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663 N. Dixie Blvd Ste K Radcliff, KY 40160

Ph: 270-806-0015 │Fax: 502-430-2416 admin@serenitycounselingky.org

www.serenitycounselingky.org

IN-PERSON INTAKE AND ANNUAL FORMS

Informed Consent for Therapy This notice describes the process of therapy, including methods and roles of therapist and client.

1. The purpose of therapy is to gain self-awareness, achieve personal growth, and improve overall mental and emotional health. Goals and treatment modalities are tailored to the specific client and his/her needs and will be discussed throughout the treatment process. You, as the client, are expected to actively participate in treatment planning and review of goals throughout the therapeutic relationship.

2. You have the right to privacy and confidentiality throughout the counseling process and none of your protected health information will be released without your written consent, unless otherwise required by law. Conditions that will require confidential information to be released include suspected child abuse or neglect; suspected elder abuse or neglect; or if you are at risk to harm yourself or someone else. If any of these conditions arise, you will be informed of the process to report the risk to the appropriate authorities.

3. We will not participate in court proceedings on your behalf, do not make custody recommendations, do not complete disability evaluations, and will not release information to courts without a signed subpoena from a judge. If you are currently involved in a custody, CPS, disability, or criminal case please inform your provider immediately so that we can make appropriate referrals to clinicians who are equipped to provide these services.

4. We can be reached during business hours by phone, text message, or email. If you are unable to reach your therapist by phone, you may leave a message on our confidential voicemail for a return phone call within two business days. If you choose to

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email or text, you acknowledge understanding of the risks of confidentiality through these electronic methods. If you have a mental health emergency outside of normal business hours, you should call 911 or the National Suicide Prevention Lifeline at 1-800-273-8255.

5. If a third party, such as an insurance company, is paying for part of your bill, your therapist is normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. Diagnoses will be discussed with the client and will be informed by objective and subjective assessment.

6. As you have willingly entered into the therapeutic process, you have the right to terminate therapy at any time. Terminating therapy is a process in itself, so consulting with your provider prior to ending therapy is preferred.

7. We understand that circumstances may occur that prevent you from attending your appointments, but we appreciate notice if you are not able to attend scheduled appointments. Please note that any no call/no show appointment will result in a $25 fee. Please call or email prior to your appointment to avoid incurring any fees.

8. This agreement may be modified or amended as required by law or in the course

of health care operations. ____ I HAVE READ AND UNDERSTOOD THIS INFORMED CONSENT AND AGREE TO ENTER INTO TREATMENT WITH SERENITY COUNSELING, LLC. Late Cancellation/No-Show Policy We understand that circumstances may occur that prevent you from attending your appointments, but we appreciate notice if you are not able to attend scheduled appointments. When a session is cancelled without adequate notice, we are unable to fill this time slot by offering it to another current client or a client on the wait list. We are also unable to bill your insurance company for sessions that are not kept. In order to provide the best care to all clients, please be aware of the following:

You must call, email, or text your provider at least 12 hours prior to your scheduled appointment time to avoid incurring any fees.

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Late cancellations and no call/no-show appointments will result in a $25 fee that must be paid prior to scheduling your next appointment.

If you arrive more than 15 minutes late for your appointment, it will be considered a no-

show appointment and you will have to reschedule. This may also result in a no-show fee.

You may be discharged from services following two (2) no call/no show appointments. Full payment of fees will be required before re-initiating services with our office.

____ I ACKNOWLEDGE UNDERSTANDING OF THE LATE CANCELLATION/NO SHOW POLICY FOR APPOINTMENTS AND I WILL BE RESPONSIBLE FOR ANY FEES INCURRED.

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about resuming in-office services in light of the COVID-19 public health crisis. As mental health professionals, we understand the need to continue services with as little interruption as possible and the importance of face-to-face contact with your therapist. These guidelines have been set into place to protect you, the client, and your therapist. Please read this carefully and let your therapist know if you have any questions. When you sign this document, it will be an official agreement between you and your therapist.

Office safety precautions in effect:

1. The waiting area has been eliminated, which will require clients to wait in their car until they are alerted by their therapist to enter the building.

2. Your therapist will wear a mask where social distancing is not feasible, or at your request. 3. Restroom soap dispensers are available, and we observe hand washing between clients. 4. The office, furniture, and doorknobs will be sanitized between each client. 5. Appointments will be scheduled at intervals to minimize the number of people in the office

simultaneously. 6. Hand sanitizer is provided upon entering and leaving the office.

Decision to meet face-to-face: You and your therapist have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic, your therapist may require that you meet via telehealth. You understand that if your therapist deems it necessary to return to telehealth, it will be to benefit the well-being of all involved. If you decide at any time that you would feel safer or more comfortable with telehealth, we will provide that service as long as it is feasible and clinically appropriate. Reimbursement for telehealth services is determined by insurance companies and applicable law, so coverage may change in the future, but this will be discussed with you as soon as possible.

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Risks of opting for in-person services: You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus.

Client responsibility to minimize exposure: To obtain in-person services, you agree to take certain precautions which will keep everyone (you, your provider, our families, and other clients) safer from exposure, sickness, and potential death. If you do not adhere to these safeguards, it may result in returning to telehealth services.

By initialing this form, you agree to observe the following precautions:

1. You will only keep your in-person appointment if you are symptom free. This includes elevated temperature, cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell.

2. You will wait in your car until you are alerted by your therapist to enter the building. 3. You will use hand sanitizer when you enter the office. 4. You will adhere to safe social distancing with no physical contact. 5. You will wear a mask when social distancing is not feasible. 6. You will try not to touch your face or your eyes with your hands. 7. You will not bring anyone with you to the appointment unless clinically necessary. 8. You will take steps in between your appointments to minimize your exposure to COVID. 9. If you come in contact with any symptomatic person, or anyone who tests positive for the virus,

you will immediately inform your therapist to resume telehealth services.

These guidelines may change according to local, state, or federal orders.

___ I HAVE READ AND AGREE TO THE TERMS OUTLINED IN THE INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS.

Insurance Billing Agreement I authorize the release of any information to my insurance carrier(s) necessary to process my claim, including but not limited to my protected health information as described in the HIPPA Privacy Policy. I authorize my insurance company to pay benefits to Serenity Counseling, LLC (Tax ID # 81-4839674). I further agree to pay all non-covered expenses in accordance with Serenity Counseling, LLC’s policies. Our office will provide you with an initial estimation of insurance benefits, but it is the

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client’s responsibility to know and understand their insurance coverage. The insurance company determines covered services and copay/deductible amounts, so if you have questions about your insurance coverage it is best to call the number on your insurance card. Clients are also responsible for informing our office of any insurance changes. I agree that a reproduced copy of this authorization is as valid as the original. ___ I HAVE READ AND AGREE TO THE TERMS OUTLINED IN THE INSURANCE BILLING AGREEMENT.

Credit Card Authorization

We require you to provide your credit/debit card information on file with us so we can automatically charge any co-pays, co-insurance, deductible amounts, and professional service charges such as late cancelation or missed appointment charges. All credit card data is tokenized and encrypted, protecting private payment information from tampering. We store financial information and other protected health information in an encrypted, HIPAA compliant site. The site is compliant with the Payment Card Industry Data Security Standard (PCI-SS), a set of data security requirements established and governed by Visa®, MasterCard®, American Express®, and Discover® to protect cardholder account information.

Please visit: https://www.pcisecuritystandards.org/ for more information.

Payment is required at the time of service. We provide regular statements for your account balance via mail or through the patient portal. It is the client responsibility to keep cards accurate and up to date. You may pay your balance in session with your therapist, or by check or cash. If balance accrues and no payment is received, we reserve the right to seek payment by using the credit/debit information we have on file. We may be willing to work out a client payment plan that includes a reasonable period for resolving the balance. If the client balance remains unpaid, we reserve the right to suspend services until the balance is paid in part or in full.

___ I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND AGREED TO THIS CREDIT CARD AUTHORIZATION POLICY.

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Consent to Release Information Form

Client Name: _______________________________DOB: ___________________

Phone Number: ______________________

Mental Health Professional/Primary Care Physician

☐ I authorize Serenity Counseling, LLC to communicate with the mental health professional/primary care physician stated below.

Facility Name: _______________________________________________________

Facility Address: ______________________________________________________

Facility Phone Number: ________________________________________________

☐ I decline authorization Serenity Counseling, LLC to communicate with my mental health professional/primary care physician.

☐ I have not seen another mental health professional in the last six months

☐ I do not currently have a Primary Care Physician.

General Information

☐ I grant permission for my protected health information to be released to/from:

Name: ________________________________________________________________

Address: _______________________________________________________________

Phone Number: _________________________________________________________

Purpose: ☐ Emergency Contact ☐ Party Responsible for Billing

☐ Other: ______________________________________________________

Information to be released: ________________________________________________

☐ I do NOT grant permission for my protected health information to be released.

I understand that protected health information such as assessment, diagnosis, treatment plan, and progress notes may be released upon request to/from the above indicated person for the purpose outlined above. I understand that I can revoke this request for release of information at any time. This release of information will remain in effect from one year of the original signature date.

_______________________________________ _______________________

Individual or Legal Representative (please print) Date

_______________________________________ _______________________

Signature of Individual or Legal Representative Date

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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review carefully.

1. Your medical records are used to provide treatment, bill and receive payments, and conduct healthcare operations. Examples of these activities include but not limited to review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal used outlined above except required by law or authorized by the patient or legal

2. Federal and State laws require abuse, neglect, domestic violence and suicidal or

homicidal threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further harm.

3. Disclosed information will be limited to the minimum necessary. You may

request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.

4. You, or your legal representative, may request your records to be disclosed to

yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at any time. Psychotherapy notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records are stored off site.

5. You may request corrections to your records.

6. A request for disclosure may be denied under the following circumstances:

disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.

7. If a request for disclosure is denied for reasons outlined in Section 6, you or your

legal representative may request review of the denial. A review will be conducted by

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another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.

8. You may request that we restrict uses and disclosures outlined in Section 1.

However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while required by law or in an emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement.

9. If you wish to complain about privacy related issues you may contact the

Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington DC, 20201. In any case there will not be any retaliation against you or your legal representative for filing a complaint.

10. This agreement may be modified or amended as required by law or in the course

of health care operations. ___ I HAVE READ AND UNDERSTOOD THIS PRIVACY NOTICE AND MY RIGHTS CONCERNING USE AND DISCLOSURE OF PROTECTED HEATLH CARE INFORMATION.

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) Not at all

Several days

More than half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a failure or

have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the

newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead or of hurting

yourself in some way 0 1 2 3

FOR OFFICE CODING 0 + + +

=Total Score:

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

P A T I EN T H E AL TH Q U E S T I O N N A I R E - 9 ( P H Q - 9 )

Generalized Anxiety Disorder 7-item (GAD-7) scale

Date: _______________ Name: _____________________________________ DOB: _______________

Over the last 2 weeks, how often have you been

bothered by the following problems? Not at

all Several

days Over half

the days Nearly

every day

1. Feeling nervous, anxious, or on edge0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it's hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might

happen

Add the score for each column

Total Score (add your column scores) =

0 1 2 3

+ + +

If you checked off any problems, how difficult have these made it for you to do your work, take

care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder.

Arch Inern Med. 2006;166:1092-1097.