OUTPATIENT COUNSELING

INFORMED CONSENT FOR TREATMENT

I understand the risks of unencrypted communication and do herby give permission for Paradigm Counseling Services to contact me or to reply to me via unencrypted e-mail and or other telecommunication options available.

I, the undersigned,

1. Voluntarily consent to treatment as recommended and fully explained to me by Paradigm Counseling personnel and understand that I am free to withdraw my consent and discontinue

treatment at any time.

2. Understand that I have rights as a recipient of counseling services, that I have received a description of my rights, and that I may receive additional information about my rights from the Recipient Rights

Advisor identified to me.

3. Understand that the confidentiality of records is protected by Federal Regulations and MI Compiled Laws. Any identifying information to outside sources regarding a patient's treatment may not be

disclosed unless the client gives consent. Program staff may release client information without client consent under the following specific conditions:

Patient threatens to harm self or others;Suspicion of child abuse or neglect; Medical personnel, to meet a bona fide medical emergency when there is immediate threat; Research activities and program evaluation. Personnel may not identify directly or indirectly any

individual patient in any report or otherwise disclose patient identities in any manner; Management and financial audits. Examiner must furnish to the program a written statement

that no record will be made of client identifying information unless notice is provided to the program, and, if necessary, setting forth the specific purpose for which identifying information is being retained, how it is to be retained and the contact person; or Authorized by court order under Sub Part E - Section 2.61 of 42 CFR Part 2. In addition, there are times where it may be necessary to share information during a professional consultation if it appears beneficial to your success in therapy. Request must be in writing. Release of records form must be signed for release of records. There is a fee for photo copy of records and they must be paid in full. Please allow a one-week

turnaround time. Some parties prefer to communicate about appointment times or other administrative issues via e-mail. E-mail transmitted through regular services may not be encrypted. This means that a third party may be able to access information in an e-mail and read it. In addition, once the email is received by you, someone may be able to access your email account and read it. This may include your employer if you use a work-related email address. Please be aware that all information is stored on a password protected devices. Please initial below if you give permission to communicate via tele-therapy communicative options to meet your needs. This can be changed at any time. 4. Understand that unauthorized photography, audio and/or visual recording are prohibited.

6. Understand I am to follow through to the best of my ability in developing and achieving treatment goals/ objectives, as agreed upon by my therapist and myself. I understand that if I fail to follow through on significant parts of my treatment plan, possibly resulting in harm to myself or others, my therapist may choose to refer me to a more appropriate treatment setting.  I understand that in order for letters of communication (ie status letter to probation officer) to be5. Suspected violations of municipal laws may be reported to appropriate authorities in accordance with the govern authority regulations. Federal regulations do not protect any information about a crime committed by a client in regards to treatment or against any person who works for the program or about any threat to commit such a crime.

7. Acknowledge that any violent or hostile behavior will result in discharge. I understand that possession of a weapon during face-to-face therapy encounters is prohibited. I understand that services may be terminated on any day that I present during my appointment intoxicated. I understand and have been advised of additional policies regarding conditions under which I may be discharged. I further understand that I have the right to appeal this action to the clinical manager within 5 days from which it occurs.completed, I must be in active counseling with my therapist, including meeting all financial responsibilities unless otherwise specified by plan.

8. Understand that I have the right to speak to the Program Manager or Recipient Rights Advisor at any time I feel my rights have been violated.

CLIENT ACKNOWLEDGEMENT

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Paradigm Counseling Services Informed Consent identifies privacy and confidentiality practices, clients rights and responsibilities and information about how protected health information about me (the client) including  health and substance abuse treatment records are protected under municipal regulations, and psychological and social services records, including communications made by me to a social worker or psychologist, probation officer or court administrator (if any) may be used and disclosed. I understand that the circumstances may change and that I may obtain a current copy by request.  I understand information may be shared on a need-to-know basis, including information covered in the Michigan Mental Health Code, which may include behavioral health and/or substance abuse records.

By signing below, Client(s) have reviewed and fully understand the terms and conditions of this Agreement.  Client(s) are acknowledging receiving information regarding confidentiality, grievances, client rights and responsibilities.  Client(s) have discussed such terms and conditions with the therapist and have had any questions with regard to its terms and conditions answered.  Client(s) agree to abide by the terms and conditions of this Agreement and consent to participate in therapy.  Moreover, the Client(s) agree to hold Paradigm Counseling Services and the Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

TREATMENT SERVICES FEE AGREEMENT

Welcome to Paradigm Counseling Services. In order for us to continue offering helpful services to you and others, it is most important that you are a responsible participant in treatment.  

1. I acknowledge that I have disclosed all information regarding my health insurance.

2. I further acknowledge the insurance information to be accurate and complete.

3. I accept the responsibility for my fees, co-pays, deductibles, changes in insurance, and for all services rendered to me.

4. I accept responsibility to check with my insurance to understand what services are covered.

5. I authorize the submission of billing statements to my insurance carrier(s) for the purpose of receiving reimbursement for services until payment is received for all services provided to me.

6. I further understand that I am responsible for the cost of my treatment, and that I will be billed directly if insurance claims are rejected or denied.

7. Finally, I understand that established appointments are reserved for me, and that I may be subject to the usual and customary charge for late arrival, all appointments missed or canceled without 24 hour notice.

The sessions are weekly unless the severity and nature of your concerns warrant an adjustment.

I acknowledge that I am responsible for the following fees if applicable:

• Initial assessment - $225.00

• Individual session/Intensive Outpatient Program - $125.00

• Family session - $150.00

• Report(s) - $185 flat fee 

• Photocopy fee of $ .50/page will be charged. 

• Personal Copy of Medical Records - Up to $100

• Forms, reports or letters requested by client - $185($ flat fee)

• Testimony / Depositions / Consultations: 

By therapist: $450 (initial 2-hours)     $250 (each additional hour)

• Mileage for Out of Office Appearance  - IRS allowable rate

• Non-Sufficient Funds bank fee (NSF) - $25

By my signature, I acknowledge my responsibility for the above fees whenever applicable. I understand that I must pay these fees when due before services can continue.

PARTICIPATION AGREEMENT

I am aware and in agreement with my treatment goals and objectives. I have been informed by my therapist and understand that based on my treatment needs goals and objectives may require modification in the future. I will be an active participant in the development of those modifications should they be needed.