HIPAA FORM

Consent to use and disclose your health information. This form is an agreement between you and Silver Lining Psychiatry. When we evaluate, diagnose and treat you we will be collecting PHI (Protected Health Information) about you. This information will be used  to make a specific treatment plan unique to your needs. By signing this form you are providing consent to allow us to use your information  related to your care and share with others per HIPAA guidelines as a covered entity. The Notice of Privacy Practices explains more in depth, your rights and how we can use and share your information. You may read this before signing this Consent form. You can retrieve a copy of the NPP from the receptionist. If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices we cannot treat you. After you have signed this consent, you have the right to revoke it and we will conform with your wishes about using or sharing your information from that time on. (But  any sharing that took place prior to your rescind  cannot be redone).

“Financial and Office Policy” Contract. Payment for services is your responsibility. We will not become involved in disputes between you and your insurance company regarding payments.Your deductible and copayment are due at the time of your visit. We accept cash and all major Credit Cards (Visa, Master, American Express, Discover, etc..) We do not do any legal forms, employment related forms, FMLA,  Short/Long term disability forms, School (semester) drop form.  (we can provide excuse for the day of office visit)

Providing a letter is solely upon practice discretion. Practice reserves the right to decline to furnish such letters. Each case will be decided on an individual basis.  We ask that you give us at least 3- 5 working days advance notice. There will be a charge of $100-400 based on the type or nature of the letter/form. (Fee schedule provided upon request). In need of a medical record for any purpose, we provide a summary of your medical chart to your desired destination. That medical record document  could be somewhere between 1-2 pages of typed up summary. We don’t share exact copies of medical records.

There will be a charge of $300 - $500 for that service based on the length and type of sharing. There will be a 2 dollar charge per page for furnishing labs or other ancillary non clinical documents.

You must call the office 48 business hours in advance for any appointment change or cancellation to avoid the “NO SHOW” fee. There will be a charge of $100 for appointment cancellation less than 48 business hours.  A late arrival more than 15 min will be considered as no show, which may incur the aforesaid charges outlined. Any such charge will be done by the office per office policy. 

Accounts that are 90-120 days past due may be turned over for collection. Not all psychiatric conditions or therapy services are covered by some insurance plans. If your insurance does not pay for a particular service, you will be responsible for the payment in full.

It is your responsibility to understand your plan's benefits. We only file with your primary insurance. It is the patient’s responsibility to file or claim any additional insurance

Any non-compliance with clinic policy/multiple or repeated  phone calls/ verbal abuse/ threats/unprofessional behavior with office staff or providers will result in termination of care from this clinic. The clinician reserves the right to terminate the counseling relationship if 2 or more sessions are missed without proper notification.

The clinician charges her hourly rate in quarter hours for phone calls over 10 minutes in length, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care. All costs for services outside of session will be billed. This will be billed to the credit card on file.

TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case. In order to protect your confidentiality, we strongly suggest not being involved in the court. If your clinician gets called into court by you or your attorney, you will be charged a fee of $400 per hour to include travel time, court time, preparing documents, etc.

PHONE CONTACTS AND EMERGENCIES: If you need to contact the clinician for any reason please call the office main number, leave a voicemail, and a return call will be made within 24 Hours or as soon as possible). In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 988 or 1-800-273-8255. If either you or someone else is in danger of being harmed, dial 911.

Any question or concern will be directed to the providers via Medical Assistant/Front desk. Providers will communicate through the medical assistant/Front desk.

This practice does not communicate through emails (except the document exchanges).

Please call us at least 48 business hours (2 business days) prior to your appointment if your insurance has changed. Not doing so can delay the verification process and you may be subject to the full visit fee payment.

CREDIT CARD PAYMENT CONSENT FORM

I hereby authorize Silver Lining Psychiatry to charge and store my card information for routine charges/fees, Refill charges, dues, copay, missed or last minute cancellation of visits per clinic policy.  If I have questions about these charges, I agree to contact the practice via phone. I agree that I will not pursue a refund directly through my credit/debit company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay all penalty fee(s) incurred to my provider. (ALL charges will be administered and collected by Silver Lining without Border, S Corp) I have read and understand the Credit Card Payment consent.

I HAVE READ AND UNDERSTAND THE CONTRACT (S) STATED ABOVE.

I HEREBY PUT MY SIGNATURE AS AN APPROVAL WITHOUT ANY COERCE.

TREATMENT CONSENT FORM

AND PERMISSION TO PHONE REMINDER & LEAVE any MESSAGE

Providers: Justin Colson LMHC

I do hereby voluntarily consent to evaluation and treatment by Silver Lining Psychiatry. I acknowledge that no guarantees have been made as to the result or outcome of diagnoses and counseling. 

1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent. I have discussed any questions that I have regarding this information with the clinician. My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent. I authorize clinician to provide counseling services that are considered necessary and advisable.
2. I authorize the release of treatment and diagnosis information (as described in Part III, above)

necessary to process bills for services to my insurance company, and request payment of benefits to clinician acknowledge that I am financially responsible for payment whether or not covered by insurance. I understand, in the event that fees are not covered by insurance may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney.

3. Consent to Treatment of Minor Child(ren): I hereby certify that I have the legal right to seek

counseling treatment for minor(s) in my custody and give permission to clinician to provide treatment to my minor child(ren). If I have unilateral decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to clinician prior to or at the initial session. Otherwise, I will have the other legal parent/guardian sign this consent for treatment prior to the initial session. 

I HAVE READ AND UNDERSTAND THE CONTRACT (S) STATED ABOVE.

I HEREBY PUT MY SIGNATURE AS AN APPROVAL WITHOUT ANY COERCE.

Therapy Consent, Policies & Agreement

STRUCTURE OF THERAPY:

• Intake Phase – During the first session, therapeutic process, structure, policies and procedures will be discussed. We will also explore your experiences surrounding the presenting problem(s).

• Assessment Phase – The initial evaluation may last 2-4 sessions. During this assessment phase, your therapist will be getting to know you. The therapist will ask questions to gain an understanding of your worldview, strengths, concerns, needs, relationship dynamics, etc. During this relationship building process, your therapist will be gathering a lot of information to aid in the therapeutic approach best suited for your needs and goals. If it is determined by your therapist that he/she is not the best fit for your therapeutic needs, he/she will provide referrals for more appropriate treatment.

• Goal Development/Treatment Planning – After gathering background information, we will

collaboratively identify your therapeutic goals. If therapy is court ordered, goals will

encompass your goals and court ordered treatment goals, based on documentation from the

court (please provide any court documents). Once each goal is reached, we will sign off on

each goal and you will receive a copy.

• Intervention Phase – This phase occurs anywhere from session two until

graduation/discharge/termination. Each client must actively participate in therapy sessions,

utilize solutions discussed, and complete assignments between sessions. Progress will be reviewed and goals adjusted as needed.

• Graduation/Discharge/Termination – As you progress and get closer to completing goals,

we will collaboratively discuss a transition plan for graduation/discharge/termination.

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for approximately 45-55 minutes depending upon the nature of the presenting challenges and insurance authorizations. It is difficult to initially predict how many sessions will be needed. We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.

CONFIDENTIALITY:

Anything said in therapy is confidential and may not be revealed to a third party without written

authorization, except for the following limitations:

• Child Abuse - Child abuse and/or neglect, which include but are not limited to domestic

violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc.

If you reveal information about child abuse or child neglect, we are required by law to report this to the appropriate authority.

• Vulnerable Adult Abuse - Vulnerable adult abuse or neglect. If information is revealed about

vulnerable adult or elder abuse, we are required by law to report this to the appropriate

authority.

• Self-Harm: Threats, plans or attempts to harm oneself. We are permitted to take steps to

protect the client’s safety, which may include disclosure of confidential information.

• Harm to Others: Threats regarding harm to another person. If you threaten bodily harm or

death to another person, I am required by law to report this to the appropriate authority.

• Court Orders & Legal Issued Subpoenas: If we receive a subpoena for your records, we will

contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. Your clinician will contact you twice by phone. If we cannot get in touch with you by phone, I will send you written correspondence. If a court of law issues a legitimate court order, we are required by law to provide the information specifically described in the order. Despite any attempts to contact you and keep your records confidential, we are required to comply with a court order.

• Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services. We will discuss the information and/or documentation with you in session prior to sending it to the court.
• Written Request: Clients must sign a release of information form before any information may be sent to a third party. A summary of visits may be given in lieu of actual “psychotherapy/process notes”, except if the third party is part of medical. If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.
• Fee Disputes: In the case of a credit card dispute, clinician reserves the right to provide the necessary documentation (i.e. your signature on the “Therapy Consent & Agreement”) that covers the cancellation policy to your bank or credit card company should a dispute of a charge occur. If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted.
• Couples Counseling & “No Secret” Policy: When working with couples, all laws of confidentiality exist. We request that neither partner attempt to triangulate the clinician into keeping a “secret” that is detrimental to couple’s therapy goal. If one partner requests that the clinician keep a “secret” in confidence, your clinician may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive.
• Dual Relationships & Public: Our relationship is strictly professional. In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship). If we run into each other in a public setting, I will not acknowledge you as this would jeopardize confidentiality. If you were to acknowledge me, your confidentiality could be at risk.
• Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients. If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality.  The clinician cannot be held liable if someone identifies you as a client. Posts and information on social media are meant to be educational and should not replace therapy. Please do not contact us through any social media site or platform. They are not confidential, nor are they monitored, and may become part of medical record.
• Electronic Communication: If you need to contact your clinician outside of scheduled sessions, please do so via phone.

Clients often use text or email as a convenient way to communicate in their personal lives. However, texting introduces unique challenges into the therapist–client relationship. Texting is not a substitute for sessions. Texting is not confidential. Phones can be lost or stolen. DO NOT communicate sensitive information over text. The identity of the person texting is unknown as someone else may have possession of the client’s phone.

Do not use e-mail for emergencies. In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room. Additionally, e-mail is not a substitute for sessions. If you need to be seen, please call to book an appointment. E-mail is not confidential. Do not communicate sensitive medical or mental health information via email. Furthermore, if you send email from a work computer, your employer has the legal right to read it. E-mail is a part of your medical record.

• Sessions Outside the Office: From time to time, clients like to meet in an alternate location

(i.e. their home, in public, or somewhere more conducive for them). We are not able to accommodate this request at this time.

HEALTH INSURANCE

YOUR INSURANCE COMPANY – By using insurance, your clinician is required to give a mental health disorder diagnosis that goes in your medical record. The clinical diagnosis is based on your current symptoms even though you may have been previously diagnosed. We will discuss your diagnosis during session. Your insurance company will know the times and dates of services provided. They may request further information to authorize additional services regarding treatment.

IMPORTANT: Some psychiatric diagnoses are not eligible for reimbursement (i.e.: marriage/couples therapy). In the event of non-coverage or denial of payment, you will be responsible to pay for services provided. Clinician reserves the right to seek payment of unpaid balances by collection agency or legal recourse after reasonable notice to the client.

PRE-AUTHORIZATION & REDUCED CONFIDENTIALITY– When visits are authorized, usually only a few sessions are granted at a time. When these sessions are complete, we may need to justify the need for continued service, potentially causing a delay in treatment. If insurance is requesting information for continued services, confidentiality cannot be guaranteed. Sometimes, additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not met.

Your signature signifies that you agree to and have received a copy of the “Therapy Agreement, Policies and Consent” for your records.

I HAVE READ AND UNDERSTAND THE CONTRACT (S) STATED ABOVE.

I HEREBY PUT MY SIGNATURE AS AN APPROVAL WITHOUT ANY COERCE.