Welcome to NU Vision Counseling & Consulting Services,
We value transparency and informed consent. We want you to feel comfortable and confident in your decision to seek counseling services. That’s why we provide all the necessary information in our policy document, ensuring that you are fully informed about our services and processes. It is important that you read all consents thoroughly and ask any questions you may have before starting your treatment. We believe that an open and honest dialogue from the beginning is crucial for building a strong and effective counseling relationship.
Informed Consent, Client Rights, and Policies for Mental Health Services
1. Client Rights and Responsibilities – Counseling and Psychotherapy Services: As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights of which you should be aware. In addition, NU Vision Counseling & Consulting Services and your assigned therapist have a responsibility to you. These rights and responsibilities are described in the following sections.
2. Benefits and Risks; No Guarantees: Our approach to psychotherapy is tailored to your needs and, at the same time, makes use of interventions such as support, insight, and behavioral suggestions, which research has generally found to be effective. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, like sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals and families who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. Psychotherapy requires a very active effort on your part. To be most successful, you will have to work on things we discuss outside of sessions. Your participation can be expected to improve the results you achieve; however, psychotherapy cannot be guaranteed to result in emotional or functional improvement for everyone.
3. Limits of Practice and Scope of Services: NU Vision Counseling and Consulting Services, LLC is an outpatient remote & office-based practice, and does not provide services at a level of intensity sufficient to treat unmanageable mental or emotional states, intense interpersonal conflicts, or other crises. If you have problems or issues for which our clinician, interns, or supervisees are NOT trained and/or DO NOT have the appropriate skills to meet your needs, our office will refer you to another facility or provider who may have the resources, training, and experience to provide you with the services you require.
You agree to accept a referral based upon this determination and acknowledge that this action is necessary to protect our clients and clinicians, interns, or supervisees. ALL Licensed Professional Therapists/Counselors, Psychologists, Interns, and supervisees are bound by an ethical responsibility to respect our client's values, including religious and cultural values, and that our personal beliefs or values will not be a reason to refer a client elsewhere. In the event that we have a clinician onboard that you strongly feel shares your values and would be a better fit, our office will attempt to recommend such a person. (a referral/recommendation is not an assignment, and is subject to the acceptance/approval of the clinician/therapist/agency or provider).
4. Confidentiality: NU Vision Counseling and Consulting Services, LLC’s policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. [Reference your initial intake forms]. A copy of our privacy practices was given to you during the intake process along with the opportunity for you to ask questions and/or address any issues or concerns concerning confidentiality; See the “Insurance and Privacy” section of this statement also.
Protecting your confidentiality is an ethical responsibility NU Vision Counseling and Consulting Services, LLC takes seriously. Protection of your confidentiality is also governed by several laws and regulations including your state Mental Health and Developmental Disabilities Confidentiality Act, the Federal Health Insurance Portability and Accountability Act (HIPAA), the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, and federal regulations governing drug and alcohol abuse records. Any authorization to release confidential information must specify the limits of what is released including the type of information, the purpose of the release, the consequences of refusal to release, and the time limit that the authorization will remain in effect. Please remember that you may reopen the conversation about privacy and confidentiality at any time during our work together.
MANDATED REPORTING, DUTY TO WARN: You should also be aware that all clinicians/therapists, interns, and/or supervisees are mandated reporters of child and adult abuse and/or neglect, and are responsible for protecting the rights of the elderly and other dependent individuals. In addition to the above, there may be complex scenarios that require your clinician/therapist. intern or supervisee to take reasonable steps to warn and/or protect another individual or group of individuals of any threat or intent to harm if the clinician/therapist, intern, and/or supervisee becomes aware of such a threat or intent to harm another or oneself while respecting client confidentiality to the extent that is possible.
PARENTS & MINORS: While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is NU Vision Counseling and Consulting Services, LLC policy not to provide treatment to a child under age 16 unless s/he agrees to have whatever information our office and clinician consider necessary with a parent. For children 16 and older, our office will require an agreement between the client and the parent(s) allowing our office to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement unless the assigned clinician believes that there may be a safety concern (see also above section on Confidentiality for exceptions), in which case our office will make every effort to notify the child/client of the intention to disclose information ahead of time and make every effort to handle any objections that are raised.
5. Treatment Planning: The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, your clinician will be able to offer you some initial impressions of what your work together might include. At that point, your clinician will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own decision about whether you feel comfortable and wish to continue with your assigned clinician. If you have questions about a procedure, you should discuss them as soon as possible or whenever they arise with your assigned clinician or someone at our office. If your doubts persist, our office will be happy to help you set up a meeting with another mental health professional for a second opinion.
6. Appointments, Missed Appointments, and Cancellations: Appointments will ordinarily be 45-55 minutes in duration, once per week at a time agreed on by you and your assigned clinician, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is set by you and assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide our office with at least 24 hours' notice. If you miss a session without canceling or cancel with less than 24-hour notice, our policy is to collect $30 [unless your clinician indicates that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for canceled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, our office will help you to find another time to reschedule your appointment. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time.
7. Professional Fees: Our standard fees ensure that you receive the highest quality care, with an initial intake fee of $200.00 and subsequent psychotherapy sessions priced at $150.00 for 45-50 minutes and $125.00 for 28-44 minutes. Please note that fees must be paid at the time services are rendered, unless prior arrangements have been made.
For clients with a patient financial responsibility, our policy ensures that sessions are defaulted to $75 per session until the financial responsibility is met. It is the responsibility of the client to keep track and notify our office once the patient’s financial responsibility is met, allowing for a stress-free and transparent financial experience.
We want to ensure your focus is on your mental health, not on your account balance. We kindly ask our clients to check their balance and bring it to $0.00 before or on the day of their session. With our convenient online payment portal, you can easily pay your balance before your session, ensuring a seamless process. In the event that there is a remaining balance after services have been rendered, we will automatically charge the card on file, unless alternative arrangements have been made.
You may pay by check, cash, or credit card. Any checks returned to our office are subject to an additional fee of up to $25.00 to cover the bank fee that is incurred. Checks returned for NSF will result in all future fees and co-payments being payable by credit card only. If you refuse to pay your debt, NU Vision Counseling and Consulting Services, LLC reserves the right to use an attorney or collection agency to secure payment. (Payment options are restricted for DOT Substance Abuse Professional Evaluations.)
OTHER FEES: In addition to weekly appointments, we also offer a range of professional services on a prorated basis including consultations, specific assessments, evaluations, screening, court appearances, and clinical summaries, (including disability, worker compensation, accommodation letters and/or other reports). In addition to the above fees, there are fees for extended telephone conversations, attendance at meetings, consultations, or any other services requested of your clinician. Transparency and open communication are our top priorities when it comes to your mental health care. If you anticipate becoming involved in a court case, it is recommended that you discuss this fully with your therapist/clinician before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required (including preparation and travel) even if another party compels our testimony.
8. Insurance: In order for us to set realistic treatment goals and priorities, it is important to evaluate the resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, our office can assist you in filing claims and obtaining information about your coverage, but you are responsible for knowing your coverage and for letting our office if/when your coverage changes. Health care plans often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow for extended services once your benefits end. If this is the case, and you are not in a position to pay for services our office will do our best to find another provider who will help you continue your psychotherapy.
HEALTH INSURANCE AND PRIVACY: You should also be aware that most insurance companies require you to authorize our office to provide them with a clinical diagnosis. Diagnoses are terms that describe the nature of your problems and help providers suggest generally accepted treatments. Mental health diagnoses come from the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) and/or the International Classification of Diseases (ICD). Sometimes additional clinical information such as treatment plans or summaries, or (in rare cases) copies of the entire record are requested but you will be notified prior to releasing this information. This information will become part of the insurance company files and may be stored electronically. Although HIPAA and other laws and regulations apply to health records, our office has no control over what insurers do with personal health information once it is in their hands. Although employers generally do not have access to this information, it may affect your ability to enroll in life or health insurance plans in the future. Insurers may also share the information with a national medical information databank. Our office will provide you with a copy of any report that we are asked to submit if you request it. Your signature on the release authorization above ensures that we can provide the requested information to your carrier if you plan to pay with insurance.
PREAUTHORIZATION: If you plan to use your insurance or EAP benefit, authorization from the insurance company or EAP Company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient/client. Either amount is to be paid at the time of the visit by check, credit card, or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies begin paying any amount for services. This will typically mean that you will be responsible for paying for sessions up until your deductible has been met; the deductible amount may also need to be met at the start of each calendar or benefit year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by a provider contract.
OUT-OF-NETWORK BENEFITS: If we are not a participating provider for your insurance plan, our office will supply you with a receipt of payment for services rendered using a superbill which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers, and coverage is often reduced. If you prefer to use a participating provider, our office will attempt to locate an “In-network” provider for you, or you may wish to contact your insurance carriers for an up-to-date list of in-network providers.
9. Employee Assistance Program (EAP) Services, If Applicable: There are several EAP organizations within which our office is contracted to provide assessment, referral, short-term counseling, and follow-up services to covered employees and their family members. EAP benefits may be managed by your health insurer or by a separate organization. In general, employees and their family members may receive EAP services with no co-payment or fee charged. Some contracts require our office to refrain from charging for missed appointments or services that are denied payment by the EAP or health plan; however, missing an appointment will usually reduce the number of EAP sessions available to you. Sometimes there is initial confusion about whether EAP benefits, health insurance, or both, apply to your services. For this reason, we reserve the right to charge for services for which your failure to secure authorization results in a denial of payment for services provided. In that situation, you agree to be responsible for the fees for services that have been provided. You should contact your human resources department concerning any questions you may have about your responsibilities for accessing EAP benefits, prior to starting to receive services. An Authorization code is normally given and must be submitted to our office prior to approving your appointment.
10. Liability for Others’ Use of Clinical Findings: Our clinician may also provide formal evaluations for child custody and/or fitness for employment, DUI services under certain state laws; However none of our clinicians at this time provide Psychological evaluations nor do we provide any forensic evaluations. These evaluations are conducted by designated professionals such as psychologists, or psychiatrists.
Our SAP providers (Substance Abuse Professionals) who are under the US Department of Transportation do not serve the client, they serve the Department of Transportation. Therefore clients who require clearance to return to such employment must have the proper information available at the time of their inquiry about SAP services; If our SAP clinician is asked to do this, we require written consent from you to release such information.
Responsibility for the final decision to place an employee back on duty, or for any decisions to terminate employees, rests with the employer and not with our SAP providers; as our clinicians do not make any warranty as to what your employer's actions will be or that any such decision will be favorable to the employee. Likewise, your clinicians' reports and records about you may be used (with or without the permission of either party) in court cases and other situations in which they are compelled to provide records or testimony.
Our SAP’s sole responsibilities are to perform a thorough assessment and to exercise careful and sound judgment in reporting clinical findings within the standard of care for a licensed behavioral health clinician. You agree that our clinicians will not be held liable for decisions by other parties, using any of our clinicians' reports and/or records, which may be unfavorable to you. (Please note that the role of our Substance Abuse Professional under US Department of Transportation regulations involves additional responsibilities, and you should read the section of this website on “SAP Evaluations” to be sure that you understand the limits of confidentiality, and our duty to protect the public imposed by the regulations governing the return-to-duty process).
11. Professional Records: Our office is required to keep appropriate records of the services that we provide. Your records are maintained as an electronic medical record (EMR) in your portal. Your clinician may also keep brief records noting that you were seen, your reasons for seeking therapy, the goals and progress set for treatment, your diagnosis, topics discussed, your medical, social, and treatment history, records received from other providers, copies of records requested or sent to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be unclear for untrained readers to understand or interpret. For this reason, we recommend that you initially review them with your therapist, or have them forwarded to another mental health professional to discuss the contents. If access to your records is refused, you have a right to have that decision reviewed by another mental health professional, which can be discussed with you upon your request. You also have the right to request that a copy of your file be made available to any other healthcare provider at your written request.
12. Contact Information and Emergency Procedures: Telephone or fax are considered secure communications, while e-mail is not, and if used, you do so at your own risk. Our office runs part-time Only and many of our clinicians work outside of our office; as a result, they may not immediately be available by telephone. Therefore, we ask that you obtain your therapist's contact information so that you may reach out to them directly. In addition, if we are open and with a client or otherwise unavailable, we ask that you leave a detailed message on our confidential voicemail or send an email directly to our office or your therapist; Someone will return your call as soon as possible (it may take a day or two for non-urgent matters). Phone service, voice mail, and e-mail are all subject to outages and interruptions. If, for these reasons or any number of other unforeseen reasons, you do not hear from someone from our office or your therapist is unable to reach you, We encourage you to try contacting the office again. If you are unable to reach someone in our office and you feel you cannot wait for a return call, or if you feel unable to keep yourself safe, 1) contact your local crisis line or mental health agency (I can provide these numbers for you and they are listed in the phone book), 2) go to your local hospital Emergency Room, or 3) call 911 and ask to speak to an emergency worker. If you feel that you are in danger from a family member or domestic partner, you should contact law enforcement or the local domestic violence agency.
VACATIONS AND OTHER ABSENCES: Our office will make every attempt to inform you in advance if your therapist is unable to meet with you whether for planned or unplanned absences, office closures, and/or shutdown.
13. Other Rights: If you are unhappy with what is happening in therapy, we encourage you to talk with your therapist so that they may have the chance to address/respond to your concerns. Your concerns will ALWAYS be taken seriously and handled with care and respect. You may also request to be referred to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about the specific training and experience of your assigned therapist. It is our policy that no therapist, clinician, or intern/supervisee employed with NU Vision Counseling & Consulting Services, LLC engage in any social or sexual relationships with clients or with former clients. If it comes to our attention that a multiple (dual) relationship exists (such as a business or family connection) or a role that is deemed a conflict of interest or otherwise compromises the effectiveness of our services you will need to be referred to another competent provider.
INFORMED CONSENT TO PSYCHOTHERAPY:
Your signature on the Application for Services form indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms. You may keep this agreement for future reference.
If you have any questions or concerns at any time, you may contact Deena Terrell, LCSW, BC-TMH by phone, mail, or e-mail.
WE THANK YOU FOR ALLOWING US TO SERVE YOU!