Adult Consent to Treatment Form


 

Client Treatment Details

Payment is due at the time of services.  Clients may pay for services with insurance, debit, credit or HSA cards.  $80 per 60-minute hour is the normal fee for services. 

Adult or senior substance abusers, of legal or illegal substances, must be clean and sober before services can begin at Beth Powell’s In-Family Services.  Questions must be answered honestly on the Caregiver Biography regarding substance use.  If Beth Powell determines that substance use has exceeded use and is instead abuse or dependency, then her services will be terminated and the person will be correctly referred to a licensed chemical dependency provider for services.

Appointments must be cancelled 24 hours ahead of time.  Healthcare providers cannot bill a client’s insurance company for a missed or late-cancelled appointment.  Missed and late-cancelled appointments (no-shows) are billed in full to the client.   A credit card number is given at the time the initial appointment is made to ensure proper cancellation of scheduled future services.

$80 an hour is charged to the client for all business time outside the client’s therapy session.  This includes emergency phone calls and letter writing.  Testimony or advocacy in any type of court or potential legal proceeding is not within this health care provider’s scope of practice.  You may not volunteer Ms Powell’s services to any entity that she has not agreed to consult with.  This would include entities like school diagnosticians, attorneys, CPS case workers, the YES Waiver people, etc.  This does not pertain to the referring of Ms Powell to potential clients who could benefit from her services.  If you like her services, feel free to refer.  Retrieval and delivery of client medical records is $35.  Records will only be released to the client or to the custodians of a client.  They can be sent by encrypted email.  The current evaluation and treatment plan can be emailed via encrypted email to the client at no charge.

 

Texting and E-mail Policy And Consent

Regulations of HIPAA and the Social Worker Code of Ethics require that your Protected Health Information (PHI) be private and secure; however, with your permission, texting and emailing can be allowed for handling administrative details, emailing handouts, telehealth reminders and encrypted registration materials and treatment plans.  Some potential risks that can be encountered with communicating by email or texting include:  Delivery of email or texts can go to an incorrectly typed address; email and text accounts can be hacked; email and text providers keep a copy of each email on their servers where it might be accessible to their employees, etc.  If you agree to texting or emailing with Lucy (Beth) Powell, LCSW, you are agreeing only to use these modalities in the following ways:

Texting: 

--To reschedule or cancel an appointment at least 24 hours ahead of time.

--Other scheduling or appointment time issues

Emailing:

--To submit registration materials
--To receive telehealth links to appointments
--To receive handouts
--To receive encrypted treatment plans

You may not cancel your appointment by e-mail!!!!
You may cancel by phone call or text only!!
Please Identify yourself when sending texts.
You may NOT contact Ms Powell via Facebook nor any other form of social media.

 

Telehealth Services Information

Until further notice, telehealth is provided at Beth Powell’s In-Family Services.  Clients are reminded of their appointments via emailed telehealth session invites.  There will be no recordings of any of the online sessions by either party.  The privacy laws that protect the confidentiality of your protected health information also apply to telehealth.  During a telehealth appointment, this therapist will need to know your physical location in case an emergency should arise.  The emergency person listed on your PHI form is the contact this therapist would call in case of emergency.  This therapist will call 911 if necessary.  This therapist can only Zoom with one electronic device at a time. 

 

Notice of Privacy Practices and Acknowledgement of Notice

Your privacy is protected by federal and state law.  What is said in this office will remain private and confidential.  All associates who are affiliated with Beth Powell’s In-Family Services and who have potential access to your personal health care information must sign a HIPAA-compliant agreement.  By law you are required to sign paperwork related to HIPAA for services to be rendered.  It is a legal requirement to keep records (Private Health Information or PHI) which require information such as name, diagnosis, date of service, type of service, billing information, evaluations and session narratives.

What follows is how your PHI may be used at Beth Powell’s In-Family Services: 

  1. For insurance billing purposes: Our billing company files with your insurance company who may request your personal records for payment purposes.
  2. As required by law: We must disclose your PHI to you upon your request.  In addition, we must make disclosures to the Department of Health and Human Services, if asked, for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
  3. We may also disclose your PHI to a state or local agency that is authorized to receive reports of child abuse or neglect such as CPS or Adult Protective Services.
  4. We may also disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
  5. We may disclose your PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to your death, based on your prior consent.
  6. We may disclose your PHI in an emergency situation only in order to prevent serious harm. This includes calling law enforcement or an ambulance.  We will also disclose that same information to the person you have designated as your emergency contact. 

 

Breaches and Complaints:  If there is a breach of unsecured PHI concerning you, we will notify you of this breach.  If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our privacy officer at Beth Powell’s In-Family Services or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 2021 or by calling (202) 619-0257.  We will not retaliate against you for filing a complaint.  The effective date of this notice is January 1, 2022.

 

Consent:

I have read and I agree with Beth Powell’s In-Family Services Notice of Privacy Practices.  I understand if I have any questions regarding the notice or my privacy rights, I will contact Lucy (Beth) Powell, LCSW, Privacy Officer.

 I have kept a copy for my records of this Consent to Treatment form which includes the Texting and Email Consent Policy, Telehealth Services Information, and the Notice of Privacy Practices.  I have no further questions regarding what I have signed and understand and agree to Beth Powell’s In-Family Services Consent to Treat policies.  I understand that if I have a question regarding the professional performance of Lucy (Beth) Powell, LCSW, SW License 18222, I will contact:  BHEC at 1-800-821-3205 or go to bhec.texas.gov/discipline-and-complaints/index.html .

There are no risks, only potential benefits to treatment

at Beth Powell’s In-Family Services.

 

I (we) Name of Responsible Party:

The initial appointment has been scheduled for:

From:    

To approximately:      

If we must cancel or postpone, we agree to do so at least one business day in advance as outlined above.

Today's Date: April 13, 2024

Leave this empty:

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Signature Certificate
Document name: Adult Consent to Treatment Form
lock iconUnique Document ID: 9d12eb2c1d14075b8f4cdc975ea548f8fffbd204
Timestamp Audit
December 13, 2016 9:39 pm CDTAdult Consent to Treatment Form Uploaded by Beth Powell - bethpowell@therapysecure.com IP 70.139.88.25