COMMUNITY MENTAL HEALTH CORP INTAKE FORM

— Please Print and Sign the following Form —

Disclaimer and Consent for Treatment

Mental Health sessions carry both benefits and risks. Mental Health sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these mental health sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of mental health sessions. By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

____________________________________________________________________
Print Name Signature Date

Cancellation Policy

To ensure high quality of services, the CMHC professional enters into a partnership with their clients. As part of the partnership, clients are responsible for keeping all appointments with the CMHC professional and notifying them when an appointment needs to be cancelled or rescheduled.

1. A cancellation is defined as at least 24 hour notice of non-attendance at a scheduled appointment. 2. A “no-show” is defined as less than 24 hours’ notice of non-attendance at a scheduled appointment. Exceptions will be made on a case-by-case if the client was unable to contact the CMHC professional due to a crisis or emergency. 3. Clients will be charged their full session fee for each missed/no-show appointment, using the credit card information that the Client provided in the intake documents. 4. Tardiness to an appointment of 15 minutes or more will be counted as a “no-show”. 5. After the first no-show, the client will be issued a reminder of the missed appointment and the cancellation policy by phone contact. 6. After the second no-show, the client will be provided a reminder of the missed appointment as well as the cancellation policy. If clinically appropriate, i.e., beneficial to the client’s progress in treatment, a behavioral contract may be developed. 7. After three “no-shows”, services can be discontinued at the discretion of your CMHC professional. Referrals will be provided for the client to other programs and/or agencies. 8. Failure to contact your CMHC professional regarding the missed appointments(s) will be considered a self-discontinuation of treatment. The client will be provided with a minimum of two (2) courtesy calls before treatment is discontinued. At this time, the client will also be provided the option of contacting your CMHC professional for possible continuation of treatment or referrals.

____________________________________________________________________
Print Name Signature Date

Credit Card Policy

Payment for life coaching sessions is available via SQUARE Cash, Zelle, cash, or check. We ask for credit card information should you miss sessions or fail to cancel within 24 hours. Please see cancellation policy for more information.

Credit Card Information

Name on card __________________________________

CC#________________________________________________

EXP ______________________ CCV# _________ Billing ZIP ________

I understand that this credit card information will only be used for the ease of payment for services provided by CMHC professional. In the event that I am not able to cancel an appointment, I understand that I may be charged the full session fee.

____________________________________________________________________
Print Name Signature Date

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 AND SIGN THE FORM INDICATING YOU HAVE RECEIVED IT. Feeling safe to talk about personal feelings and experiences is critical to effective therapy. Your participation in counseling is confidential. Your privacy is of the highest priority. In order for you to feel safe, it is important to know how the information you share with me is protected. Mental health professionals have been, and continue to be, bound by professional standards of confidentiality that are often more stringent than those required by law.

What Is "Protected Health Information" (PHI)? ​ - Protected Health Information (PHI) is a legal term that refers to the information that obtained the process of your work with CMHC professionals. Your PHI typically includes your name, address, phone numbers, your symptoms, personal history, payment information, diagnoses, treatment goals, and treatment methods. It will also include “case notes” which is a brief summary of your sessions with the CMHC professional. It might include information obtained from other professionals who have treated you.

How, When, and Why Your Information is Used and Disclosed ​- There are different reasons how, when, and why personal information will be used and disclosed. A “use” of information occurs when I examine information within my practice for the purpose of better understanding your case and improving your treatment. A “disclosure” occurs when your PHI is released to a third party. Both the fact that you are visiting a mental health professional and the content of those conversations will not be disclosed to anyone without your written authorization. However, there are exceptions to this rule, when your CMHC professional is legally obligated to reveal confidential information with or without your permission. These situations will be described below.

Safeguards of Your Privacy - ​In order to protect your PHI against unauthorized access, CMHC maintains physical, electronic, and procedural safeguards that comply with state and federal regulations. As a member of a group practice, other professional members of the group practice have access to your PHI. The individual electronic communications between you and your CMHG professional are not accessible by any other CMHG professionals. Voicemail is password protected. CMHC representatives are also responsible for billing, and handle all written correspondences pertaining to your case. If a request from third parties for information or records is received, you will be consulted first. If you are under age 18, your parents have a right to know about your treatment. A noncustodial parent has a right to know about your therapy as well. Because privacy in therapy is so important, particularly for teenagers, it is our policy to ask parents of children over the age of 12 to respect the confidentiality of their child’s therapy. If your CMHC professional feels that the child is in danger we will notify parents of our concern. We also will provide parents with general information about the progress of treatment. Written records of service are required by clinical standards, ethics, and law to be kept. Client records are stored in a secure CMHC electronic drive, accessed only by CMHC professionals. Records may be destroyed after a period of time prescribed by ethics and law. It is important to note also that email communication is less secure than other forms of communication, although it is sometimes a necessary means of scheduling or transmitting information. Your PHI will not be provided to accountants, attorneys, or other business consultants involved in my practice. To maintain the highest ethical and legal standards of protecting your privacy, CMHC will adhere to these policies and may amend them in the future as needed to remain current. Any changes will apply to all information maintained at that time.

Disclosures Allowed with Your Authorization - ​Disclosures of your PHI generally require your prior written consent. The authorization must include what will be released, to whom, and for what purpose. If you choose to sign an authorization to disclose information, you can revoke or modify it in writing at any time to stop any future disclosures of information. If you are using health insurance, it will be necessary to disclose limited personal information to your insurance company to obtain eligibility and benefit information as well as to bill and collect payment for the treatment. For billing purposes, your name, address, social security number, diagnosis, and dates of services are typically provided to your insurance company. Certain insurance companies require preauthorization of treatment before services will be reimbursed as well as periodic treatment plans in order for them to authorize additional treatment. Treatment plans typically include the following: symptoms, diagnosis, risk assessment, goals, and progress. This information will become part of the insurance company’s file. Any institutions outside my office that have access to your PHI such as insurance companies are similarly required to protect your PHI by law. To maintain high standards of care, CMHC professionals periodically obtain consultation from colleagues within the company about cases. In such consultations, any information which could identify you will not be disclosed. Information, such as hospital records, that has been provided to CMHC by other health care professionals, will not be released and falls under your CMHC-protected PHI.

Exceptions to Privacy - ​I may disclose PHI without your consent in the following circumstances.

Child Abuse​ - If there is a reasonable suspicion of physical, and or sexual abuse or neglect of an identifiable child under the age of 18, we must report it to designated public agency. If we have knowledge of or reasonably suspect that mental suffering has been inflicted upon a child, we may report it.

Elder and Dependent Adult Abuse - ​If there is a reasonable suspicion of physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, we must report it to a designated public agency.

Danger to self or other - ​If you communicate to me a serious threat of physical violence against an identifiable victim, we must make reasonable efforts to communicate that information to the potential victim and the police. If we have reasonable cause to believe that you are a danger to yourself or others, or unable to care for yourself, we may take protective action, including hospitalization or contact family members or others who can help provide safety. Limited information may be disclosed to facilitate this process.

Judicial or Administrative Proceedings - ​If you are involved in a court proceeding and a request is made about the professional services that we have provided you, the court might order CMHC to provide records or testimony concerning you. ​If a complaint is filed against a CMHC licensed professional, their registered Board has the authority to subpoena confidential information from me relevant to that complaint.

HIPPA Compliance - ​We may be required to disclose some information to government agencies that check to determine compliance with the privacy laws.

Worker’s Compensation - ​If you file a worker’s compensation claim, we must furnish a report to your employer, incorporating my findings about your injury and treatment as may be required by the administrative director of the Worker’s Compensation Commission in order to determine your eligibility for worker’s compensation.

Medical Emergency - ​If you become unconscious in the office or are in severe pain and cannot communicate, we may call emergency medical services and/or the emergency contact you named on the information form.

Unpaid bill - ​If you fail to assume financial responsibility for your bill, limited personal information may be disclosed for purposes of debt collection, such as your name, nature of services you have received, and the amount due.

Incapacitation or Death - ​If you are incapacitated or deceased, your information remains secure. However, disclosure may be authorized by the entity with health care power of attorney or charged with making decisions about your estate.

Therapist’s Illness - ​In the event your CMHC professional is incapacitated, the CMHC CEO will administer to all confidential matters as necessary for the continuity of your care.

What Rights You Have Regarding Privacy - ​You have the right to inspect or obtain a copy of your PHI. Under rare conditions where we feel the information may cause harm to you, we might deny this request. Instead we will provide you with a summary of the information. Your CMHC professional will discuss with you the reasons as well as the recourse you have for appeal. If you request a copy of your PHI, there may be a reasonable charge for the time required to copy this information. You have the right to request restrictions on certain disclosures of your PHI. We will use our professional judgment to respond to this request and am not required to agree to this restriction. If you believe that there is a mistake in your PHI, you have the right to request that the existing information is corrected or add the missing information. You must provide the request and your reason for the request in writing. You have the right to get a list of instances in which we have disclosed your PHI. You can receive information at an alternate address or by alternate means (for example, fax instead of regular mail) so long as we can easily provide the information to you in the format you requested.

Changes of Privacy Policy - ​CMHC reserves the right to change privacy policies and practices described in this notice. Unless you are notified of such changes, CMHC is required to abide by the terms currently in effect. You will receive a copy of this policy at the start of counseling and may request a copy of changes by contacting Community Mental Health Group at communitymentalhealthgroup@gmail.com or at 1901 Newport Blvd, STE 350 Ofc#349, Costa Mesa, CA 92627

Questions or Complaints about Privacy - ​If you have questions or believe your privacy has been violated, you are encouraged to address your concerns directly with CMHC CEO Dr. Taryn Feuerberg at 949)479-0163 or at 1901 Newport Blvd, STE 350 Ofc#349, Costa Mesa, CA 92627. You may also contact the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, DC 20201, by calling (202) 619-0257, or by accessing the internet at http://www.hhs.gov/ocr/hipaa. You have specific rights under the Privacy Rule and CMHC will not retaliate against you for exercising your right to complain.

This notice went into effect on April 14, 2003.

Notice: Please be aware that we have a motion-activated camera in our office for the safety of the staff, clients, and all their personal health information. The camera records still pictures of the entrance/exit only- rather than video- and of course no sound is recorded. Your safety and privacy is paramount to Community Mental Health Corp.

____________________________________________________________________
Print Name Signature Date

Informed Consent for Telepsychological Services

Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

• Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

• We agree to use the video-conferencing platform selected for our virtual sessions, and the mental health professional will explain how to use it.

• You need to use a webcam or smartphone during the session.

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

• It is important to use a secure internet connection rather than public/free Wi-Fi.

• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the mental health professional in advance by phone or email.

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.

• If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

• As your mental health professional, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.

____________________________________________________________________
Print Name Signature Date