INFORMED CONSENTS TO RECEIVE TREATMENT
Soul Care Christian Counseling Services provides Outpatient Services for Mental & Behavioral health including Counseling, Psychotherapy, Psychiatric Assessment and Medication Management Services. We provide individual and group services and work with children, teens & adolescents, adults, couples and families.
Our goal is to provide our valued clients with care for the whole person. Soul Care offers an Integrated Team Approach to meet your Mental & Behavioral Health needs. Our staff consists of a Supervising Psychiatrist, Physician Assistant, Professional Counselors, Social Workers, Marriage & Family Therapists, Pastoral Care Counselors and Administrative Personnel . During your first appointment, one of our staff psychiatric clinicians will complete a psychiatric assessment and provide diagnostic and treatment recommendations. Please understand that this first appointment is a consultation and that attending this appointment does not establish a patient-physician relationship with one of our staff psychiatric providers. If indicated, medications may be prescribed or continued for patients currently taking medications but is based on the clinician’s judgment and is not guaranteed. Patients may be referred for counseling services to one of our therapists or outside our office if needed. Our psychiatric providers do not provide urgency or emergency psychiatric evaluations. Please call 911 or present to an ER or urgent care for emergency evaluations.
ACKNOWLEDGEMENTS
By signing, I acknowledge the following:
• I am giving my informed consent to receive treatment at Soul Care Christian Counseling Services. Treatment may consist of Counseling, Psychotherapy, Psychiatric Assessment and Medication Management Services.
• I have been offered the “Notice of Privacy Policies and Clients Rights.”
• I understand Soul Care serves as a training ground for mental health professionals and that I may be seen by an intern who will provide care to me under the supervision of a licensed professional. I authorize the services deemed necessary or advisable by my Clinicians to address my needs.
• I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of Soul Care. I authorize Soul Care to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Soul Care may release objective clinical information related to my diagnosis and treatment that may be requested by my insurance company (if applicable) or its designated agent.
• I authorize and request my insurance plan(if applicable) pay directly to Soul Care the amount due for services rendered to the patient, myself, or others covered by the above insurance plan(s). I authorize the release of any medical, mental health, or substance abuse information necessary to process insurance claims for services rendered. I understand this consent is subject to revocation at any time, except where action has already been taken on the basis of this release. Unless revoked earlier, this consent will be null and void six months after the final payment has been received on this account. This consent is subject to state and federal confidentiality regulations.
• I agree to take full responsibility for the entire amount due for any and all services rendered. If the provider is contracted with my insurance company, I will be responsible only for the co-pay, co-insurance, deductible, and non-covered services as determined by the insurance plan. If I do not inform Soul Care in a timely manner of any changes to my insurance coverage, I understand that I may need to pay for services in full if payment is denied in part or in full by my insurance carrier. I further understand that I may not be able to schedule appointments if my account becomes delinquent and/or my account is turned over to collections.
• I understand that my patient records are the property of Soul Care and shall be treated as confidential; that Soul Care will conduct routine patient audits to insure quality record maintenance; that my records will not be released without my written consent or as provided by the laws of the State where I am receiving treatment. I understand that if I choose to have my records or treatment updates provided to a third party, I must request this in writing using Soul Care “Authorization for Use and Disclosure of Protected Health Information” form or another acceptable form, with the exception of information I have agreed to release per this Acknowledgement.
• I acknowledge that if I need to cancel or reschedule an appointment I will provide a minimum of one business day’s notice. Otherwise, I understand that I am subject to a $35 charge for the missed appointment and am responsible for payment in full prior to the next scheduled appointment.
• I attest that I am coming strictly for counseling needs, not for any type of litigation purposes. If in the course of my care, I become involved in litigation and need Soul Care to provide any type of report, testimony or other litigation required services, I understand I am fully responsible for any fees for these services and that these fees are payable in full and in advance of services.
• I acknowledge that Soul Care is not a 24/7 care facility and that I am responsible for seeking care at my nearest emergency center or through another provider of choice when my Soul Care Clinician is not available.
• I certify that all the information I have provided above is true and correct.
• AUTHORIZATION FOR VOLUNTARY TREATMENT: I authorize and agree for Soul Care Christian Counseling Services to administer such treatment as is necessary while I am receiving services. Providers at Soul Care will explain in detail a specific treatment or a change in treatment, such as the use of a therapeutic approach or different medication. I understand I will be offered verbal information and explanation of services being proposed, the intended outcome from my participation in the services, the nature and procedures of the proposed treatment, and the risks and side effects of the proposed treatment. I also understand I will be offered verbal information regarding the risks of not proceeding with the proposed treatment and be informed of alternatives to the proposed treatment. I understand informed consent is voluntary and I may withdraw or modify my consent to treatment at any time in writing.
Our goal is to provide our valued clients with care for the whole person. Soul Care offers an Integrated Team Approach to meet your Mental & Behavioral Health needs. Our staff consists of a Supervising Psychiatrist, Physician Assistant, Professional Counselors, Social Workers, Marriage & Family Therapists, Pastoral Care Counselors and Administrative Personnel . During your first appointment, one of our staff psychiatric clinicians will complete a psychiatric assessment and provide diagnostic and treatment recommendations. Please understand that this first appointment is a consultation and that attending this appointment does not establish a patient-physician relationship with one of our staff psychiatric providers. If indicated, medications may be prescribed or continued for patients currently taking medications but is based on the clinician’s judgment and is not guaranteed. Patients may be referred for counseling services to one of our therapists or outside our office if needed. Our psychiatric providers do not provide urgency or emergency psychiatric evaluations. Please call 911 or present to an ER or urgent care for emergency evaluations.
ACKNOWLEDGEMENTS
By signing, I acknowledge the following:
• I am giving my informed consent to receive treatment at Soul Care Christian Counseling Services. Treatment may consist of Counseling, Psychotherapy, Psychiatric Assessment and Medication Management Services.
• I have been offered the “Notice of Privacy Policies and Clients Rights.”
• I understand Soul Care serves as a training ground for mental health professionals and that I may be seen by an intern who will provide care to me under the supervision of a licensed professional. I authorize the services deemed necessary or advisable by my Clinicians to address my needs.
• I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of Soul Care. I authorize Soul Care to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Soul Care may release objective clinical information related to my diagnosis and treatment that may be requested by my insurance company (if applicable) or its designated agent.
• I authorize and request my insurance plan(if applicable) pay directly to Soul Care the amount due for services rendered to the patient, myself, or others covered by the above insurance plan(s). I authorize the release of any medical, mental health, or substance abuse information necessary to process insurance claims for services rendered. I understand this consent is subject to revocation at any time, except where action has already been taken on the basis of this release. Unless revoked earlier, this consent will be null and void six months after the final payment has been received on this account. This consent is subject to state and federal confidentiality regulations.
• I agree to take full responsibility for the entire amount due for any and all services rendered. If the provider is contracted with my insurance company, I will be responsible only for the co-pay, co-insurance, deductible, and non-covered services as determined by the insurance plan. If I do not inform Soul Care in a timely manner of any changes to my insurance coverage, I understand that I may need to pay for services in full if payment is denied in part or in full by my insurance carrier. I further understand that I may not be able to schedule appointments if my account becomes delinquent and/or my account is turned over to collections.
• I understand that my patient records are the property of Soul Care and shall be treated as confidential; that Soul Care will conduct routine patient audits to insure quality record maintenance; that my records will not be released without my written consent or as provided by the laws of the State where I am receiving treatment. I understand that if I choose to have my records or treatment updates provided to a third party, I must request this in writing using Soul Care “Authorization for Use and Disclosure of Protected Health Information” form or another acceptable form, with the exception of information I have agreed to release per this Acknowledgement.
• I acknowledge that if I need to cancel or reschedule an appointment I will provide a minimum of one business day’s notice. Otherwise, I understand that I am subject to a $35 charge for the missed appointment and am responsible for payment in full prior to the next scheduled appointment.
• I attest that I am coming strictly for counseling needs, not for any type of litigation purposes. If in the course of my care, I become involved in litigation and need Soul Care to provide any type of report, testimony or other litigation required services, I understand I am fully responsible for any fees for these services and that these fees are payable in full and in advance of services.
• I acknowledge that Soul Care is not a 24/7 care facility and that I am responsible for seeking care at my nearest emergency center or through another provider of choice when my Soul Care Clinician is not available.
• I certify that all the information I have provided above is true and correct.
• AUTHORIZATION FOR VOLUNTARY TREATMENT: I authorize and agree for Soul Care Christian Counseling Services to administer such treatment as is necessary while I am receiving services. Providers at Soul Care will explain in detail a specific treatment or a change in treatment, such as the use of a therapeutic approach or different medication. I understand I will be offered verbal information and explanation of services being proposed, the intended outcome from my participation in the services, the nature and procedures of the proposed treatment, and the risks and side effects of the proposed treatment. I also understand I will be offered verbal information regarding the risks of not proceeding with the proposed treatment and be informed of alternatives to the proposed treatment. I understand informed consent is voluntary and I may withdraw or modify my consent to treatment at any time in writing.
