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New Client Intake

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PART 1 - Informed Consent for Psychotherapy

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.

Treatment Plans

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.

Confidentiality

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:

If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

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.

Please check the following to signify your agreement and acknowledgement:

(please check box to initial) I have read and fully understand the above Informed Consent for Psychotherapy, including limitations to my confidentiality.

(please check box to initial) I agree to participate in outpatient psychotherapy provided by Bluestone Psychotherapy, PLLC as outlined in my treatment plan. I have been informed of the services in terms that I can understand. I have also been informed of the alleged benefits, potential risks and possible alternative methods of treatment. I understand that I am free to discontinue services at any time.

PART 2 - Notice of Privacy Practices

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:

- Make sure that protected health information (“PHI”) that identifies you is kept private.
- Give you this notice of my legal duties and privacy practices with respect to health information.
- Follow the terms of the notice that are currently in effect.
- I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

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:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

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:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations for judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I 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.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

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.

COMPLAINTS

If 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.

Please check the following to signify your agreement and acknowledgement:

(please check to initial) I have reviewed and understand the Notice of Privacy Practices for BlueStone Psychotherapy, PLLC.

PART 3 - Authorization to Release/Exchange Confidential Information

PLEASE NOTE: You must enter your name and relationship to client below even if you are not authorizing communication/release of information.

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:

to release records by means of written or verbal dissemination

to request information

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:

self

Parent/legal guardian

other (describe)

Please check the following to signify your agreement and acknowledgement:

(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.

Part 4 - Client Records Policy

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.

Confidentiality:

All information shared will be kept confidential with the following exceptions;

If I believe you are a danger to yourself or someone else
If you give me written permission to disclose information
In the case of abuse to a child or an elderly person confidentiality will be waived
If the information is court ordered
In case of a Medical Emergency
These rights are waived if accusations of misconduct are brought

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.

Disability

Bluestone Psychotherapy is a non-disability facility and cannot accommodate wheel chair accessibility at this time.

Please check the following to signify your agreement and acknowledgement:

I have read and fully understand the Client Records Policy.

PART 5 - Your Rights

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:

Ask that printed information explaining your rights be given to you in a way that you can understand.
Know what to do and who to call if you believe someone is trying to take away your rights.

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 know about medication: You have the right to know the possible side effects of medication and to be free from unnecessary or excessive medication. Medication cannot be used as a punishment, discipline or for the convenience of staff.
To accept or refuse services: By law, you can accept or refuse any service, medication, test or treatment. However, during an emergency situation, treatment may be necessary without your permission.
To be involved in the service plan: It is your right to be involved in your treatment plan, which is developed within 15 business days of admission to BlueStone Psychotherapy, PLLC. You have a right to be involved in the development and review of your plan before you sign it and receive a copy of all updated plans. You will not be charged if you need a duplicate copy. You simply need to provide a written request for a copy.
To make certain treatment choices: It is your right to be informed of the potential risks, benefits and alternatives to the treatments being offered to you.

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:

If Medicaid pays for your services, you may appeal the changes through the Division of Medical Assistance. Follow the directions in the written letter for your federal rights. If you appeal the decision by the deadline in the letter, your services will continue during the appeal.
If your services are paid for by state funds (sometimes called IPRS funds), you may appeal the decision to the MCO. If you still are unsatisfied with what the MCO decides, you may appeal to the state DMH/DD/SAS to review the decision. Your services may or may not continue while you are appealing this decision.
If your private insurance company pays for your services you can appeal their decision through your insurance company. If you are unsure how to appeal changes to your services or if you have questions about appeals, contact your MCO customer service office at 1-800-939-5911 or contact the Advocacy & Customer Service Section at DMH/DD/SAS at (919) 715-3197. For all appeals, call the number on your appeal notice.

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:

Assistance with TTY.
Sign language interpretation.
Interpretive services if you do not speak English.
Assistance for the visually impaired.

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 Psychotherapy
Attn: Suzie Jones
17714 Kings Point Dr
Suite B
Cornelius, NC 28031
Telephone: 704-997-5397

suzie@bluestonepsychotherapy.com

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 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD :(800) 537-7697
Email: ocrmail@hhs.gov

North Carolina Division of Mental Health / Developmental Disabilities / Substance Abuse Services
www.ncdhhs.gov/mhddsas
Main: 919-733-7011
DHHS CARE-LINE: 1-800-662-7030 (Voice/Spanish)

Disability Rights NC
3724 National Drive, Suite 100
Raleigh, NC 27612
Toll-Free: 877-235-4210
Phone: 919-856-2195
TTY: 888-268-5535
Fax: (919) 856-2244
Email: info@disabilityrightsnc.org

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(please check to initial) I have read and fully understand my rights and responsibility as a client of BlueStone Psychotherapy, PLLC.

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Signed by BlueStone Psychotherapy, PLLC
Signed On: March 14, 2023

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January 16, 2021 12:03 pm EDT

New Client Intake Uploaded by BlueStone Psychotherapy, PLLC - suzie@bluestonepsychotherapy.com IP 104.139.124.160