THE WELL ROOTED LIFE, LLC - DISCLOSURE STATEMENT AND CONSENT TO
TREAT
The purpose of this document is to allow you, the client and/or
Guardian, to make an informed decision about your treatment. For
clarification about any part of this document, feel free to ask
questions.
Information about your therapist:
The individual therapist who operates this practice is:
Kirsten Powell, LCSW-16086, Licensed Clinical Social Worker
Your therapist will verbally discuss her professional background
with you and provide you with information related to her
experience, education, special areas of practice, and
professional orientation. This practice is committed to your
treatment and believes in a collaborative relationship between
the therapist and the client(s).
Therapeutic
Services:
Psychotherapy varies per
client and their individually identified treatment goals. It is
your therapist's role to evaluate all information provided and
offer therapeutic recommendations that will best address
identified problems and result in progress toward desired goals.
As a client, you have the right to refuse treatment, ask for
clarification of and/or challenge procedures, understand the
goals of therapy, seek a second opinion, or terminate treatment
at any time.
The preference is to see new patients weekly for four to six
sessions to build safety and rapport. After this period, the
frequency of sessions can be re-evaluated and determined at that
time. Session length is 50-60 minutes per session. If you require
more frequent sessions, such as twice per week, the therapist and
the paid billing service representatives can assist in
determining if your insurance will cover more frequent sessions.
If not, private pay is an option.
Psychotherapy involves both risks and benefits. Each person
responds differently to treatment and there are no guarantees
about the outcomes.
Risks Involved:
Talking about highly emotional life experiences, such as trauma,
can elicit strong emotional reactions that can vary from sadness,
anxiety, guilt, and anger. It is highly recommended that should
these reactions be disruptive; you inform your therapist to
schedule an emergency session in which an assessment will be
conducted to determine next steps in treatment.
Benefits Involved:
Individuals participating in psychotherapy often benefit from the
act of sharing and processing life experiences with another
person. Psychotherapy often elicits a feeling of relief resulting
in improved quality of life, acquisition of new coping skills and
perspectives, and improved self-awareness.
Confidentiality:
You have the right to privacy, and all information identifying
you will remain confidential, as require by the legal and ethical
standards set forth by Arizona Board of Behavioral Health. All
communications that occur with your therapist will be maintained
in strict confidence unless you provide written permission to
release information about your treatment.
As a mandated reporter, your therapist is required to break
confidentiality in the following instances:
- danger to self
- danger to others
- elder or vulnerable adult abuse
- physical abuse, sexual abuse, or neglect of a child
- imminent danger
Should any of these situations be identified throughout the
therapeutic process, your therapist will file a report with the
appropriate authorities. Be advised that therapeutic records may
be subpoenaed under a court of law. Should that occur, your
therapist will advise you as such and make records available.
Should you participate in family therapy, your therapist will not
disclose confidential information about your treatment unless all
persons involved in treatment provide their written authorization
to release the information. It is critical to note that your
therapist uses a "no-secret" policy when conducting family
therapy. This policy means that if you participate in family
therapy, your therapist can use information obtained in
individual sessions you may have had with her to aid the
therapeutic process.
Therapist is bound by confidentiality. At times, this therapist
may provide services to family members or receive referrals from
individuals who know one another in personal spheres. In the case
of services provided to family members, each client is treated as
an individual client and confidentiality is strictly enforced for
each client. Confidentiality will only be broken if client is
determined to be a danger to self or others. Parents of minor
children will only be provided therapeutic updates regarding
homework or interventions learned to be a source of support and
encouragement between sessions. No information will be shared
with others without an active Release of Information on file.
In the event a current client makes a referral of
friend/acquaintance to this therapist for services, the therapist
will strictly observe confidentiality for each party and will not
discuss or acknowledge the outside relationship. This
practice will strive not to schedule referred clients at
different times. In the event an overlap occurs, this therapist
will preserve confidentiality and will promptly transfer client
into session.
In the Case of Custody and Guardianship:
Please be advised that strict criterion is observed within this
practice in accordance with Arizona Revised Statutes and Arizona
Board of Behavioral Health requirements.
- Consent for therapeutic services can only be authorized by a
current legal Guardian.
- If parents are separated and share medical decision making,
then consent must be given by both parents.
- For divorced parents, consent may be given by the parent
authorized to make legal medical decisions. If there are joint
decision-making orders in place, both parents are required to
sign consent forms.
- Emails may be used to communicate about therapy issues at the
risk of the legal guardian. Email is not a guaranteed
confidential method of communication. Text messages are not
secure, and therapist may opt not communicate via text.
- You may be requested to provide a copy of your legal documents
identifying you as the parent authorized to make legal medical
decisions.
-The Well Rooted Life, LLC is not a party to any agreement
between parents - legal or informal; therefore, cannot be
responsible for enforcing their terms. This practice has the
right to discharge any client if an issue comes between the
(divorced/separated) parents which would disrupt this practice in
any way. This practice maintains that divorce, separation, and
custody agreements should not enter into the medical care of a
child; such matters should remain between the parents.
Request for Records:
You have a right to your records or a summary of your records as
deemed appropriate by your therapist. Requests must be made in
writing and it may take up to 30 days to obtain your records,
depending on the amount of information requested.
There is a fee for requested documents. Each page costs $1.00 per
page to copy. Records will be mailed at cost of shipping to
client.
Please be advised that therapist has the legal right to omit or
redact any information that may be deemed harmful to the client.
Progress notes are protected documents per HIPPA and are not
legally required to be included in a medical records request.
Therapist has discretion in the release of records and may
require a court order or subpoena, which will be the financial
responsibility of the client.
Therapist will complete forms or write letters on an individual
basis and if it does not relate to topic outside of scope of
practice. Therapist will also provide a treatment summary if
needed. The cost of letters or forms is $50 as they are often
complex in nature.
Confidentiality Specific to Child and Adolescent
Therapeutic Process:
Sometimes child
therapy involves disagreement among parents and/or disagreement
between parents and therapist regarding the best interests of the
child. If such disagreements occur, therapist will strive to
listen carefully so that she can understand your perspectives and
fully explain therapeutic perspective. At times disagreements can
be resolved or both parties "can agree to disagree", so long as
this enables your child's therapeutic progress. Ultimately, you,
as the parent, or guardian, will decide whether therapy will
continue. If either of you decides that therapy should end, that
decision will be honored, however therapist asks that you allow
her the option of having a few closing sessions to appropriately
end the treatment relationship.
Therapy is most effective when a trusting relationship exists
between the therapist and the client. Privacy is especially
important in securing and maintaining that trust. One goal of
treatment is to promote a stronger and better relationship
between children and their parents. However, it is often
necessary for children to develop a "zone of privacy" whereby
they feel free to discuss personal matters with greater freedom.
This is particularly true for adolescents who are naturally
developing a greater sense of independence and autonomy. By
signing this agreement, you will be waiving your right of access
to your child's treatment records.
It is this practice's policy to provide you with general
information about treatment status. Therapist will raise issues
that may impact your child either inside or outside the home. If
it is necessary to refer your child to another mental health
professional with more specialized skills, therapist will share
that information with you. Therapist will not share with you what
your child has disclosed without your child's consent. Therapist
will tell you if your child does not attend sessions.
If your child is an adolescent, it is possible that he/she will
reveal sensitive information regarding sexual contact, alcohol
and drug use, or other potentially problematic behaviors.
Sometimes these behaviors are within the range of normal
adolescent experimentation, but at other times they may require
parental intervention. It is important that direct discussion
occurs about your feelings and opinions regarding acceptable
behavior. If therapist believes that your child is at serious
risk of harming him/herself or another, therapist will inform you
immediately.
Although therapist's responsibility to your child may require
involvement in conflicts between the parents, it is critical that
both parents agree that therapist involvement will be strictly
limited to that which will benefit your child. This means, among
other things, that you will treat anything that is said in
session with the therapist as confidential. Neither parent will
attempt to gain advantage in any legal proceeding between the two
of you from therapist involvement with your child/children.
Therapist asks your agreement that in any such proceedings,
neither party will ask therapist to testify in court, whether in
person, or by affidavit. You also agree to instruct your
attorneys not to subpoena therapist or to refer in any court
filing to anything therapist has said or done in the confines of
the therapeutic relationship.
Note that such agreement may not prevent a judge from requiring
therapist's testimony, even though therapist will work to prevent
such an event. If therapist is required to testify, therapist is
ethically bound not to give an opinion about either parent's
custody or visitation suitability. If the court appoints a
custody evaluator, guardian ad litem, or parenting coordinator,
therapist will provide information as needed (if appropriate
releases are signed or a subpoena is provided), but therapist
will not make any recommendation about the final decision.
Furthermore, if therapist is required to appear as a witness, the
party responsible for therapist participation agrees to reimburse
at the following rates which are non-negotiable:
Telephone Consultation (per 15 minute
segments)
$100.00
Appearance / Court Testimony (per
hour)
$450.00
Record review, subpoena response, report writing (per
hour)
$450.00
Client/attorney or attorney staff consultation (per
hour)
$450.00
Deposition lasting between one and four hours (per
hour)
$650.00
Deposition rate for each additional hour after first four hours
(per hour)
$450.00
Conciliation consultation (parenting advisors,
etc.)
not available
Therapeutic visitation (4 hours paid in advance)
not available
(Any part of an hour-no reimbursement if session is stopped)
Travel time reimbursement rate, rounded up to next hour (per
hour)
$200.00
Mileage (per mile)
$2.00
Payment/Cancellation Policy:
This practice accepts insurance currently. Any payment such as
copayments, late cancellation, no call/no show, or deductibles is
required at the time of service. The card on file can be used to
collect unpaid balances by insurance even after discharge. If
this occurs, you will be notified prior to charging your card on
file and a receipt will be sent for your records.
Payment methods accepted include cash, personal check, and
credit/debit cards. A super bill can be created for you to submit
to your HSA or out of network health insurance provider. This
will be provided to you at your next scheduled appointment if
requested. Private pay options are also available or a sliding
scale if needed. This practice utilizes an outside billing
service, CF Medical Management, and this agency may have access
to your records solely to assist with billing for services
rendered.
All returned checks will have a charge of $25 dollars and all
fees associated with returned check. If more than two checks are
returned, you will be required to make all future payments in
cash only. Immediate reimbursement will be required before a new
appointment can be scheduled.
If you need to cancel an appointment, you are expected to contact
your therapist at least 48 hours prior to your scheduled
appointment. If you do not provide at least 48-hour notification
in advance, you may be responsible for the full fee of the missed
session. The credit card on file will be charged the full price
session cost that day. If your credit card on file is declined,
it will result in cancellation of future appointments until
balance is paid in full. Should you fail to pay any outstanding
balances, your account may be sent to a collections agency and
addition costs will be incurred by the client.
If you fail to attend your appointment it will be identified as a
"no show." Greater than 15 minutes late to your appointment is
also considered a "no show" and the remainder of the appointment
may be cancelled at your therapist's discretion. You will be
responsible for the full fee of the session at appointment
regardless of length of session. Should you have two or
more "no shows" your therapist reserves the right to terminate
you as a client with the practice and may assist in locating
other clinicians if requested.
If missed appointment is related to a genuine emergency,
therapist reserves the right to waive all outstanding fees and
may request proof of documentation from client.
Therapist may confirm your appointment via email, which is not a
secure form of communication. If you choose not to receive
appointment confirmation via email, please inform therapist. You
will also receive non-email reminders from the practice via
secure client portal, CounSol.
Therapist does not prefer to communicate via text messages as
they are not secure, and confidentiality cannot be ensured.
However, due to the fact that text is a common form of
communication in today's age writer will correspond as long as it
is related to scheduling or coordination of services.
Good Faith Estimate
You have the right to receive a "Good Faith Estimate" explaining
how much your medical care will cost. Under the law, health care
providers need to give patients who don't have insurance, or who
are not using insurance, an estimate of the bill for medical
items and services.
You have the right to receive a Good Faith Estimate for the
total expected cost of any non-emergency items or services. Make
sure your health care provider gives you a Good Faith Estimate in
writing at least 1 business day before your medical service or
item. You can also ask your health care provider, and any other
provider you choose, for a Good Faith Estimate before you schedule
an item or service. If you receive a bill that is at least $400
more than your Good Faith Estimate, you can dispute the bill. Make
sure to save a copy or picture of your Good Faith Estimate. For
questions or more information about your right to a Good Faith
Estimate, visit www.cms.gov/nosurprises or call us at 602-833-2019.
Therapist Availability and Emergencies:
You may leave a message for your therapist at any time on
voicemail. If you wish to receive a return call, please be sure
to leave a message including your name, contact phone number,
best time to return the call, and nature of the matter. Your
therapist will return your call within 24 - 48 hours.
A temporary break in treatment may be necessary when your
therapist is ill, on vacation, or has a personal emergency.
Therapist will return calls upon return to office. Please note
that advance notice of appointment cancellations or rescheduling
will be offered as far in advance as is possible.
In the event of a medical emergency please contact 911. Should
you be experiencing a mental health crisis please contact
602-222-9444.
NOTICE OF PRIVACY PRACTICES
I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
II. THERAPIST HAS A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED
HEALTH INFORMATION (PHI).
This practice is legally required to protect the privacy of your
PHI, which includes information that can be used to identify you.
This information can be obtained from documents you have provided
to this practice, documentation that has been created in
accordance with legal and ethical standards, documentation
received from other sources, or written information about your
past, present or future health conditions, the provision of
health care to you, or the payment of this health care. Therapist
must provide you with this Notice about my privacy practices, and
such notice must explain how, when, and why practice will "use"
and "disclose" your PHI. A "use" of PHI occurs when practice
shares, examines, utilizes, applies, or analyzes such information
within this practice; PHI is "disclosed" when it is released,
transferred, has been given to, or is otherwise divulged to a
third party outside of my practice. With some exceptions,
therapist may not use or disclose any more of your PHI than is
necessary to accomplish the purpose for which the use or
disclosure is made. And, therapist is legally required to follow
the privacy practices described in this notice. However,
therapist reserves the right to change the terms of this notice
and privacy policies at any time. Any changes will apply to PHI
on file with practice already. Before therapist makes any
important changes to policies, practice will promptly change this
notice and post a new copy of it in my office and on client
portal (if applicable). You can also request a copy of this
notice from me, or you can view a copy of it in office or on
portal (if applicable).
III. HOW THERAPIST MAY USE AND DISCLOSE YOUR PHI.
Therapist will use and disclose your PHI for many different
reasons. For some of these uses or disclosures, therapist will
need your prior written authorization; for others, however,
therapist does not. Listed below are the categories of uses and
disclosures along with some examples of each category.
A. Uses and Disclosures Relating to Treatment, Payment, or Health
Care Operations Do Not Require Your Prior Written Consent.
Therapist and 3rd Party Biller, Cuub Med Management, can use and
disclose your PHI without your consent for the following
reasons:
1. For Treatment and Coordination of Care. Therapist can use your
PHI within practice to provide you with mental health treatment
and whole health education, including discussing or sharing your
PHI with billers. Therapist can disclose your PHI to physicians,
psychiatrists, psychologists, and other licensed health care
providers who provide you with healthcare services or are
involved in your care. For example, if a psychiatrist is treating
you, therapist can disclose your PHI to your psychiatrist to
coordinate your care.
2. To Obtain Payment for Treatment. Therapist can use and
disclose your PHI to bill and collect payment for the treatment
and services provided by therapist to you. For example, therapist
might send your PHI to your insurance company or health plan to
get paid for the health care services provided to you. Therapist
may also provide your PHI to business associates, such as billing
companies, claims processing companies, and others that process
this practice's health care claims.
3. For Health Care Operations. Therapist can use and disclose
your PHI to operate practice. For example, therapist might use
your PHI to evaluate the quality of health care services you
received or to evaluate the performance of the health care
professionals who provided such services to you. Therapist may
also provide your PHI to my attorney, accountant, consultants, or
others to further this practice's health care operations.
4. Patient Incapacitation or Emergency. Therapist may also
disclose your PHI to others without your consent if you are
incapacitated or if an emergency exists. For example, your
consent is not required if you need emergency treatment, as long
as therapist tries to get your consent after treatment is
rendered, or if therapist tries to get your consent but you are
unable to communicate (for example you are unconscious or in
severe pain) and therapist thinks you would consent to treatment
if you were able to do so.
B. Certain Other Uses and Disclosures Also Do Not Require Your
Consent or Authorization. Therapist can use and disclose your PHI
without your consent of authorization for the following
reasons:
1. When federal, state, or local laws require disclosure. For
example, therapist may have to make a disclosure to applicable
governmental officials when a law requires mandated report
information to government agencies and law enforcement personnel
about victims of abuse or neglect.
2. When judicial proceedings require disclosure. For example, if
you are involved in a lawsuit or a claim for workers'
compensation benefits, therapist may have to use or disclose your
PHI in response to a subpoena.
3. When law enforcement requires disclosure. For example,
therapist may use or disclose your PHI in response to a search
warrant.
4. When public health activities require disclosure. For example,
therapist may have to use or disclose your PHI to report to a
government official an adverse reaction to a medication.
5. When health oversight activities require disclosure. For
example, therapist may have to provide information to assist the
government in investigating or inspection of a healthcare
provider or organization.
6. To avert a serious threat to health or safety. For example,
therapist may have to use or disclose your PHI to avert a serious
threat to the health or safety of others. However, any such
disclosures will only be made to someone able to prevent the
threatened harm from occurring.
7. For specialized government functions. If you are in the
military, therapist may have to disclose your PHI for national
security purposes, including protecting the President of the
United States or conducting intelligence operations.
8. To remind you about appointments and to inform you of
health-related benefits or services. For example, therapist may
have to use or disclose your PHI to remind you of your
appointments, or give you information about treatment
alternatives, other health care services, or other healthcare
benefits that I offer that may be of interest to you.
C. Certain Uses and Disclosures Require You to Have the
Opportunity to Object.
1. Disclosures to Family, Friends, or Others. Therapist may
provide your PHI to a family member, friend, or other person that
you indicate is involved in your care or the payment for your
health care, unless you object in whole or in part. The
opportunity to consent may be obtained retroactively in emergency
situations.
D. Other Uses and Disclosures Require Your Prior Written
Authorization. In any other situation not described in sections
III A, B, and C above, therapist will need your written
authorization before using or disclosing any of your PHI. If you
choose to sign an authorization to disclose your PHI, you can
later revoke such authorization in writing to stop any future
uses and disclosures (to the extent that I haven't taken any
action in reliance on such authorization) or your PHI by me.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI. You have the
following rights with respect to your PHI.
A. The Right to Request Restrictions on Practice Uses and
Disclosures. You have the right to request restrictions or
limitations on uses or disclosures of your PHI to carry out
treatment, payment, or health care operations. You also have the
right to request that therapist restrict or limit disclosures of
your PHI to family members or others involved in your care or who
are financially responsible for your care. Please submit such
requests to practice in writing. Therapist will consider your
requests but is not legally required to accept them. If therapist
does not accept your requests, therapist will put them in writing
and will abide by the law, except in emergency situations.
However, be advised, that you may not limit the uses and
disclosures that therapist is legally required to make.
B. The Right to Choose How Therapist Sends PHI to you. You have
the right to request that therapist send confidential information
to you at an alternative address (for example sending it to your
work address rather than your home address) or by alternative
means (for example, email or text instead of regular mail).
Therapist must agree to your request so long as it is reasonable
and you specify how or where you wish to be contacted and, when
appropriate, you provide therapist with information as to how
payment for such alternative communications will be handled.
Therapist may not require an explanation from you as to the basis
of your request as a condition of providing communications on a
confidential basis.
C. The right to inspect and receive a copy of your PHI. In most
cases, you have the right to inspect and receive a copy of the
PHI that therapist has, but you must make the request to inspect
and receive a copy of such information in writing. If therapist
doesn't have your PHI but therapist knows who does, therapist
will tell you how to get it. Therapist will respond to your
request within 30 days of receiving your written request. In
certain situations, therapist may deny your request. If request
is denied, therapist will tell you, in writing, the reasons for
the denial and explain your right to have the denial
reviewed.
If you request copies of your PHI, therapist will charge you no
more than 25 cents for each page. Instead of providing you the
PHI you requested, therapist may provide you with a summary or
explanation of the PHI as long as you agree to that and the cost
in advance.
D. The Right to Receive a List of the Disclosures Therapist Has
Made. You have the right to receive a list of instances, i.e. an
Accounting of Disclosure, in which therapist has disclosed your
PHI. The list will not include disclosures made for my treatment,
payment, or health care operations; disclosures made by you;
disclosures you authorized; disclosure permitted to or required
by federal privacy rule; disclosures made for national security
or intelligence; disclosures made by correctional institutions or
law enforcement personnel; or disclosures made before April 14,
2003.
Therapist will respond to your request for an Accounting of
disclosures within 60 days of such request. The list therapist
provides will include disclosures made in the last six years
unless you request a shorter time. The list will include the date
the disclosure was made, to whom the PHI was disclosed (including
address if known), a description of the information disclosed,
and the reason for the disclosure. I will provide the list at no
charge, but if you make more than one request in the same year, I
may charge you a reasonable, cost based fee for each additional
request.
E. The Right to Amend Your PHI. If you believe there is a mistake
in your PHI or that a piece of important information is missing,
you have the right to request I correct the existing information
or add the missing information. You must provide your request or
the reason for your request in writing if the PHI is (i) correct
and complete, (ii) not created by me, (iii) not allowed to be
disclosed, or (iv) the information is not part of my original
records. My written denial will state the reasons for the denial
and explain your right to file a written statement of
disagreement with the denial. If you don't file one, you have the
right to request that your request and my denial be attached to
all full disclosures of your PHI. If I approve your request, I
will make the change to your PHI, tell you that I have done so,
and tell others that need to know about the change to your
PHI.
F. The Right to Receive a Paper Copy of this Notice. You have a
right to receive a paper copy of this notice and/or receive it
via email.
V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you believe therapist may have violated your privacy rights,
or you disagree with a decision therapist made with regard to
accessing your PHI, you may file a formal complaint with the
Secretary of the Department of Health and Human Services at 200
Independence Ave S.W., Washington, D.C.20201. This practice will
take no retaliatory against you if you file a complaint regarding
privacy practices.
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES
By signing this form, you acknowledge receipt of the Notice of
Privacy Practices provided in this document. Please feel free to
copy this document after signing and retain for your records.
This Notice of Privacy Practices provides you information about
how this practice/therapist may use and disclose your protected
health information. Please read it in its entirety as it is
updated yearly to be in accordance with current legal
requirements.
This Notice of Privacy Practices is subject to change. If a
change is implemented, you may obtain a copy of the revised
notice for your personal records. At that time, you will be asked
to sign a new acknowledgement of receipt to keep in your personal
file.
This signature is an acknowledgment of the receipt of the Privacy
Practices for The Well Rooted Life, LLC and Kirsten Powell, LCSW,
CWHE, CIMHP.