Contract for Services Contrato Para Servicios
Informed Consent For Services And Confidentiality
- I understand that I have the rights to participate in the development and ongoing review of a service plan that meets my individual needs, and which reflects my strengths and respects my cultural values, believes, and traditions.
- I have been provided with sufficient information regarding the services I will receive from the Yahara Counseling Center, LLC (YCC).
- Side effects of counseling and other potential unpleasantness:
- As you learn more about yourself, you might encounter increased conflict with friends, co-workers, and family members. It is possible that you might become somewhat depressed. Counseling is intended to alleviate those problems, but sometimes at first, as you get to the root of some things, you may feel them even more acutely than in the past.
- Sometimes counseling requires trying new and unfamiliar ways of doing things. You will always be free to move at your own pace.
- We will work with you to make changes, but we cannot promise anything about the results you will obtain. The outcome you achieve will depend on many things.
- If we believe that your problem requires knowledge that we do not have, we may refer you for a consultation with someone with specific training or experience. We will discuss any such referral with you before we act.
- At the beginning, we will create a treatment plan with you. Later, we review the plan to see if it needs to be updated, and how we know you are succeeding.
- I understand that I have a confidential treatment record and that confidentiality about my mental health and/or alcohol/drug treatment services is protected by the state and federal laws.
- I also understand that there may be times when detailed confidential information about my services, including treatment plans and progress notes, can legally be shared with persons outside YCC, including:
- Emergency situations that involve imminent harm to myself or others
- Neglected or abused minor, elder, or other adult at risk
- Insurance companies and county and state agencies that are paying for my services. By your signature, below, you authorize our office to provide information to your insurance and managed care companies to the extent necessary for them to pay for your services.
- Judicial Proceedings: YCC may disclose information in response to a specific legal proceeding, court order or other legal process, as stipulated by law.
- Limited information may be shared with your spouse, parent, adult child or sibling, but only if therapist have verified that the family member is directly involved in providing or monitoring your treatment.
Fees and Billing
- You are ultimately responsible for the cost of treatment. By you signature below, you acknowledge that you have discussed the cost of therapy with your therapist. ($100.00 per session). I understand that a reduction in fees may be available at the discretion of my therapist. We accept cash and credit cards.
- Cancellations and No Shows: Cancellations need to be made 24 hours in advance of the scheduled appointment. You may be charge for appointments cancelled with less than 24 hours notice. Please note that we are not permitted to bill insurance for missed appointments, and therefore you will be responsible for paying for missed appointments.
- If you miss a schedule visit, it is your responsibility to call the office to schedule another appointment if you wish to continue your counseling effort. If you do not call our office within ten days to reschedule, your counselor will accept that as your notice that you have terminated counseling with our office and you wish no further services from our office.
Emergency Procedures
- In the event of an emergency, you can leave a message and your therapist will be contacted. During a life threatening crisis, please call 911 or go to an emergency room.
- If you have any questions or concerns about any of the above, please discuss these with your therapist.
Internet And Electronic Communication
You may use email to communicate with your counselor. If you choose to communicate via email, remember that email communications are not private. Email communication with our office should be limited to administrative and logistical matters; your counselor will NOT use email to discuss important personal and counseling matters. If you wish to authorize us to communicate via email, please provide your preferred email address:
Consentimiento para tratamiento y Confidencialidad
- Yo entiendo que yo tengo el derecho de poder participar en desarrollar el enfoque de mi tratamiento y de poder revisarlo para enfocarme en mis necesidades individuales que reflejen mis abilidades y que respeten mis valores culturales, creencias, y tradiciones.
- Se me ha provisto de suficiente información en relación a los servicios que recibiré en Yahara Counseling Center, LLC.
- Algunos de los posibles efectos secundarios y otros sentimientos desagradables:
- Mientras más uno aprende a conocerse uno mismo, puede que uno sienta conflictos con los amigos, compañeros de trabajo, y miembros de la familia. Es possible que pueda sentirse un poco deprimido. La consejería es creada para aliviarle a uno los problemas, pero de ves en cuando, al uno enfrentarse a la raíz de los problemas, puede que se acentuen sus emociones.
- A veces las consejerías requieren que uno trate nuevas experiencias que no son familiares. Usted siempre estará libre de hacerlas a su propio ritmo o cuando se sienta listo (a).
- Nosotros trabajaremos con usted para hacer los cambios necesarios, pero no podemos prometerle nada de los resultados que usted obtenga. Los resultados dependerán de muchos factores.
- Si usted cree que sus problemas requieren conocimientos que no temenos disponible, nosotros podremos referirlo a un especialista. Pero antes, nosotros consultaremos con usted si este referido es necesario
- Al principio, nosotros crearemos un plan de tratamiento para usted. Luego, revisaremos su plan para ver si este necesita actualizarse, y como podriamos ayudarlo a obtener exito.
- Yo entiendo que tendré un archivo confidencial de mi tratamiento y de mi estado mental y/o tratamiento de alcohol/drogas y que estarán protegidos por las leyes Estatales y Federales.
- Yo tambien entiendo que puede que hayan ocasiones donde una información detallada de los servicios recibidos, incluyendo plan de tratamiento, notas de mi progreso, pueden que sean legalmente compartido con personas fuera de YCC, incluyendo:
- Situaciones de emergencia que envuelva daños hacia usted u otras personas.
- Abuso o negligencia de menores, ancianos, u otra persona a riesgo.
- Compañias aseguradoras, el Condado u Agencias del Gobierno que pagan por los servicios. Con esta firma, abajo, usted autoriza que nuestra oficina les pueda prover la informacion necesaria para que las aseguradoras y/o el Gobierno puedan pagar por los servicios recibidos.
- Procesos judiciales: YCC podrà difundir información en respuesta a alguna vista judicial, y por orden de la Corte u otro proceso judicial estipulado por la ley.
- Información limitada puede que sea compartida con su esposo(a), padres, adulto o hermano(a), pero solamente si el terapista a verificado que ese miembro de la familia esta directamente envuelto en el monitoreo del tratamiento.
Other Office Policies
Our counselors are not allowed to accept gift from clients. While we appreciate your thoughtfulness, we are prohibited by the cannons of our profession from accepting gifts from our clients. Similarly, our professional practice standards prohibit our counselors from accepting requests to connect or to be “Friends” on the internet sites such as Facebook, Linkedin, Twitter, and other electronic and social media.
By your signature below, you authorize our office to designate an appropriate professional to serve as a custodian of your record, and who will assume possession of, and responsibility for your treatment record in the event of your counselor’s death or disability. In that event, a notice will be posted, as necessary, on your counselor’s webpage and voice mail.
By signing this form, I understand that this consent and that it is valid for one year from the date I sign it. In addition, I understand that I can withdraw from my treatment anytime.
Otras Reglas de Oficina
Nuestros consejeros no tienen permiso de aceptar regalos de sus clientes. Aúnque apreciamos su gesto, se nos prohibe, por causa de nuestra profesión de aceptar regalos de nuestros clientes. Igualmente, nuestros estandards de nuestra profesión prohibe a los consejeros aceptar solicitud de “amigo” en el internet en las redes sociales como Facebook, Linkedin, Twitter, y otros medios sociales electrónicos.
Con su firma abajo, usted autoriza a un profesional de nuestra oficina la custodia de mantener su archivo, y que este asumirá la responsabilidad del archivo de su tratamiento en el evento que su terapista fallezca o quede inválido. De ocurrir esto, una nota sera publicada, y como sea necesario, estara anunciado en la página web y vía mensaje grabado de la oficina de YCC.
Type your full name and date into the fields below so that they match the information below the field to sign this document
Al firmar este formulario, yo entiendo que este consentimiento es valido por un año desde el dia que lo firme. Para añadir, yo entiendo que yo puedo terminar mi tratamiento en cualquier momento.
Esciba su nombre completo y la fecha en el espacio disponible. De esta manera sera igual a toda la información anterior.
Your Service Contract has been Sent!
Thank you for taking the time to complete this form. Your therapist will be following with any questions via email.
