I hereby authorize Masquigon Integrative Behavioral Health to provide testing/assessment, counseling, and/or psychotherapy as explained to me. I understand that while this therapy may be beneficial, as with any treatment, there are inherent risks. During counseling and testing/assessment, I will discuss personal issues which may bring up uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling or testing/assessment can far outweigh this discomfort and can lead to benefits such as improved personal relationships and reduced feelings of emotional distress. My clinician will help process these feelings during my sessions and provide me with appropriate recommendations. Participation in services is voluntary, but the cancellation policy outlined below continues to apply. I acknowledge, however, that no warranty or guarantee can be made as to the results of therapy.

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CONFIDENTIALITY: I understand that discussions between myself and my therapist as well as any records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to me. No information will be released without my written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following: abuse of any other person, sexual exploitation, AIDS/HIV infection and possible transmission, criminal prosecutions, child custody cases, lawsuits in which the mental health of a party is an issue, situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose, a negligence suit brought by the client against the therapist, or the filing of a complaint with the licensing or certifying board. If I have any questions regarding confidentiality, I will bring them to the attention of my therapist. By signing this Information and Consent Form, I am giving consent to the undersigned therapist to share confidential information with all persons mandated by law and with the agency that referred me and the insurance carrier responsible for providing my mental health care services and payment for those services. I am also releasing and holding harmless the undersigned therapist and Masquigon Integrative Behavioral Health from any departure from my right of confidentiality that may result. PRIVACY: I understand that Masquigon Integrative Therapy follows all privacy practices mandated by HIPAA (Health Insurance Portability and Accountability Act of 1996). This means that my information will be utilized for the purposes of treatment, obtaining payment, and supporting the day-to-day healthcare operations of Masquigon Integrative Behavioral Health. Information may also be shared with the appropriate entities to support government audits and inspections, law-enforcement investigations, and to comply with mandated reports as mandated by law. My information may also be shared among staff for scheduling needs.

 

TELEHEALTH: The laws protecting my medical information also apply to telehealth. I understand that I will need to utilize my client portal to engage in telehealth services which require the use of a smartphone device with a cellular connection or access to the internet. I also understand that the appointment may be disturbed by poor connection or other technical difficulties which may delay my treatment. I also understand that security protocols could fail and cause a breach of privacy of personal medical information, although rare. I will not operate a vehicle during the session and must remain in a private confidential space while in session to maintain my confidentiality. I will alert my clinician if I choose not to participate in telehealth services.

 

MY RIGHTS: I may request a report outlining the use of my information at any time after which I will be provided a summary by my provider. Unlimited access to my information (e.g., session notes) may cause emotional distress and disrupt the therapeutic relationship. Therefore, I am not given access to my treatment notes unless my provider provides me access or I obtain a court order after which my clinician has thirty days to respond.

 

CLINICIAN INCAPACITY: In the event that the clinician is no longer available due to illness, death, or other personal circumstances, you will be contacted as feasible with referrals to other providers.

 

DUTY TO WARN/DUTY TO PROTECT: If my therapist believes that I am in physical or emotional danger or I am a danger to another human being, I understand that my therapist is required by law to contact medical or law enforcement personnel to prevent harm to another person or me, and may contact the person in danger.

 

COMPLAINTS: If I am concerned that my privacy rights have been violated and would like to submit a complaint, I can send correspondence to the director of Masquigon Integrative Behavioral Health at complaints@masquigonintegrativebehavioralhealth.com. I may also contact the Secretary of the Department of Health and Human Services. I will not be retaliated against for filing a complaint against Masquigon Integrative Behavioral Health.

 

APPOINTMENTS: Services are by appointment only. Scheduling appointments is done through our website under the service tab. Upon completion of these forms and scheduling my initial appointment, I will receive a client portal login through which I may communicate my scheduling needs. If the need arises for me to change my appointment time, or cancel an appointment, please cancel as soon as possible. Assessment appointments require a refundable scheduling deposit of $400 due when scheduling the second assessment appointment (the appointment after the intake session). This fee will be refunded upon attendance of the second assessment appointment.

 

TESTING APPOINTMENTS CANCELLATION POLICY: Assessment appointments are in high demand and require my psychologist to block out several hours of their time for me. If for some reason I need to cancel or postpone my appointment, I will try to give a one-week notice so they may fill my spot. If less than 72 hours notice is given to cancel or reschedule my appointment, or if I fail to show up for my scheduled appointment, I will forfeit the scheduling fee. I understand that insurance does not pay for charges associated with missed appointments. Further, I understand that at my testing appointment, I will be given take-home assessments (e.g., observer questionnaires) to complete before my feedback session can be scheduled. I also understand that I must complete and return the take-home assessments no later than 60 days after my testing appointment. If these take-home assessments are not completed within the 60-day time frame, I will be required to restart the testing process as necessary (e.g., intake, questionnaires).

 

FEEDBACK SESSION CANCELLATION POLICY: The clinician is not able to bill for the various hours spent writing the report until I have attended the feedback session. Therefore, I understand that I must provide at least a 72 hours notice to cancel or reschedule my appointment. If I fail to provide a 72-hour notice to cancel or reschedule my appointment or if I fail to show up for my scheduled appointment, I will be charged a cancellation fee of $50 per hour spent writing the report and an additional $50 cancellation fee for the hour feedback session. This fee will be charged to the credit card on file.

 

THERAPY APPOINTMENTS CANCELLATION POLICY: Therapy appointments require a 24-hour notice if I need to cancel my appointment. A cancellation fee of $75 will be charged to the credit card on file if I fail to attend a scheduled session (i,e., no-show) or if less than 24-hour notice is given. Please note that insurance does not pay for charges associated with missed appointments.

 

GOOD FAITH ESTIMATE: Good Faith Estimates are provided to clients who are not using their insurance or do not have insurance. These are provided at least one day before my initial appointment. This bill is an estimation of the costs of services. If I receive a bill for more than $400 of my Good Faith Estimate, I have a right to dispute this bill.

 

INSURANCE: Masquigon Integrative Behavioral Health is currently in the process of credentialing with insurance companies. This means that they are not in network with insurance providers. Therefore, I have the choice of paying privately (i.e., out of pocket) for services or submitting my monthly bill (i.e., superbill) to insurance as an out-of-network provider. Masquigon Integrative Behavioral Health does not guarantee that insurance will reimburse me if I submit the bill to my insurance as an out-of-network provider.

 

PAYMENT: Payment is due at the time of services before the session begins to reduce confusion about account balances. For therapy, this means that payment is due at the conclusion of the session. For testing, this means that payment is due after the testing/assessment session has concluded but before I leave the office. In general, we accept cash, debit, VISA, MasterCard, Discover, American Express, Health Savings Accounts (HSA), and Flex Savings Accounts (FSA). We do not offer sliding scales or reduced fees for testing/assessment. This is due to the time-consuming process, cost of materials, and specialized training that a comprehensive assessment requires. Realizing that not everyone can agree to these terms, we can refer me to other agencies and providers upon request. We also do not offer sliding scales or reduced fees for therapy as the therapist's fees reflect their continuing specialty training and allow them to continue to stay up to date with treatment methods and modalities. Therapy is an investment in my future. All unpaid balances past 90 days will be sent to collections.

 

COURT: If the clinician is summoned to court and compelled by law to disclose my records or to testify in court, I am responsible to pay for the costs involved. This is because court proceedings require the clinician to clear their schedule to accommodate these needs. Insurance will not cover court costs. Records for court are subject to a $5 per page fee. Any report writing, deposition, mediation, and testifying is subject to a $150 per hour fee which includes travel and wait time.

 

PROFESSIONAL JUDGEMENT: My practitioner is a licensed professional with various dynamic training experiences. They reserve the right to determine whether testing/assessment is clinically appropriate and medically necessary. This includes the instruments utilized to comprehensively evaluate my symptoms and meet my needs. With me, my clinician will collaboratively review the methods and procedures.

 

RELATIONSHIP: The relationship between a mental health professional and a client is strictly professional. No other relationship may develop between the clinician and client to maintain the effectiveness of treatment. For example, gifts, bartering, trading services, and social media friend requests are not appropriate.

 

COVID-19: I agree that I am responsible for minimizing my exposure to illnesses such as COVID-19. By attending in-person appointments, I am risking exposure to illness. I will not attend in-person appointments if I am showing symptoms of illness (e.g., sore throat, fever, cough, congestion). If I show symptoms, I will request a telehealth appointment when possible or reschedule my appointment. I understand that the cancellation fees will not apply to me if I am ill. I also understand that my clinician reserves the right to reschedule my appointment if I show up to my appointment with symptoms of illness.

 

CONSENT TO TREATMENT: Testing/Assessment, counseling, and/or psychotherapy as stated, including the possible risks, complications, options, and expectations have been explained to me or my representative, and consent for treatment is thus given as noted by signature. I voluntarily agree to receive mental health testing/assessment, treatment, and services for me, and I understand that I may stop such treatment or services at any time.