Consent for Services – Adult

Consent for Services

This form is called a Consent for Services (the “Consent”). Your health professional (“therapist”) at Samaritan Center (“Samaritan Counseling Center”, “SCC” or the “Center”) has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, please contact us at 717-560-9969.

THE THERAPY PROCESS: Therapy is a collaborative process where you and your therapist will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your therapist have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their therapist. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit. Therapy begins with the intake process. First, you will review Samaritan Counseling Center’s policies and procedures, talk about fees, and identify emergency contacts. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your therapist is practicing under the supervision of another professional at SCC, your therapist will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your therapist may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your therapist’s office or through video, called telehealth. Participation in therapy is voluntary – you can stop at any time.

It is our belief that we can best assist you if your treatment is coordinated with other health care professionals who are treating you. In order to accomplish this, with your permission, we will initiate contact with your primary care provider or other pertinent providers.

Samaritan Counseling Center is a faith-aware organization and we have expertise in including client’s faith/spiritual beliefs and practices as a part of the therapeutic process. It is our philosophy to work within the belief system of the client. The Center’s therapists do not impose their personal beliefs upon clients and only include discussion of spirituality/religion/faith according to the expressed preference of the client.

CONFIDENTIALITY: Samaritan Counseling Center will not disclose your personal information without your permission unless required by law. If your therapist must disclose your personal information without your permission, your therapist will only disclose the minimum necessary to satisfy the obligation. There are a few times that your therapist may not keep your personal information confidential.

• If your therapist believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your therapist can explain more if you have questions.
• If your therapist has reason to believe a minor is a victim of abuse or neglect (including the viewing of child pornography), they are required by law to contact the appropriate authorities.
• If your therapist believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your therapist will work with you to discuss other options to keep you safe.

There may be times where a spouse, family member, or friend, participates in therapy to assist in your treatment. These persons would not be considered a patient, and therefore would not need to consent to treatment, would not be given a diagnosis or treatment plan, nor would they have any right to access your chart without your written consent.

Please remember that in order to bill your insurance company for your services, information must be provided to your insurer. In most cases, this information is the diagnosis code for your treatment here but an insurer, as the payor, may request additional information, such as a treatment plan or progress notes. We release the minimum amount of information required for compliance. In situations such as worker’s compensation or an auto accident claim, your record from each session must accompany each claim for each date of service. Like Samaritan Counseling Center, your insurer must comply with privacy practices as a part of the Health Insurance Portability and Accountability Act (HIPAA).

FEES AND PAYMENT FOR SERVICES: All fees for services received at the Samaritan Counseling Center are your responsibility. Since insurance coverage is variable, SCC cannot guarantee what services will be covered by any insurance plan. SCC requests that you contact your insurance company for benefit information related to outpatient mental health.

If SCC is a contracted provider with your insurance company, a co-pay and/or co-insurance and/or deductible amount will be expected at the time of each session. Co-pays/co-insurance/deductibles are determined by your insurance company and your plan. If your payment is determined to be incorrect upon receipt of the Explanation of Benefits from the insurance company, you are responsible for any underpayment; SCC will refund any overpayments. Clients are responsible for any annual deductible. Please obtain co-pay, co-insurance, deductible and mental health benefits information from your insurance company prior to the first appointment.

If SCC is not a contracted provider with your insurance company, payment in full will be expected at the time of each session. An itemized receipt will be given to you at each session for submission to your insurance company. Please refer to the fee schedule:

• Initial Evaluation $180.00
• Ongoing Session (38-52 minutes) $120.00
• Abbreviated ongoing session (16-37 minutes) $85.00
• Extended ongoing session (greater than 53 minutes) $150.00
• Ancillary Services: $100 per hour. Not billable to insurance (see above).
• Vouchers from Partner Churches are worth one session – session can be one initial evaluation or one ongoing session.

We accept Mastercard/Visa/Discover/AmericanExpress, check made payable to Samaritan Counseling Center or cash. A $15 service charge will be levied on all checks returned by a bank for insufficient funds. Samaritan Counseling Center requests that you keep a valid credit or debit card on file through this patient portal (see the Payment Authorization Form). This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

NO-SHOW AND LATE CANCELLATION FEES: If you are unable to attend therapy, you must contact Samaritan Counseling Center or your therapist at least 24 hours before your session. This can be accommodated by speaking with someone or leaving a voice mail. Otherwise, you may subject to fees. For cancellations or reschedules made with less than 24 hours notice or for a missed appointment, clients will be charged $40. If two or more appointments are missed, cancelled or rescheduled with less than 24 hours notice, clients will be charged $80. Insurance does not cover these fees. Unforeseen emergency situations will be taken into account.

BALANCE ACCRUAL: Full payment is due at the time of your session. If you are unable to pay at that session, discuss this with your therapist. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.

FEE SUBSIDIES: Thanks to Samaritan Counseling Center’s generous donors, in the case of special financial need, a subsidized fee may be arranged with the therapist as funds are available. Payment of the client’s portion of the fee is to be made at each session.

ADMINISTRATIVE FEES: Your therapist may charge administrative fees for requested services beyond the typical standard of care such as (but not limited to) records review from another provider or school, writing a letter or report at your request; or consulting with another healthcare provider or other professional outside of normal case management practices. These services are billed directly to you at $100 per hour and are not reimbursable by your insurance company. Payment is due in advance.

EMERGENCIES: The Center does not provide emergency services. If a client has an urgent concern, that client’s therapist will try to schedule an appointment with the client as soon as possible. The Crisis Intervention Center (717-394-2631) or your local emergency room are available for emergencies.

TERMINATION: If a client makes the decision to terminate counseling, Samaritan Counseling Center requests that a termination session be scheduled with your therapist. This is to allow time to finish the therapeutic process and to provide adequate aftercare.

CONSULTATION, EDUCATION AND SUPERVISION: Relevant material from the counseling sessions may be discussed with professional staff and consultants for consultation, education, or supervision purposes. All information will be handled professionally and confidentially.

RECORD KEEPING: Samaritan Counseling Center is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

ARTIFICIAL INTELLIGENCE (AI): As part of Samaritan’s commitment to provide the best possible services, your therapist may utilize artificial intelligence writing tools that assist in generating clinical documentation. The AI tools Samaritan utilizes prioritize the privacy and confidentiality of your protected health information (PHI). Your session information is strictly used for the purpose of your ongoing care and your information is subject to strict data privacy regulations and is always secured and encrypted. Additionally, your therapist may ask for your consent to temporarily record your session for the purpose of generating clinical documentation. Sessions will never be recorded without your consent and you may choose to opt-out of recordings or to withdraw recording consent at any time. Recordings are temporary and, until their destruction, are kept secured and encrypted.

TELEHEALTH SERVICES: Videotherapy services involves the delivery of health care services using electronic communications, information technology or other means between a health care provider employed by or otherwise contracted with Samaritan Counseling Center and a client who are not in the same physical location. Videotherapy may be used for diagnosis, treatment, follow-up and/or education, and may include, but is not limited to:

• Electronic transmission of clinical records, photo images, personal health information or other data between a member and a Provider;
• Interactions between a client and Provider via audio, video and/or data communications; and
• Use of output data from clinical devices, sound and video files.

The vendor of the electronic systems used in the provision of Videotherapy Services has represented that it incorporates industry standard network and software security protocols to protect the privacy and security of health information. To use telehealth, you need an internet connection and a device with a camera for video. Your therapist or the intake staff can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your therapist will recommend a different option. There are some risks and benefits to using telehealth:

Possible Benefits of Videotherapy

• Can be easier and more efficient for you to access clinical care and treatment from a Provider.
• You can obtain clinical care and treatment at times that are convenient for you.
• You can interact with a Provider without the necessity of an in-office appointment.

Possible Risks of Videotherapy

• Information transmitted to your Provider may not be sufficient to allow for appropriate clinical decision making by the Provider.
• The inability of your Provider to conduct certain tests or assessments in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency clinical care or treatment for you.
• Your Provider may not able to provide clinical treatment for your particular condition via VideoTherapy and you may be required to seek alternative care.
• Delays in clinical evaluation/treatment could occur due to failures of the video technology.
• Security protocols or safeguards could fail causing a breach of privacy.
• Given regulatory requirements, your Provider’s treatment options may be limited.

Additional Information

• You must have a webcam or a smartphone to utilize Videotherapy services.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be in a quiet, private space that is free from distractions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• It is important to be on time. If you need to cancel or change your Videotherapy session, you must notify the Provider at least 24 hours in advance. Late cancel/missed appointment charges may apply.
• In the event of technical problems, the Provider will contact you via phone number on file.
• Please provide the contact information for at least one emergency contact.

By accepting this Consent to Videotherapy Services, you acknowledge your understanding and agreement to the following:

• I understand that the delivery of health care services via Videotherapy is an evolving field and that the use of Videotherapy in my clinical care and treatment may include uses of technology not specifically described in this consent.
• I understand that while the use of Videotherapy may provide potential benefits to me, as with any clinical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
• It is my duty to inform my Provider of other in-person or electronic interactions regarding my care that I may have with other health care providers.
• I understand that my Provider may determine in his or her sole discretion that my condition is not suitable for treatment using Videotherapy, and that I may need to seek clinical care and treatment in-person or from an alternative source.
• A variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My Provider has explained the alternatives to my satisfaction.
• I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these Videotherapy Services.
• I agree and authorize my Provider and Center to share information regarding the Videotherapy exam with other individuals for treatment, payment and health care operations purposes as allowed by law.
• I understand that I can withhold or withdraw my consent at any time by emailing or providing other such written notification to my Provider with such instruction, without affecting my right to future care or treatment. Otherwise, this consent will be considered renewed upon each new Videotherapy consultation with my Provider.

COMPLAINTS: Client satisfaction and quality of care are of utmost importance at Samaritan Counseling Center. Clients who have a complaint or would like to express concerns are encouraged to discuss the issue directly with their therapist. Clients may also contact the Executive Director or the Clinical Director at 717-560-9969 or the Chair of the Board of Directors in care of Samaritan Counseling Center, 1803 Oregon Pike, Lancaster, PA 17601 in an envelope marked “Confidential”. The Executive Director, Clinical Director or Chair of the Board of Directors will respond to your complaint, in writing, within two weeks of receiving your complaint. The SCC will not retaliate against any person for filing a complaint.

If you feel your Provider has engaged in improper or unethical behavior, you can talk to your provider, the contacts listed above, or you may contact the licensing board that issued your Provider’s license, your insurance company (if applicable), or the US Department of Health and Human Services.

Samaritan Counseling Center locations are smoke, vape, and tobacco-free and weapons-free (knives, firearms, etc.) environments.

ACKNOWLEDGEMENT: My signature on this document represents that I have received the Consent for Services form and that I understand and agree to the information therein.