Consent to Treatment Form

Financial Agreement

Payment is due at the time of services.  Clients may pay for services with cash, insurance, debit, credit or HSA cards.  $80 per 60-minute hour is the normal fee for services that are not covered by insurance. 

If you are paying by insurance, you must tell Beth Powell immediately if your insurance changes as she may not have a contract with your new insurance plan.  You are responsible for the payment of the services rendered if this important communication is neglected.  As well, if your child has Medicaid, your child only receives 30 visits a year.  If you add the services of another outpatient behavioral health therapist or counselor while you are also seeing Ms. Powell, you must let her know this immediately.  If both professionals are utilizing the same 30 sessions, one or both professionals may not get reimbursed by Medicaid for services rendered because there may not be enough visits for both professionals to utilize.

$80 a 60-minute hour is charged to the client for all business time outside of the client’s therapy session.  This includes emergency phone calls and letter writing.  Records will only be released to the client or to the custodians of a client.  They can be sent by encrypted email. 

Services Agreement

Appointments must be cancelled at least 24 hours ahead of time.  There are no exceptions.  Missed and late-cancelled appointments are billed in full to the client. 

Calls are only returned during active business hours from 8 am to 6 pm Monday through Friday.   If you have an after-hours emergency, please call 911.   

If you are a caregiver seeking services for your child, you must familiarize yourself with Ms. Powell’s FAQ and therapy approach with children in families before consenting to treatment.  These sections are available on her web site.    

Testimony, consultation or advocacy in any type of court or potential legal proceeding is not within Ms. Powell’s scope of practice.  Ms. Powell cannot advocate legally for you as she is not a forensic mental health professional.  Ms. Powell is also not available to consult with any other professional entity that is working with you or a family member.  This includes, but is not limited to, attorneys, school diagnosticians, probation officers, psychiatric hospitals, IOP or RTC staff, etc.  Ms. Powell will give you copies of the client’s plans of treatment.  You are free to distribute those plans as you wish.  

Questions must be answered honestly on all forms.  Ms. Powell cannot work with a caregiver or a client who is abusing substances.  This includes alcohol and marijuana. 

Telehealth Agreement

Until further notice, telehealth is provided at Beth Powell’s In-Family Services.  There will be no recordings of any of the online sessions by any party.  Ms. Powell must know your physical location during a telehealth call should you have an emergency. 

The privacy laws that protect the confidentiality of your protected health information also apply to telehealth.  Ms. Powell is a professional who values your time, your focus, and your respect for her services and expertise.  You must join the telehealth call from a location that is private.  Grocery stores, teacher’s lounges, waiting rooms, hair salons, ball parks, etc. are not private.

As well, under no circumstances can you join the remote meeting with Ms. Powell while you are in a moving vehicle.  This is unprofessional and unsafe.  Ms. Powell requires your full concentration during her sessions with you.  Multi-tasking during these remote meetings is also prohibited.  This includes but is not limited to cooking, eating, texting with friends, cleaning house, quilting, etc.  

To summarize, a telehealth appointment requires the same conduct as a brick and mortar “live” appointment.

If the above professional courtesies and confidentiality protocols are not respected, Ms. Powell reserves the right to terminate the client-therapist relationship immediately.

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:

If you have a question or other information that does not pertain to the form you are completing, you must call with that question or other information. You may NOT send an email with that question or other information. This includes all forms of email, encrypted and non-encrypted.

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 cancel by phone call or text only!!

Please Identify yourself when sending texts.

You may NOT contact Ms Powell via any form of social media.

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, in Texas (TX License Number 18222), I will contact TX BHEC at 1-800-821-3205 or go to bhec.texas.gov/discipline-and-complaints/index.html.  For Lucy (Beth) Powell, Mississippi LCSW (MS License Number C10405) I will contact MBOE 601-987-6806 or at swmft.ms.gov//complaints.

There are no risks, only potential benefits to treatment

at Beth Powell’s In-Family Services.

By submission of the below information, I (we) acknowledge I (we) have read, understood and agreed to the above information and have made a copy for my (our) records. Any information that was unclear has been explained.

I (we) Name of Responsible Party:

Caregiver of:

The initial appointment has been scheduled for:

From: 123456789101112  000510152025303540455055 AMPM 

To approximately: 123456789101112  000510152025303540455055  AMPM 

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

Today's Date: January 25, 2025

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Document name: Consent to Treatment Form

Unique Document ID: 37bb9b56fe3c575e03df5e27ff7a4846659b690f

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Timestamp	Audit
January 27, 2017 10:16 am CST	Consent to Treatment Form Uploaded by Beth Powell - bethpowell@therapysecure.com IP 70.139.88.25

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