Cameron Ashworth, at 757-827-7707.

    We respect the privacy of your personal health information and are committed to maintaining our clients’ privacy and confidentiality. This Notice applies to all information and records related to your care that our Provider has received or created. We need these records to provide you with quality care and to comply with certain legal requirements. It extends to information received or created by our employees, staff, volunteers and clinical director. This Notice informs you about the possible uses and disclosures of your personal health information. It also describes your rights and our obligations regarding your personal health information.

    We are required by law to:

    • maintain the privacy of your protected health information;
    • provide to you this detailed Notice of our legal duties and privacy practices relating to your personal health information;
    • and abide by the terms of the Notice that are currently in effect.

    I. How Genesis Counseling Center may use & disclose health information about you. The following categories describe different ways that we use and disclose health information. Following each use or disclosure, there will be a brief description further explaining it. All of the ways we are permitted to use and disclose information will not be listed but will fall within one of these categories.

    For Treatment. We may use and disclose health information for your treatment and to provide you with treatment-related health care services which may include periodic case consultation with Genesis’ clinical staff with de-identified demographics when necessary. We may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office or facility, who are involved in your medical care and need the information to provide you with medical care. 

    For Payment. We may use and disclose health information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. 

    For Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services.  We may use and disclose health information to contact you to remind you that you have an appointment with us.  We also may use and disclose health information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. We may use and disclose medical information about you by having you sign in when you arrive at our office.  We may also call out your name when we are ready to see you.

    Individuals Involved in Your Care or Payment for Your Care.  We may share health information with a person who is involved in your medical care or payment for your care, such as your family or a close friend.  We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.  If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances.  If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

    Research. Under certain circumstances, we may wish to use and disclose health information about you for research purposes. If this is the case, we will request ahead of time that you sign an authorization form allowing us to use and disclose this information. If you wish not to participate, you can let us know at that time.

    Business Associates.  We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

    As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.  This includes using or disclosing your health information to provide legally required notices of unauthorized access to or disclosure of your health information.

    To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

    Military & Veterans. If you are a member of the armed forces or separated / discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

    Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

    Public Health Risks. We may disclose health information about you for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; to report births or deaths; to report abuse or neglect; to report reaction to medications or problems with products; to notify people of recalls of products they may be using; to notify person or organization required to receive information on FDA-regulated product; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and to notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

    Lawsuits & Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you 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.

    Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

    Marketing and Sale of Personal Health Information. We must receive your written authorization for any disclosure of personal health information for marketing purposes or for any disclosure which is a sale of personal health information.

    Change of Ownership.  In the event that this Provider is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another Provider.

    Not Otherwise Permitted.  In any other situation not described above, we may not disclose your personal health information without your written authorization. 

    II. Your rights regarding health information about you. You have the following rights regarding health information we maintain about you:

    Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. This includes health and billing records, but not psychotherapy notes.  To inspect and copy health information that may be used to make decisions about you, you must complete a written request to Genesis Counseling Center detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing.  If you request a copy of the information, we will charge a reasonable fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

    Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. You must make a request to amend in writing and include the reasons you believe the information is inaccurate or incomplete.  We are not required to change your health information and will provide you with information about this medical practice's denial and how you can disagree with the denial.  If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

    We may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the health information kept by or for our community; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

    Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosure of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, as previously described.

    To request this list of disclosures, submit your request in writing to our office. Your request must state a time period which may not be longer than six years. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

    Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must complete the form that can be attained from the clinic. The form will require the information you want to limit and to whom you want the limits to apply. The form must then be submitted to the office manager.

    Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your personal health information to a health plan if the personal health information pertains to health care services or items for which you or anyone other than your health plan paid in full.

    Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must submit your request to our office. We will not ask you the reason for the request and we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

    Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured personal health information.

    Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from our office.

    You may also obtain a copy of this notice either from the front desk at Genesis Counseling Center or our website. If we know that the electronic message has failed to be delivered, a paper copy of this notice will be provided. Even if you have received a copy electronically, you still retain the right to receive a paper copy upon request.

    III. Changes to This Notice.

    We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our Provider. In addition, each time you register for treatment or health care services, you may ask for a copy of the current notice in effect.

    IV. Complaints

    If you believe your privacy rights have been violated, you may file a complaint with us.  You will not be penalized in any way for filing a complaint. To file a complaint with us, contact Cameron Ashworth, Director of Operations.  If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint with the Secretary of the Department of Health and Human Services. The complaint form may be found at Complaint Form.  Again, you will not be penalized in any way for filing a complaint.

    V. Other Uses of Health Information

    Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you make revoke that permission, using the form obtainable from the clinic, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

    VI. Acknowledgment of Receipt of Notice.

    Your signature in this online form acknowledges that you received this Notice.

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