Journey Assistance Counseling – Therapy for Individuals & Couples

Today's Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Cell Phone*
Work Phone
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Age*
Birth Place*
Best time to contact you*
Employer and current position*
How long have you worked with this organization?
What is your level of satisfaction with your occupation?
What is the highest level of Education you have achieved?
Health insurance provider and ID number*
Primary Subscriber Name (if different from client)*
Subscriber DOB*

MEDICAL HISTORY
Please describe any current/recent medical problems that might be relevant to your reason for seeking counseling*
Are you currently receiving any medical treatment? If yes, please describe*
Please list all medications you are currently taking & the reason for taking (even if seldom used)*
Name of Medication, Dosage and Reason for Taking
Are you taking these medications according to the doctor’s recommendations?*
- Yes
- No
If no, please explain

Consent*
I consent to JAC providing mental health treatment
INFORMED CONSENT FOR MENTAL HEALTH TREATMENT

As a client of JAC, you are not required to accept treatment from JAC at any time, and you have the right to decline part or all of your treatment, including withdrawal from services
should you not be willing to participate.

The Counselor-client relationship is a professional relationship engaged in for the purposes of working on client-identified goals, using the professional and academic experience of the counselor and the relationship built in sessions. While the relationship may be significant, it is in no way of a personal or romantic nature.

As your counselor I will do my best to assist you. Counseling is a collaborative process, and
there are no guarantees that you will be satisfied with your treatment.

I understand and consent to Journey Assistance Counseling (JAC) having one medical record for
me. I understand that my counselor will have access to all clinical notes in my clinical record.
Signature*
Date*
MM slash DD slash YYYY

Consent*
I have read and agree to all Policies and Procedures
POLICIES AND PROCEDURES

Welcome to Journey Assistance Counseling (JAC). The purpose of JAC mental health treatment is to help you achieve your goals and overcome any obstacles that led you to seek counseling with JAC. This treatment will include various mental health treatment modalities. You are encouraged to work with me in the development of your treatment plan and you should be informed of the process
of any new modes used within your treatment process. The associated risks of mental health counseling are limited. You may experience some emotional difficulty, which I will do my best to assist you in working through. The benefits to be gained from counseling include improved outlook
on life, more effective coping skills, greater understanding of yourself, and better communication tools that will have positive effects on your relationships, as well as in many spheres of your life.

1. CONFIDENTIALITY

All information obtained/derived by the course of treatment is fully confidential; disclosures you share with your therapist are confidential. Exceptions to this guideline include instances when 1) the patient is a clear danger to (a) themselves or (b) others and, 2) instances when the patient is a minor (under the age of 18) and reports that he or she is or has been a victim of physical or sexual abuse, and 3) there is any suspected abuse to a child or adult. In the event you wish information to be released to a third party, you must first consult with the therapist in order to discuss purpose and format so the therapist can decide
whether to comply with the request. There may be a fee associated with release of information, which will be determined and paid prior to release of the information.

2. ELECTRONIC COMMUNICATIONS

Electronic communications via email, text, or social media are not secure or confidential. Unauthorized users or hackers can access electronic communications via malicious software (e.g., spyware) or a virus stored on any computer unbeknownst to you. Many people are still
comfortable using electronic communications because of installed firewalls or internet security protection software to detect spyware, viruses, or threats. However, there is no
guarantee that such programs provide 100% protection.

Sent and received email or text messages are stored on both JAC and your electronic devices until deleted. JAC does not conduct therapy via email or text message. Communications via email or text will be limited to administrative purposes (e.g. scheduling, billing and payment questions). JAC will maintain records of all email communications in a password-protected account with encryption capacity, accessed only by representatives of JAC. I understand the disclosures listed above regarding electronic communications, give permission for JAC to send (i.e. initiate or reply) email or text messages to me, and accept the above stated risks that confidentiality cannot be assured.

3. TELEPHONE CALLS

Occasionally the need to talk to your therapist may arise between normally scheduled sessions. It is difficult to conduct psychotherapy over the telephone but I will respond to your call during normal business hours. If there is an emergency, call 911, 988, or go immediately to your local Emergency Room.

4. LENGTH OF SESSION

The psychotherapy session is about 45-50 minutes in length beginning at our appointed time (75 minutes sessions may be prearranged). Sessions must end 45-50 minutes after the appointment time regardless of your arrival time (full fee for the session will be charged).

5. FEES AND PAYMENT

All copays are due at the time of service. We accept cash (exact amount), debit and credit cards. Fees associated with correspondence written on behalf of the client and in cases where the therapist decides to release file documents will be assessed based on the nature of
the request.

6. INSURANCE

We will bill your insurance company for all sessions unless otherwise agreed upon. Please note that you are responsible for payment in cases where your insurance company does not pay for our services.

If your insurance changes or terminates, please call JAC as soon as possible to provide your new information. Your failure to notify us will result in the claim being denied from the insurance company and you will be held responsible for the entire fee.

7. CANCELLATIONS AND MISSED APPOINTMENTS

When an appointment is scheduled, that time is reserved for you. It is your responsibility to provide at least 24 hours’ notice if you must miss or cancel your appointment. A
late cancellation fee of $100.00 will be charged each time an appointment is missed or cancelled with less than 24 hours’ notice. This fee is assessed regardless of the reason for canceling or missing the originally scheduled appointment and is subject to change. Please note that most insurance carriers do not cover missed appointment fees. Clients with “standing” session slots (weekly, every other week and/or monthly) will lose their
slot if they establish a pattern of session cancellations.

8. INCLEMENT WEATHER POLICY

The therapist is responsible for determining if the weather is too hazardous to commute to your practice location. If I decide to hold the session as originally scheduled, you are
expected to show and will be charged a cancellation fee for missed appointments. If I decide to cancel your session, I will contact you to inform you of the change.

I trust that your experience with Journey Assistance Counseling will be helpful and profitable to you. If you have any questions regarding these policies or other aspects of your relationship, please discuss them with me immediately. My signature certifies that I have read, understand, and have been given a copy of the Policies and
Procedures document.
Signature*
Date*
MM slash DD slash YYYY

Consent*
I consent to the Privacy Notice
PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE PORTABLILITY AND ACCOUNTABILITY ACT OF 1996 (HIPPA) that prescribes legal duties and privacy practices to protect the privacy of your individual identifiable health information; this is, Protected Health Information (PHI), as that term is defined in the HIPPA under Information.

THE EFFECTIVE DATE OF THIS NOTICE IS APRIL 14, 2003. Journey Assistance Counseling (JAC) is required to follow the terms of this Notice until it is replaced. JAC may
make changes to the terms of this Notice at any time. Upon your request, we will provide you with a copy of the current Notice. JAC reserves the right to make the changes apply to your Information maintained in our files before, and after, the effective date of the new Notice. The following is a general description of how Federal and State law permits us to use and disclose your Information. Purposes for which JAC May Use or Disclose Your Mental Health Information with

Your Consent to Treatment

Treatment. JAC will use and disclose your Information to provide, coordinate, or manage your mental health care and any related services. JAC may disclose your Information to
physicians, therapists, other mental health providers, or other health care providers who are treating you or assisting in your diagnosis, treatment or recovery.

Payment. Your Information will be used and disclosed, as needed, to obtain payment for your mental health care services. This may include certain activities that your health insurance plan undertakes before it approves or pays for the mental health care services we recommend
for you; such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and utilization review activities. If more than one third-party payer is responsible for payment for your health care, JAC may disclose your Information to more than one health plan and those health plans may share your Information with each other. Your Information may also be used and disclosed as
needed to obtain payment for mental health care services rendered to you by other providers.

Mental Health Care Operations. JAC may use or disclose, as needed, your Information in order to support delivery of mental health care services. JAC may call you by name in the waiting room area. JAC may use or disclose your Information, as necessary, to contact you to schedule an appointment or remind you of your appointment.

JAC may share your Information with third party Business Associates who perform various administrative services. For example, those within JAC, or with whom JAC contracts, who perform billing services, transcription services, record retention, or other professional
consultants. Whenever an arrangement between a Business Associate and JAC involves the use or disclosure of your Information, we will have a written contract that contains terms that will protect the privacy of your Information.

Business Associates: JAC may share your information with third party Business Associates who perform various administrative services. Whenever an arrangement between a Business Associated and JAC involves the use or disclosure of your information, we will have a written
contract that contains terms that will protect the privacy of your information.

Health Care Services. Your Information may be used and disclosed to contact you and to give you information about treatment alternatives or other health benefits and services that may be of interest to you.

Uses and Disclosures With Your Written Authorization
Except as provided below, your Information will not be used for any non-routine purposes unless you give your written authorization to do so. If you give written authorization to use or disclose your Information for a purpose that is not described in this Notice, then, with certain exception, you
may revoke it in writing at any time. Your revocation will be effective for the Information JAC maintains, unless JAC has taken action in reliance on your authorization.

Uses and Disclosures Without Your Consent

As required by law

To comply with legal proceedings, such as a court or administrative order or subpoena To law enforcement officials for limited law enforcement purposes
To avert a serious threat to your health or safety or the health or safety of others To a governmental agency authorized to oversee the mental health care system or
government programs To federal officials for lawful intelligence, counterintelligence, and other national security purposes To public mental health authorities for public health purposes

Your Rights

You may make a written request to JAC to do one or more of the following concerning your

Information:

Put additional restrictions on use and disclosure of your Information
Communicate with you in confidence about your Information by a different means than JAC
is currently doing
See and get copies of your Information, including this notice
Receive a list of disclosures of your Information that JAC has made for certain purposes,

which includes exceptions for disclosure made directly to you or made pursuant to your
authorization

If you want to exercise any of these rights or require further information about privacy practices, please contact me at the address above. JAC is not required in all instances to agree to your request for release of information to third parties. Should we agree to provide information to a third
party, JAC will give you the necessary information and forms for you to complete and return to request your Information. JAC is permitted, by law, to charge you a fee for copying any documents requested in accordance with your rights as listed above. (Fee $2.00 per page, and is subject to change.)

Complaints

If you believe that JAC violated your privacy rights, you have the right to complain to me or to the Secretary of the U.S. Department of Health and Human Services (DHHS). You may file a written complaint with me at the address above. An individual must file a complaint within 180 days of when he/she knew or should have known that the act or omission occurred, unless the time limit is waived by the Secretary of DHHS. JAC will not retaliate against you if you choose to file a complaint.

PRIVACY NOTICE ACKNOWLEDGEMENT

As a client of Journey Assistance Counseling, I acknowledge that I have been given the Privacy
Notice required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of my individually identifiable health information, by Journey Assistance Counseling.
Signature*
Date*
MM slash DD slash YYYY

Consent*
I agree to the Financial Policy

FINANCIAL POLICY

Out of Pocket Fees, Copayments and Deductibles:

Payment is expected at the time service is rendered. All payments are to be made by cash or
credit card.

Insurance payments only:

I/we understand that even though Journey Assistance Counseling is billing my/our insurance that I/we are responsible for any balance that insurance does not cover.

All balances on accounts will be collected from clients within 45 days after insurance has been billed. This means that Journey Assistance Counseling is giving your insurance company 45 days to pay the claim. The law states that it must be processed within 30 days
of receipt.

After 45 days, you are responsible to pay Journey Assistance Counseling directly. We will give you a receipt, which you can provide to your insurance company for reimbursement.

I/we understand that by signing this form, I/we agree to pay Journey Assistance Counseling any unpaid balance on my/our account in a prompt manner.
Signature*
Date*
MM slash DD slash YYYY

Consent*
I agree to the Telehealth agreement form
TELEHEALTH (VIDEO/PHONE) COUNSELING AGREEMENT

The purpose of this form is to obtain your consent to participate in telemental health, which involves counseling by phone, video, or secure online email portal.

Participating in telehealth sessions is based on compliance with the following:

• If we are connecting by video, I will send you a link to sign in to my secure and HIPAA-compatible video platform. You don't need to set up an account of any kind in advance. It is OK to "arrive" early -- I will connect with you at the time of the session.
• I will be in a private location where I am alone in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where others can hear you, I cannot be responsible for your confidentiality.
• At the start of the session, I may verify your location (street address). This enables me to send help, if needed, and to verify that you are in-state. I can only provide therapy to you while you are in the state where I am licensed (Maryland). If I do not ask, please be sure to tell me if you are not at your home.
• Do not invite others to join us for any part of the session without discussing this with me in advance.

For video sessions: If we lose our video connection during our session, please quit and restart your search engine (or computer), and sign in again to the video platform. If you can't reconnect, call my office number (see first page of this agreement), If I do not hear from you within 5 minutes, I will call and email you. I will remain available during the time of our scheduled session, so we can reconnect and continue, if possible.

Billing for a disrupted session: If the disconnection is due to my service or equipment, I will not charge you for the session, or will prorate it for what time we talk. If the disconnection is due to your service or equipment, you will be charged in full for the session (not just a copayment).

Security: To ensure the security of the telehealth sessions we will I utilize video software and hardware tools that adhere to security best practices and legal standards for the purposes of protecting your privacy. Addionally, please comply with the following security requirements:

• It is not recommended that you communicate using a public wireless network.
• You represent that you are not using someone else's device or your employer's computer, since employers have the right to monitor their equipment and networks, which could compromise your privacy.
• You have the sole responsibility for security and privacy of your devices, equipment, and internet connection.

No sessions will be recorded by me, and the telehealth platform provider. Please note that recording or screenshots of any kind of any session are not permitted, and are grounds for termination of the client-therapist relationship.

Payments for services must be made prior to our session or the day of the session. I will charge your credit card on file on the session date. If you have insurance and I am on your insurance provider list, I will bill insurance on your behalf, but you remain responsible for any portion they do not pay.

Session Cancellations: Phone/video sessions are treated as in-office sessions when it comes to late cancellations and no-shows -- 24-hour advance notice is required, otherwise you will be charged the applicable fee.

Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.

Consent to Participate in Telehealth Sessions
By signing below, you agree that you have read and understand all of the above. You agree and understand the limitations associated with participating in telehealth sessions and consent to attend sessions under the terms described in this document.
Signature*
Date*
MM slash DD slash YYYY
Printed Name*
Printed Name

Card Holder Name*
Address*
Street Address Address Line 2 City State ZIP Code
Card Number*
Expiration Month*
Expiration Year*
Security Code*
Consent*
I agree to the Financial Policy.
I authorize Journey Assistance Counseling to bill my credit/debit card for the amount shown for services indicated below and/or for any ongoing balances on my account, including transaction service fees ($3 flat rate), until I terminate this authorization in writing. I also acknowledge that I am responsible for providing updated credit card information upon expiration or other change.
Signature*
Date*
MM slash DD slash YYYY

Client Intake Form

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