Informed Consent

I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. I understand that treatment is often provided over the course of several weeks. I agree and consent to participate in the behavioral healthcare services offered and provided by Authentic Counseling and Wellness, LLC. I understand that I am consenting and agreeing only to those services that Authentic Counseling and Wellness, LLC is qualified to provide within the scope of the provider's license, certification, and training.

I understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I also understand that my provider may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to consent to or refuse such treatment.) I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises have been made as to the results of treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time and agree to discuss this decision first with my provider.

I am aware that I must authorize my provider, in writing, to release information about my treatment (including to any consulting entity that may be involved in my medical or mental health care), but that confidentiality can be broken under certain circumstances. I authorize Authentic Counseling and Wellness, LLC to release information to my insurance company, managed care organization, state agency(ies), health care financing administration, third party administrators, and/or Worker's Compensation or its agents any information needed to process my claim and/or determine benefits payable to related services. I understand that once information is released, my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential to the best of our ability, except in the following circumstances, in which my provider is ethically or legally bound to break confidentiality:

-When there is a risk of imminent danger to myself or to another person

-When there is suspicion that a child or elder is being sexually, emotionally, neglected, or physically abused, or is at risk of such abuse
-When a valid court order is issued for medical records

I agree and consent to Authentic Counseling and Wellness, LLC sharing my information with the collection agency to collect any fees associated with services provided by Authentic Counseling and Wellness, LLC and its employees after reasonable attempts have been made to collect debt.

While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices, which has been provided to you for more detailed explanations, and discuss with your provider any questions or concerns you have.

By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my provider to provide such care, treatment, or services as are considered necessary and advisable. I understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything that is unclear to me.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, costbased fee.

Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.We will say "yes" to all reasonable requests.

Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information
You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. If this person loses that right for whatever reason, ask the office for a revoking emergency contact permissions form.

File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information as provided on our website www.authenticcw.org.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.We will not retaliate against you for filing a complaint

Scheduling Appointments 

Upon completion of your session, you will need to log into your client portal online outside of the office OR via the computer provided in the office to schedule future appointments. You will be required to utilize your client portal to schedule your next session, so please ensure you have access to your client portal and email to do so. You will be assisted in learning how to utilize our online system. You are limited to scheduling ONE individual appointment per week, and you may sign up for as many group therapy sessions as you would like, with the limitation of not scheduling an individual therapy session and group session on the same day. You and your therapist will discuss the frequency and session time you are able to schedule for.

Please note that you are required to contact the office via text message or the Mail feature on your client portal if you need to cancel a session within 72 hours of your appointment.

If you see an open appointment and would like to schedule, it is up to you to "request" the appointment via your online client portal. It is not officially scheduled until it is confirmed by office staff. The spot is held until approved or denied.

You are limited in what you can schedule, so please be respectful of others who need appointment times as well.

You will no longer receive reminder texts of your appointments from Jessica/Caitlin prior to your appointment. You will still receive the auto-populated reminders from Counsol prior to appointments if you have selected to receive them.

AVAILABILITY BETWEEN SESSIONS

If needed, you can leave your therapist and/or office staff a message on our 24-hour voicemail box, text 423-715-3904, or contact us through your client portal using the Mail feature. Your therapist will respond when they are available to do so. If you require a response from your therapist outside your individual session time, there will be a charge applied to your account that is not reimbursable through insurance. (Please see the fee schedule for the cost of these services.) When you leave a voice message, include your telephone number (even if you think we already have it), the best times to reach you, and a brief reason for your call. Therapists do not return phone calls or text messages unless specifically requested, and there will be a charge associated with the returned phone call. We make every effort to return calls in a timely manner. In the rare occurrence that a message is missed or accidentally deleted, if you do not hear back from us within two business days, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence.

If you are in an emergency situation and cannot wait for us to return your call, go to the nearest emergency room or call 911. Authentic Counseling and Wellness, LLC is not a crisis facility. Do not contact us by email or fax in an emergency, as we may not receive the information in a timely manner.

Telehealth involves the use of electronic communications to enable Authentic Counseling and Wellness, LLC to connect with clients using live interactive video and audio communications. Telehealth 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 following rights in respect to telehealth:

The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my treatment at any time, without affecting my right to future care or treatment.

I understand that there are risks and consequences involved in telehealth, including but not limited to the possibility that in spite of reasonable efforts on the part of the counselor: 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. Authentic Counseling and Wellness, LLC utilizes secure, encrypted HIPAA-compliant audio/video transmission software to deliver telehealth.

Authentic Counseling and Wellness, LLC follows Tennessee state codes for telehealth: 56-7-1002 and 63-1-155, as well as respective board regulations and ethics, and has also received training to provide telehealth services.

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 911 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Payment for Telehealth Services:
Authentic Counseling and Wellness, LLC will bill insurance for telehealth services when these services have been determined to be covered by an individual's insurance plan. The standard copay and/or deductibles will apply. If insurance does not cover telehealth, I assume responsibility for fees due and will be required to pay out-of-pocket.

Patient Consent to the Use of Telehealth:
I hereby authorize Authentic Counseling and Wellness, LLC and its associates to use Zoom and/or Counsol as a means for psychotherapy. Zoom and Counsol are HIPAA-compliant platforms for telecommunication. I further attest that since I have chosen this form of communication, I have been advised that it may not be covered by my insurance company and that I am responsible for any fees incurred during psychotherapy which incorporates telecommunication.

I understand that I may revoke this authorization at any time by giving written notice, except to the extent Authentic Counseling and Wellness, LLC has already taken action in reliance on it. I may specify the date, event, or condition on which this consent expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date it was initiated.

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.

We do not provide or perform evaluations for custody, visitation, or other forensic matters. Therefore, it is understood and agreed that we cannot and will not provide any testimony or reports regarding issues of custody, visitation, or fitness of a parent in any legal matters or administrative proceedings.

If you are requesting a letter to be sent to an attorney or court, you will be charged a fee associated with the time spent and any legal fees we incur as a result of this letter. This fee is estimated to range between $35-$250 depending on the nature of the letter and will be discussed with you when the request is submitted before proceeding with the letter.

If we are contacted by an attorney regarding your treatment (either at your behest or related to a legal matter you are involved in), please note the following:

We charge $1000 to prepare for and/or attend any legal proceeding and for all court-related services. Charges for court-related services are not covered by insurance. Court-related services include: talking with attorneys, preparing documents, traveling to court, depositions, and court appearances. If the court or attorneys do not pay our fee, you will be charged for the time we spend responding to legal matters. You will also be charged for any costs we incur responding to attorneys in your case, including but not limited to fees we are charged for legal consultation and representation by our attorneys. A collection agency may be utilized if all fees are not paid within the agreed-upon time limit set forth in this agreement.

 

Your electronic signature is acknowledgment of this policy and agreement to adhere to fees and costs of collections.

Fire
In the event of a fire, staff and clients are to egress through the doors and through the hallway and out the front door, staff and clients are to stand in the parking lot or the grass space farthest from the building.
In the event that exiting through the normal method is inaccessible, there are 4 openable windows located in the Primary office, two in the front waiting room, one in Heather's office, and one more in the back testing room. 
There is a fire extinguisher located at the back of the office, but clients are to focus on their safety and wellbeing and thus are to leave the building as quickly as possible.

Tornado
In the event of a tornado during office hours, clients and staff should file inside Keith's office, as the designated safe place for a tornado.

Flooding
In the event of flooding during office hours, staff will determine the severity and the need for further action. Depending on the severity, staff will inform clinicians after appointment is completed or will knock on the door and let the clinician know. 
In the event of life-threatening flooding during office hours, staff and clients are to climb on top of the tallest surface they can safely stand on and wait for further instructions from the staff or emergency services.

Earthquake
In the event of an earthquake, clients are to drop to the ground, move away from fragile things like glass and things that are heavy that can fall, like pictures or clocks, and cover head and neck. If able, climb under a sturdy desk or piece of furniture. Client and Staff then must wait until the earthquake stops.

Inclement Weather:
In the event of inclement weather during office hours, after your appointment is completed, you will either be asked to leave quickly, but safely, or be asked to wait if the weather is expected to get better. A decision may be made to close immediately to allow clients and employees ample time to get to safety.
In the event of inclement weather outside of office hours, staff will gather information from local authorities and assess the conditions surrounding the office. Based on the information, staff will make the decision to close the office, delay opening, or if they should operate as normal. When a decision is made, the staff will alert any clients scheduled for that day of the decision. Pertinent information will be communicated as necessary. 

Public Health Crisis
In the event of a public health crisis, all state recommended protocols will be followed and updated as they become available. Clients and staff are to take protective precautions and refrain from entering the office if they exhibit any signs or symptoms of illness.

We are committed to providing comprehensive and individualized care to meet your needs. As part of our services, we offer medication management, which is provided by our qualified Nurse Practitioner.

Medication Management Information

You will be seen and evaluated by our Nurse Practitioner, who is trained and licensed to manage medications related to your care. Medication management involves assessing your current medications, prescribing new medications if necessary, and monitoring their effectiveness and any potential side effects.

Your Options

While we are pleased to offer medication management services in our facility, we respect your preferences. If you would prefer to seek medication management services from another provider, we are happy to provide you with a referral to a qualified professional outside our practice.

Acknowledgment

Please review and sign below to acknowledge that you have been informed about our medication management services and your option for a referral if desired.

I understand that:

I may receive medication management services from the Nurse Practitioner at this practice, but it is my responsibility to schedule with them. I have the option to request a referral to another provider for medication management services if I prefer. My care and treatment decisions will remain entirely my choice.

Please remember that there is a no call/no show and late cancellation policy of 24 hours. If you must cancel an appointment and you do not give a 24 hour notice, you will be charged the FULL FEE of the amount of time you were scheduled for. We always consider the circumstances for each broken appointment individually and understand that emergencies do arise. 

However, it is important to note that insurance does not cover missed appointments. As a result, we must prioritize our financial stability. Any future appointments that were scheduled will only be reinstated once the associated fee for the late cancellation or no-show is paid. In the event that your desired time slot has been taken by others when the fee is paid, you will need to schedule a new appointment. After two such incidents, you will be charged the associated fee and may be subject to a discharge from out practice.