New Client Intake
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
Within 15 business days of your initial assessment appointment, your therapist will discuss with you their working understanding of the problem and collaborate with you in developing your treatment plan, which will be used to guide your treatment. As needed but at least annually, your therapist will meet with you to review the goals on your treatment plan and strategies to promote effective treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your therapist’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. At any time, you may submit a written request for a copy of your treatment plan to your therapist.
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on April 1, 2015. Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of this HIPPA Notice of Privacy Practices.
COMPLAINTSIf you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Bluestone Psychotherapy, PLLC, 17714 Kings Point Dr (Suite B), Cornelius, NC 28031 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling 877-696-6775. We will not retaliate against you for filing a complaint.
I, , hereby authorize:
BlueStone Psychotherapy, PLLC, 17714 Kings Point Dr, Suite B, Cornelius, NC
To communicate with or release information to:
In the following manner:
The information to be used will be limited to the following (check any that apply):
verbal or written communication between professionals dates of treatment attendance diagnosis test results treatment progress clinical and medical documentation other (specify)
Your relationship to client:
(please check to initial) I understand that the medical or mental health record to be released may contain information pertaining to psychiatric and/or substance abuse diagnosis and treatment, and may also contain confidential HIV (AIDS) – related information. I understand that the information released by this consent shall not be further released in any way to any other person, entity, or others without additional written consent from me. I understand that I may withdraw this consent at any time prior to the release of the above information. I understand that if I am signing as the parent of a minor or as a guardian, the records release may contain references to myself and my family. I understand that I may revoke this consent to release information at any time prior to the stated expiration. I also understand that any release made between the time I authorized it and then revoked it shall not constitute a breach of my right to confidentiality. This consent, if not withdrawn, will expire one year from the date of signature.
Bluestone Psychotherapy shall maintain each client record that they are providing service to and each individual shall contain, but need not be limited to: an identification face sheet that will include, client’s name (last, first, middle, maiden), client record number, date of birth, ethnicity, gender, marital status, admission date, discharged date, documentation of mental illness, developmental disabilities or substance abuse diagnosis coded according to DSM-5. Records will also include documentation of screening, assessment, and treatment plan. Emergency information should be on file for client including name, address and number of person to be contacted in case of sudden illness or accident and name, address and number of client’s preferred physician.
There should be a signed statement from the client or legally responsible person granting permission to seek emergency care from a hospital or physician. All services provided should be documented, progress toward outcomes. If applicable, physical disorders, diagnosis according to International Classification of Diseases will be documented along with any medication orders, orders, copies of lab tests and documentation of medication and administration errors and adverse drug reactions.
Bluestone Psychotherapy shall ensure that information relative to HIV/AIDS or related conditions are disclosed only in accordance with the communicable disease laws as specified in G.S. 130A-143.
Client records documentation and management will be responsibility of Bluestone Psychotherapy. Bluestone uses a management tool called Office Ally. All staff will have individual usernames and passwords to be able to obtain access to records. Each staff member is responsible for keeping all client records securely locked in their own file cabinets along with locks outside of their personal office to prevent unauthorized persons from entering. Staff will provide assurance of record accessibility to authorized users at all times and assurance of confidentiality of records. The authorized users at this time are Suzie Jones (Clinician) and Jessica Panzica (Office Manager/Insurance).
In exceptions to confidentiality the following are listed along with other exceptions listed in the citation NC policy G.S.122C 52-56.
All information shared will be kept confidential with the following exceptions;
Even under these circumstances only essential information will be revealed and as much as possible you will be informed before confidentiality is broken. In the event the client is a minor, parents or legal guardians may be included in the counseling process as is appropriate, however measures will be taken to safeguard confidentiality, always acting in the best interest of the client.
Staff Training in HIPPA
Bluestone Psychotherapy provides training in HIPPA during the orientation process and requires that all staff be acknowledgeable of the practice’s HIPPA laws, Notice of Privacy, Intake Process and Client’s Rights, Responsibility and Confidentiality. These trainings will be reviewed during the staff meetings every six months to ensure staff is updated on all laws and regulations pertaining to mental health practice.
Bluestone Psychotherapy is a non-disability facility and cannot accommodate wheel chair accessibility at this time.
As an individual receiving services from BlueStone Psychotherapy, you have the following rights:
To be informed of your rights: By law, you must be informed of all of your rights when receiving services from Bluestone Psychotherapy. You also have the right to:
To know what is expected of you: You must be told about any rules you need to follow. This information should be shared with you when you begin receiving services. If you do not receive this information, ask someone you trust to help you obtain this information.
To live as independently as possible: It is your right to receive care in your community in the least restrictive environment suitable to your individual needs.
To always be treated with respect: Staff should be polite, attentive and responsive to your needs.
To have information about you kept confidential: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the federal law that protects your private health information. The HIPAA law states that medical records, treatment plans and any other information about you (including what you say or share) must be kept private. Anyone not involved in providing your care, including family members, must first obtain your or your guardian’s permission before this information is given to them.
To understand and give informed consent: By law, you have a right to treatment, including access to medical care and habilitation, regardless of age or degree of mental illness, developmental disabilities, or substance abuse. When you are making a decision about your treatment, you should have the chance to know the most likely results of your decision and what other choices you have. Making decisions after considering all available options is called “informed consent.” Except during an emergency, informed consent is always your right. Before you give your approval for any service or treatment, be sure you have all of the information you need. This right is based on the idea that you are the person who best knows what works for you. Informed consent includes being given information:
To exercise your rights as a citizen: You have many rights as a citizen. These include buying or selling property, signing a contract, registering to vote, marrying or getting a divorce. Unless the court has declared you incompetent, you will always have these rights.
To make advance instructions: You have the right to a written plan called an “advanced instruction for mental health treatment.” This written plan describes how you want to be cared for if you ever become unable to decide or speak for yourself. You can also name a “health-care power of attorney” in your advanced instruction. This lets another person you have identified make decisions about your care if you become unable to do so. For help in preparing these plans, you should speak with someone you trust.
To review your medical records: You will have the right to review information in your medical records, which includes your service plan. Your therapist may meet with you to discuss sensitive areas of your file prior to your review.
To see a medical care provider: If you are sick or in need medical care, you have the right to treatment.
To know the costs of services: The charges or fees for services you receive should be discussed with you at your first visit. You shall also be given a written copy of the fees. Please speak to your therapist if you have questions about any costs or fees that you may be charged.
To be accepted for treatment: You have a right to receive age-appropriate treatment. Services cannot be denied, interrupted or reduced without good cause. If your services are denied, interrupted or reduced you can appeal the changes to your services.
To freely file an appeal: Before anyone can change your service or deny your request for a service, you will receive a notice explaining your rights. You have a right to appeal any changes to the services you already receive or any services you and your service provider have requested to receive. The way you appeal the changes depends on how your services are funded:
To Request Special Accommodations: If you need help or accommodations to participate in services, you may request: Accessibility and Accommodations: In accordance with federal and state laws, all buildings and programs of the NC Department of Health and Human Services are required to be physically accessible to individuals with all qualifying disabilities. If you need to request an accommodation on behalf of yourself or a family member or a friend, you can contact the MCO customer service representative. If you need more information, you can contact your MCO. Language Assistance including:
To file a grievance if you feel your rights are violated: If you feel like your rights have been violated, you have the right to express your concerns or file a grievance without retaliation. Please address your concerns to:
BlueStone PsychotherapyAttn: Suzie Jones17714 Kings Point DrSuite BCornelius, NC 28031Telephone: 704-997-5397
If unresolved, you may contact the following agencies:
U.S. Department of Health and Human Services Office for Civil Rights (Southeast Region)Sam Nunn Atlanta Federal Center, Suite 16T7061 Forsyth Street, S.W.Atlanta, GA 30303-8909Customer Response Center: (800) 368-1019Fax: (202) 619-3818TDD :(800) 537-7697Email: email@example.com
North Carolina Division of Mental Health / Developmental Disabilities / Substance Abuse Serviceswww.ncdhhs.gov/mhddsasMain: 919-733-7011DHHS CARE-LINE: 1-800-662-7030 (Voice/Spanish)
Disability Rights NC3724 National Drive, Suite 100Raleigh, NC 27612Toll-Free: 877-235-4210Phone: 919-856-2195TTY: 888-268-5535Fax: (919) 856-2244 Email: firstname.lastname@example.org
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Signed by BlueStone Psychotherapy, PLLC
Signed On: July 9, 2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Client Intake
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