CONSENT TO TREAT

Treatment is most helpful when it takes place in a framework of trust, clarity, and understanding.

This contract is intended to clarify and help this relationship. Should you have any questions concerning this covenant, please discuss them with me

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I agree to participate for the length of time. If I want to withdraw from the program, I agree to discuss this decision with my counselor prior to taking action.

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I understand that there are certain risks in treatment and that there may be alternatives to treatment. I agree to counsel with Discover & Recover Counseling Services, LLC. These services may also include group treatment, psycho-education individual, assessment, diagnostic impressions, and referrals for other needed services.

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I agree that it is essential for me to come to the session drug and alcohol-free. I understand that I will be asked to leave any session to which I come after using drugs or alcohol. I will be asked to arrange transportation home.

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I understand that if I do not have personal issues with chemical dependency, I am seeking treatment, to address how my life is directly affected as a result of a family member who has a chemical dependency problem.

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I understand that I will be expected to practice and implement some of the skills I discuss in treatment. I agree to bring the Practice Exercise sheet as assigned to discuss with my counselor. I agree to successfully complete all treatment goals and objections during the next 12 sessions for the successful completion of your Intensive Outpatient Substance Abuse Treatment program IOP and Supportive Outpatient Substance Abuse Treatment program SOP.

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Discover and Recover Counseling Services, reserves the right to amend the session times and length without notice.

FINANCIAL UNDERSTANDING

I understand that Discover & Recover Counseling Services, LLC does not accept or bill insurance for services provided. I agree to pay $30 for the intake/assessment and $50-$70 per session. Each session typically lasts 45-60 minutes. I agree to attend all sessions and to be prompt. I also agree to call in advance if I will be late for a session.

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Refunds will be given at the discretion of the counselor and only for services not rendered.  No refunds will be given for services rendered as per agencies published refund policy.

Discover and Recover Counseling Services LLC, reserve the right to amend the fees per session without notice.

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CANCELLATION POLICY

You understand if it is absolutely necessary that I you cancel or reschedule a sessionm you agree to notify by email, phone or text Mrs. Hinds,  Mrs. Mackin or Ms. Olivarez at least 24 hours in advance of you not being able to attend any session (group or individual).   You also agree that in the event that you do not give 24 hours notice of an absence, that you will pay $25 per no-show.  You agree to give 24 hours notice to cancel or reschedule your group or individual session via out virtual platform.   You also agree that you accept liability for having to pay $25 for each and every group or individual session where you fail to give 24 hours notice.

Payment for a missed appointment must be paid for prior to the start of the next scheduled appointment. Payments for missed appointments will be accepted online.

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I understand that Discover & Recover Counseling Services, LLC is a drug and alcohol-free facility, and chemical dependency treatment is intended for people who want to abstain from drugs and alcohol. I understand that I must work on remaining abstinent for this program to be most effective.

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LIMITS OF CONFIDENTIALITY

I understand that while confidentiality is central to the process of treatment, it must be broken and a report made to the proper authorities when there is abuse or neglect of children, disabled persons, and the elderly; when there is intent to harm oneself, another, or property; or when a court order is issued.

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TERMINATING TREATMENT

I understand that though I may stop treatment at any time, the ending of treatment is best if discussed with my counselor at least one session before it ends. I have reviewed the above statements with my counselor, and we both agree to abide by them.

PROGRAM GUIDELINES

1. Report all drug and alcohol use to your counselor. Failure to report substance use could result in termination of services.

2. All prescription drugs prescribed by a doctor to a client must be reported to the counselor immediately; clients must bring all medications to the following session.

3. Attend all group, individual, and family sessions.

4. Be on time for all group, individual, and family sessions.

5. Work on your issues. Complete all assignments. Failure to do so could result in program extension.

6. If a client misses any group, individual, and family sessions, they must make them up before completing the program.

7. If a client misses attending three weeks of group and individual sessions, the client is considered for unsuccessful discharge at that time. Clients can reschedule during the same week as their original appointment to avoid behavioral non-compliance contracts and avoid unsuccessful discharge.

Due to the flexibility, this program offers, missing sessions are not an option without justifiable reasons with proof in writing. Therefore, if a client misses a week of class, the client is placed on a non-compliance behavioral contract. The second missed week client’s probation officer is contacted, and the client is placed on another non-compliance behavioral contract. Suppose the client misses the third week of class. In that case, the client is placed on another non-compliance behavioral contract, probation is contacted, and the client is staffed for possible unsuccessful discharge at that time.

8. If a client relapses and is forthcoming about their relapse, their program is considered for a higher level of care (residential treatment) or program enhancement - the client must inform their probation office within 24 hours. If the client fails to report a relapse, the counselor will intervene and inform the probation officer of the client’s relapse.

9. If a client has a second relapse, the client’s probation officer will be contacted by the counselor. The client will be staffed (treatment team) and considered for a higher level of care (residential treatment).

10. If a client needs to cancel or reschedule an appointment, the client must provide the counselor notice as follows:

1.  1-hour sessions require a 2-hour notice

2.  2-hour sessions require a 24-hour notice

If notice is not provided client will be given a no-show and is responsible for covering the group and individual sessions missed at the same rate as their regular session. The client must pay payments for missed appointments must be paid for before the start of the next scheduled appointment. Discover & Recover will accept payments for missed appointments taken over the phone or in person.

11. If a client is going to be late for scheduled group and individual sessions, they are given a 15-minute grace period.

If the client has not arrived within the grace period or does not attend, the client is given a no-show and is responsible for covering the session missed at the same rate as their regular session cost. Group and individual sessions are mandatory to complete their IOP/SOP program.

12. If a client does not attend a session (group or individual) for 14 consecutive days, the client will be automatically unsuccessfully discharged from their IOP/SOP Program.

13. Clients must attend their group and individual sessions as scheduled - No Exceptions.

14. If a client has accumulated four non-compliance of any kind during their program/episode of care, the client will be staffed (treatment team) and considered for unsuccessful discharge.

15. If the following circumstances occur client is given a no-show that will not count against them:

1.    Inclement weather

2.    Unforeseen circumstance

16. IOP/SOP clients must attend groups as scheduled by Discover and Recover Counseling Services, LLC.

17. Client should not use any alcohol-based hand sanitizer before any session.

18. Discover & Recover Counseling Services, LLC reserve the right to perform random drug screens as a standard procedure. The client agrees to comply with random drug screens provided by Discover & Recover Counseling Services, LLC as a requirement of their program. If a client does not comply or refuses to take the drug screen when requested, the client will be staffed (treatment team) and considered for termination of their services for non-compliance with program guidelines.

19. Clients are responsible for their belongings, possession, and documents during attendance of group, individual, and family sessions and assessments. Counselor, staff, and Discover & Recover Counseling Services, LLC renders all responsibility for the client’s possession and accepts no liability for any loss. The client should ensure that they have all their possession/belongings/documents before leaving Discover & Recover Counseling Services, LLC offices.

20. If you cause destruction and damage to company property, clients can financially replace items broken or damaged. The cost can either be paid upfront or added to their program cost, at the counselor’s discretion. These costs must be paid before the client can complete their program/services with Discover & Recover Counseling Services, LLC. The client will sign an agreement on this fact.

21. The use of profanity is prohibited on the property.

22. Verbal or physical abuse (to self or others, being rude, racial remarks, or threats of any kind) is not tolerated and can result in immediate termination of services.

23. Disrespecting or flirting with staff members will not be tolerated and can result in immediate termination of services (including asking for their cell/home phone number, physical/verbal sexual gestures, sexist remarks, or sexual remarks about them, their body, or their attire).

24. Do not ask personal questions of staff members (where you live, the car you drive, do you have a family, etc.) as your purpose for treatment is to get treatment. Please focus on the successful completion of your program goals and objectives.

25. No texting or talking on the cell phone during class unless related to the class discussion.

26. If you email us please give us up to 24 hours to respond.

DRESS CODE:

1. Hats turned backward, sagging pants, etc., are prohibited. Clients will be asked to correct their attire or be sent home and given a no-show.

2. Clothing that is revealing but not limited to low-cut blouses, miniskirts, rear cheek revealing shorts, etc., is prohibited.

Discover and Recover Counseling Services, LLC reserve the right to amend these conditions without notification.

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CLIENT RIGHTS

This agency adheres to a strict policy related to client rights.  All clients are informed of their rights in writing, upon admission, and their rights, and protections.  All staff is required to protect client rights.  Should a staff member violate clients’ rights, he/she may be subject to civil and criminal prosecution.

Below is a listing of client rights:

1)            You have the right to accept or refuse treatment after receiving this explanation.

2)            If you agree to treatment or medication, you have the right to change your mind at any time (unless specifically restricted by law).

3)            You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.

4)            You have the right to be free from abuse, neglect, and exploitation.

5)            You have the right to be treated with dignity and respect.

6)            You have the right to appropriate treatment in the least restrictive setting available that meets your needs.

7)            You have the right to be told about the program’s rules and regulations before you are admitted.

8)            You have the right to be informed before admission:

·               the condition to be treated.

·               the proposed treatment.

·               the risks, benefits, and side effects of all proposed treatments and medication.

·               the probable health and mental health consequences of refusing treatment.

·               other available treatments and which ones, if any, might be appropriate for you; and ·the expected length of stay.

9)            You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.

10)          You have the right to meet with staff to review and update the plan regularly.

11)          You have the right to refuse to take part in research without affecting your regular care.

12)          You have the right not to receive unnecessary or excessive medication.

13)          You have the right to have information about you kept private and be told when your data can be released without your permission.

14)          You have the right to be told in advance of all estimated charges and any limitations on the length of services of which the facility is aware.

15)          You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.

16)          You have the right to make a complaint and receive an appropriate response from the facility within a reasonable amount of time.

17)          You have the right to complain directly to the Department of State Health Services at any reasonable time.

18)          You have the right to get a copy of these rights before you are admitted, including the address and phone number of the Department of State Health Services.

19)          You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being admitted.

Should agency staff restrict a client’s right to free communication, the physician or program director shall document the clinical reasons for the restriction and the duration of the limitation in the client record. The physician or program director shall also inform the client and, if appropriate, the client’s consenter of the clinical reasons for the restriction and the duration of the limitation.

I have read and understand and will uphold client rights to the federal, state, and agency standards to the best of my ability.

LIMITS OF CONFIDENTIALITY

Contents of all treatment and counseling sessions are considered to be confidential.  Unless you authorize disclosure, no information about you or the records of your sessions will be given to third parties, except under the circumstances below:

Duty to Warn and Protect:  If you disclose intentions or a plan to harm another person, I am required to warn the intended victim and report this information to legal authorities.  If you reveal or imply a suicide plan, the staff is required to notify legal authorities and make reasonable attempts to inform your family.

Abuse of Children and Vulnerable Adults:  If you state or suggest that a child (or vulnerable adult) is being abused, has recently been abused, or is in danger of being used, I must report this information to the appropriate social service and legal authorities.  If you disclose that a previous therapist has been sexually exploitive, I am required to report this information to the appropriate licensing and legal authorities.

Court orders:  If a judge requires compliance with a court order or subpoena, I am required to provide information in connection with a legal proceeding.

Minors/Guardianship:  Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers (when applicable):  Insurance companies and other third-party payers are given the information they request regarding clients’ services.  Information that may be requested includes, but is not limited to, types of services, dates/times of service, diagnosis, treatment plan, description of impairment, the progress of therapy, case notes, and summaries.

**Occasionally, we may have an intern preparing to be a licensed clinician and gain experience.  This may involve observing and conducting substance abuse treatment and counseling group and individual and family sessions.

CLIENT GRIEVANCE PROCEDURE

The policy of Discover & Recover Counseling Services, LLC shall make every effort to resolve a client’s grievance fairly and equitably. All client grievances will be investigated and resolved promptly by the Department of State Health Services (DSHS).

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1.            Discover & Recover Counseling Services, LLC shall be aware of a client’s needs and pay close attention to those situations that could lead to a grievance situation. Clients may grieve directly to Discover & Recover Counseling Services, LLC. Clients may grieve about any violation of client rights or DSHS standards.

2.            Staff members shall make every effort to resolve the grievance informally by discussing the situation or circumstances with the client.

3.            Staff members involved shall not be included in the grievance investigation or decision-making concerning the grievance.

4.            Clients who cannot resolve their grievances by discussion must put their written grievances, including date and signature.

5.            Discover & Recover Counseling Services, LLC will provide pens, paper, envelopes, postage, and access to a telephone upon request to file a complaint. Discover & Recover Counseling Services, LLC shall assist clients who cannot read or write or have difficulty reading and writing.

6.            Discover & Recover Counseling Services, LLC will acknowledge receipt of the grievance within 24 hours and investigate the grievance and interview the client as necessary.

7.            A written report of the investigation and initial disposition shall be made to the client by Discover & Recover Counseling Services, LLC, or the designee within seven days.

8.            A client who is still dissatisfied may appeal to the governing authority, and a written report of the decision will be forwarded to DSHS with a written response given to the client within 30 days.

9.            There shall be no retaliation, formal or informal, against a grieving client.

10.          Discover & Recover Counseling Services, LLC shall retain complete records of all grievances in a confidential file for three years, but not in a client’s case file.

11.          Clients may submit their grievance at any time directly to:

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Office of Attorney General

Consumer Protection Division

P O Box 12548

Austin, TX 78711-2548 (512) 463-2185

Texas Department of Insurance (TDI)

800.252.3439

Department of State Health Services

P.O. Box 149347 Austin, TX 78714 (800) 832-9623

Texas Department of Human Services Hotline:

(800) 252-5400

DARS Service Number: (800) 628-5515

U.S. Department of Health and Human Services

Office for Civil Rights

50 United Nations Plaza, Room 322 San Francisco, CA 94102

(415) 556-8730 / TDD (415) 556-8586

GENERAL INFORMATION

The confidentiality of alcohol and drug abuse client records maintained by Discover & Recover Counseling Services, LLC (DRC) is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. § 132d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2. Generally, Discover &

Recover Counseling Services, LLC (DRC) may not say to a person outside the program that you attend the program, disclose any information identifying you as an alcohol and/or drug user, or disclose any other protected information except as permitted by federal law.

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DRC must obtain your written consent before it can disclose information about you for payment purposes. For example, DRC must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before DRC can share information for treatment purposes or for health care operations. However, federal law permits TSC to disclose information without your written permission:

1. Pursuant to an agreement with a qualified service organization/ business associate;

2. For research, audit, or evaluation;

3. To report a crime committed on DRC premises or against DRC personnel;

4. To medical personnel in a medical emergency.

5. In connection with treatment, payment (insurance company), or health care operations; 6. To

appropriate authorities to report suspected child or elder abuse and/or neglect;

7. As allowed by a court order.

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Before DRC can use or disclose any information about your health in a manner that is not described above, we must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing.

Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. DRC is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. DRC will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy your own health information maintained by DRC, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal, or administrative proceeding or in other limited circumstances. Under HIPAA you also

have the right, with some exceptions, to amend health care information in DRC’s records, and to request and receive an accounting of disclosures of your health-related information made by DRC during the six years prior to your request. You also have the right to receive a paper copy of this notice.

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YOUR RIGHTS UNDER HIPAA AND THE CONFIDENTIALITY LAW

1. You have the right to have information about you kept private and to be told about the times when the information can be released without your permission. The right to confidentiality is provided for in Title 42, Code of Federal Regulations, Part 2, and HIPAA. You have the right to receive the covered entity’s Privacy Notice.

2. The right to be accorded access to your file and the right to own the information within your file with the exception of psychotherapy notes.

3. The right to request corrections or erroneous and/or incomplete information.

4. The right to prohibit re-disclosure of client information.

5. The right to request the transmittal of communications in an alternative manner.

6. The right to obtain an accounting of disclosures.

7. The right to make a complaint to the Springboard Center’s Privacy Over or the HHS Oce of

Civil Rights without fear of retaliation.

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TREATMENT OBJECTIVES

• Abstinence
• Stay in compliance with program guidelines
• Pay fees
• Complete program goals and objectives on a master treatment plan
• Complete and process assignments
• Implement new skills in daily life

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EXPECTATIONS OF COUNSELOR

• Provide assignments, insight, education, and skills to reduce the risks of relapse and recidivism
• Availability during and between sessions
• A safe and non-judgmental environment with compassion and understanding
• Privacy and confidentially

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THEORETICAL APPROACHES

Cognitive Behavior Therapy (CBT)/Rational Emotive Behavior Therapy (REBT)

“A combination of psychotherapy and behavioral therapy that can be customized to the specific

needs and personality of each client. Introduces a set of principles that they can apply whenever

they need to, and that will last them a lifetime!”

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Person-Centered (PC) “Allows one to find their own answers within themselves”

Motivation Interviewing (MI) “encourages and empowers individuals to change and gain/maintain

self-efficacy”

Solution Focused Therapy (SFT) “Staying out of the problem and in the solution

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Existential Therapy (ET) “Meaning in life”

SERVICES PROVIDED

IOP/SOP Substance Abuse Treatment Programs

Anger Management Program

Drug and Alcohol Awareness Class Program

Addiction Therapy

Substance Abuse Assessments

Individual/family; education and counseling

Aftercare- 6 months

Acudetox (stand-alone as well as incorporated into the IOP program)

SPECIALIZATIONS

PTSD/Trauma

Grief/loss

Family Conflict

Interpersonal Conflict

Depression

Anxiety

Antisocial Attitudes

Antisocial Behaviors

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REVIEWS OF SUCCESSFUL GRADUATES 2017/2018

"I am happier and healthier when sober. I have a new purpose in life and this setback/lesson was probably the best thing that happened to me. I have learned to value my career and I understand that my poor decisions and my disease could lead me to lose my job. I have learned to identify and let go of toxic relationships and replace them with positive people who will support my recovery… "  Anonymous

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"I am growing! I am glad my consequences led me to get and be open to help. Intensive Outpatient Substance Abuse Treatment/Education has helped me identify and be aware of things about addiction and faulty thinking. I see this as an awakening for a better life of not needing a crutch to deal with life, there are coping skills to better manage and understand how to deal with life without

drugs/alcohol… " Anonymous

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"Thank you for the knowledge and enlightenment about my abuse I really appreciate it and believe I'll continue to make use of and apply those skills in my day-to-day activities for the rest of my life, and also keep up with meetings. Thanks so much and look forward to talking to you in the future but not for sessions. Again LOL. Stay blessed ... " Anonymous

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TREATMENT EXPECTATIONS

Purposes, goals, and techniques

• Any restrictions placed on the license by the board.
• The limits on confidentiality; Counselors are required to disclose private information without consent for the following reasons: A client discusses plans to attempt suicide or harm another person, Current and ongoing domestic violence, abuse or neglect of children, the elderly, or people with disabilities, and Court order.
• Any intent of the licensee to use another individual to provide treatment intervention to the client
• Supervised the licensee by another licensed health care professional including the name, address, contact information, and qualifications of the supervisor. The name, address, and telephone number of the board for the purpose of reporting violations of the Act or this chapter
• The established plan for the custody and control of the client’s mental health records in the event of the licensee’s death or incapacity, or the termination of the licensee’s treatment practice.

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The counselor has explained to the client the expectations of treatment and the client understands and agrees.

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CONSENT FOR THE RELEASE OF INFORMATION

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I hereby authorize:

DISCOVER AND RECOVER COUNSELING SERVICES, LLC

2424 Wilcrest Blvd, Houston, TX, 77042

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To disclose to and receive from Harris County Community Supervision & Corrections

Department (HCCSCD) 9111 Eastex Fwy, Houston, TX 77093

(713) 696-2000

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My health information is listed below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), mental illness, chemical or alcohol dependency, laboratory test results, medical history, treatment, and related information. I understand that this information is voluntary, and I may refuse to sign this authorization.

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I understand that if the recipient authorized to receive this information is not a covered entity as defined under federal privacy regulations, the disclosed information, except for chemical dependency information may no longer be protected by federal privacy regulations.

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DESCRIPTION OF INFORMATION TO BE DISCLOSED

• Assessments
• Psychological Evaluations
• Psychiatric Evaluations
• Diagnosis
• Educational
• Medical History
• Treatment Plans
• Medications Prescribed
• Progress Notes
• Financial
• Discharge Summaries
• Physicians Orders
• Laboratory Reports
• Vocational
• Clinical

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DESCRIPTION OF THE PURPOSE OF THE USE AND/OR DISCLOSURE

• Follow-up / Case Management
• Verification of maintaining
• appointments
• Determining Eligibility
• Referral for Treatment
• Continuity of Care
• Monitor Medical Stat
• To Aid in Treatment Planning
• Financial Assistance / Verification
• Medication Verification
• Assess / Monitor Treatment Goals
• Legal Preceding
• At Clients Request
• Other Reasons

You also agree to us using / releasing any financial, attendance and any other documents required for Discover and Recover to respond to refund request and disputed payments to, but not limited to, WIX and SQUARE.​

I understand this authorization will expire in six months.

I understand that I may revoke this authorization at any time by notifying Discover and Recover Counseling Services, LLC in writing. I also understand that the written revocation must be signed and dated later than the date on this authorization. The revocations will not affect any actions taken before the receipt of the written revocation.

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A photocopy of the fax transmission of this authorization is as valid as the original

CONSENT FOR ELECTRONIC RELEASE OF INFORMATION

I hereby authorize:

DISCOVER AND RECOVER COUNSELING SERVICES, LLC

2424 Wilcrest Blvd, Houston, TX, 77042

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To release my, program and treatment documentation via electronic methods, including but not

limited to, email, and text.

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Discover and Recover Counseling Services, LLC ensures that your data is secure at all times. By signing this you authorize Discover and Recover Counseling Services, LLC, and the counselor to send documentation via electronic methods. You acknowledge that you understand the risks involved and that Discover and Recover Counseling Services, LLC has no control over who might see any emails once they are sent, even though they are sent to the email you via secure HIPPA

compliant methods.

My health information is listed below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), mental illness, chemical or alcohol dependency, laboratory test results, medical history, treatment, and related information. I understand that this information is voluntary, and  I may refuse to sign this authorization.

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I understand that if the recipient authorized to receive this information is not a covered entity as defined under federal privacy regulations, the disclosed information, except for chemical dependency information may no longer be protected by federal privacy regulations.

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DESCRIPTION OF INFORMATION TO BE DISCLOSED

• Assessments
• Psychological
• Evaluations
• Psychiatric
• Evaluations
• Diagnosis
• Educational
• Clinical
• Medical History
• Treatment Plans
• Medications
• Prescribed
• Progress Notes
• Financial
• Program Completion
• Certificates
• Discharge Summaries
• Physicians Orders
• Laboratory Reports
• Vocational

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DESCRIPTION OF THE PURPOSE OF THE USE AND/OR DISCLOSURE

• Follow-up / Case Management
• Verification of maintaining appointments
• Determining Eligibility
• Referral for Treatment
• Continuity of Care
• Monitor Medical Status
• To Aid in Treatment Planning
• Financial Assistance / Verification
• Medication Verification
• Assess / Monitor Treatment Goals
• Legal Preceding
• At Clients Request

You also agree to us using / releasing any financial, attendance and any other documents required for Discover and Recover to respond to refund request and disputed payments to, but not limited to, WIX and SQUARE.

I understand this authorization will expire in one year from the date of this authorization.

I understand that I may revoke this authorization at any time by notifying Discover and Recover Counseling Services, LLC in writing. I also understand that the written revocation must be signed and dated later than the date on this authorization. The revocations will not affect any actions taken before the receipt of the written revocation.

A photocopy of the fax transmission of this authorization is as valid as the original.

You also agree to us using / releasing any financial, attendance and any other documents required for Discover and Recover to respond to refund request and disputed payments to, but not limited to, WIX and SQUARE. 

INFORMED CONSENT FOR TECHNOLOGY-ASSISTED TREATMENT, EDUCATION & APPOINTMENT REMINDERS

INFORMED CONSENT FOR TECHNOLOGY-ASSISTED TREATMENT

The purpose of this Informed Consent for Technology-Assisted Treatment & Education is to inform you, the client, about the process of online services, the counselor, and the potential risks and benefits of these services. The purpose is to also help safeguard you, the client, and give you information regarding alternatives to online services. This consent is an addendum to the face-to-face informed consent you, the client, are required to sign for face-to-face sessions.

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Please read the entire document. Please print the document, place a checkmark stating you have read the document, sign it, and then mail it to the address located at the bottom of the page.

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This consent covers all treatment, outpatient programs, and education classes such as Drug and Alcohol Awareness, Anger  Management, and Thinking for a Change (T4C).

PRIVACY AND CONFIDENTIALITY

Maintaining client confidentiality is extremely important. The counselor will take extraordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her permission with the following exceptions:

If the counselor believes that someone is seriously considering or likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) If the counselor believes someone is engaging or intends to engage in behavior that will expose another person to a potentially life-threatening communicable disease: 4) if the counselor suspects abuse, neglect, or the exploitation of a minor or incapacitated adult; 5) if the counselor believes someone’s mental condition

leaves the person gravely disabled.

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Although the internet provides the appearance of anonymity and privacy in treatment, privacy is more of an issue online than in person. The client is responsible for understanding the potential risks of confidentiality being breached through non-encrypted email, lack of password protection, or leaving information on a public access computer in a library or internet cafe.

Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong address or if they are just not noticed by the counselor. Confidentiality could be breached in transit by hackers or internet service providers or at either end by others with access to the client’s account or computer. Clients accessing the internet from public locations such as a library, computer lab, or cafe should consider the visibility of their screen to people around them. Position yourself to avoid others seeing your screen. Using cell phones can be risky in that signals are scrambled but rarely encrypted.

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The counselor has a right to his or her privacy and may restrict the use of any copies or recordings, taking photos the client makes of their communications. Clients must seek the permission of the counselor before recording any portion of the session and/or posting any portion of said sessions on internet websites such as Facebook or YouTube.

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The client is responsible for securing their own computer hardware, internet access points, chat software, email, and passwords that are encrypted, secure, and HIPPA compliant when possible. If encryption is not made available to clients; clients should be aware that they are risking unauthorized monitoring of transmissions and/or records of internet treatment sessions.

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You agree to work with us online using any encrypted email/chat service determined to be suitable by us.

Additionally,

1) If you call us, please be aware that unless we are both on landline phones, the conversation is not confidential.

2) Any computer files referencing our communication are maintained using secure and encrypted measures. We will not respond to personal and clinical concerns via regular email.

3) If you wish to use email as a way to "journal" information between sessions, you understand that we may not have the opportunity to review your journal emails until our next scheduled session.

4) You understand that emails between sessions that contain confidential information will be sent via encryption.

We make every effort to keep all information confidential. Likewise, if we are working online together and we ask you to do the same, We ask that you determine who has access to your computer and electronic information from your location. This would include family members, coworkers, supervisors, and friends and whether confidentiality from your work or personal computer may be compromised due to such programs as a keylogger.

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We encourage you to only communicate through a computer that you know is safe i.e. wherein confidentiality can be ensured. Be sure your computer is safe and that you fully exist out of online sessions and emails. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place OUR practice as a check-in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my are on a weekly basis.

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Please be aware of this risk if you are intentionally “checking in,” if you have a passive LBS app enabled on your phone.

We may need to consult with other professionals regarding my clients, however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous, and confidentiality is fully maintained.

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It is not a regular part of our practice to search for client information online through search engines such as Google or social media sites such as Facebook. Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, we will fully document it and discuss it with you when we next meet

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LACK OF NON-VERBAL CUES AND ASYNCHRONOUS COMMUNICATION

The client should be aware that misunderstandings are possible with telephone, text-based modalities such as email, and real-time internet chat since non-verbal cues are relatively lacking. Even with video chat software, misunderstandings may occur since bandwidth is always limited and images lack detail. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online treatment before, have patience with the process and clarify information if you think your counselor has not 3 understood you well. Be patient if your counselor asks periodically for clarification as well.

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Since asynchronous communication is “not in real-time,” turnaround time for responding to emails will “lag” a response. Be aware of different time zones as well. The counselor will make every effort to respond to email requests within a 12-24 hour period. Work with your counselor to identify local resources if you have concerns about the timeliness of responses.

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POTENTIAL RISKS OF RECEIVING TECHNOLOGY-ASSISTED TREATMENT & SAFEGUARDS

There are various risks related to providing technology-assisted treatment services related to the technology used, the distance between counselor and client, and issues related to timeliness.

These risks of concerns for privacy and confidentiality were mentioned in section A.  Your counselor has selected an email, chat, and videoconferencing account that is encrypted with a HIPPA-compliant secure platform to allow for the highest possible security and confidentiality of the content of your sessions. Your personal information is encrypted and stored on a secure server.

The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others such as creating passwords to use the computer, keeping their Email and chat IDs and passwords secret, and maintaining the security of their wireless internet access points (where applicable.) Please discuss any such concerns with your counselor during your first session so as to develop ways to limit risks. If there is ever a disruption or disconnection of services on the internet, the client will need to call the counselor/staff at 346-874-0683.

DUAL RELATIONSHIPS & SOCIAL MEDIA

Counselors and staff do not engage in personal/business relationships with clients on social media or in person.

Dual relationships can impair the therapeutic process, your therapist's objectivity, clinical judgment, or therapeutic effectiveness could be exploitative in nature. We will never acknowledge working therapeutically with anyone without his/her written permission. In 4 some instances, even with permission, We will preserve the integrity of our working relationship. For this reason, we will not accept any invitations via social networking sites such as Facebook, Twitter, Linkedin, or Pinterest, nor will we respond to blogs written by clients or accept comments on my blog from clients.

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I understand that it is the policy of (Discover and Recover Counseling Services) and their therapists to NOT “Like’, “Friend” or “Follow” clients on these various social media platforms in order to maintain client confidentiality. (For example, we do not accept or ask for “Friend” requests on Facebook from clients.) I understand too that I may choose to “Like” or “Follow” the (Practice Name) social media sites and that there might be certain risks involved such as people associating you with the organization.

Please use our social media platforms with discretion. The benefits are that social media allows people to connect. However, we believe that adding clients as friends or contacts on social media sites can compromise your confidentiality and our

respective privacy. We feel that it may also blur the boundaries of our therapeutic relationship.

ALTERNATIVES TO TECHNOLOGY-ASSISTED TREATMENT, TERMINATION & REFERRALS

Online treatment may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet treatment, clients with active suicidal/homicidal thoughts, clients who are experiencing active manic/psychotic symptoms, or clients who are minors. An alternative to receiving mental health services online would be receiving mental health services face to face with the counselor or adjunct using both modalities or working with another counselor. The online counselor can and will assist clients who would like to explore face-to-face options in their local area. Many state and local agencies will treat low-income clients on a sliding scale fee.

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Also, we do not accept clients whom, in our opinion, we cannot help. In such a case, we will give you a number of referrals that you may contact. If at any point during psychotherapy, we assess that we are not effective in helping you reach your therapeutic goals, we are obliged to discuss this with you up to and including termination of treatment. In such a case, we would give you a number of referrals that may be of help to you. You have the right to terminate therapy at any time. Please feel free to request a referral any time you think a different relationship would be more practical or beneficial for you. If you choose to do so, we will make every effort to provide you with the names of other qualified professionals whose services you might prefer.

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PROXIES

The counselor only provides treatment via technology to clients who are legally in a position to consent for themselves to receive mental health services. Clients who are not in such positions include children under the age of consent (age 18 in most cases) or clients who have a legally appointed guardian.

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TELEPHONE & EMERGENCY PROCEDURES

If you need to speak with me between sessions to alert me of an emergency, please call us on our At 346-874-0683. Your call will be returned as soon as possible. Messages are checked daily (but never during the nighttime. Messages are checked less frequently on weekends and holidays.

If the client is in a state of crisis or emergency, the counselor recommends the client dial 911 or go to the local emergency room. Clients may also utilize www.Befrienders.org, 1-800-SUICIDE, or 1-800-273-TALK.

Deaf clients can call 1-800-799-4TTY.

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RECORDS

The counselor will maintain records of online services. These records can include reference notes, copies of transcripts of chat and internet communications, and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association and the Texas Board of Examiners in Counseling. The client will be asked in advance for permission before recording any audio or video session.

FEE FOR SERVICE AND CANCELLATION POLICY

Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 2-hour notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. If we are scheduled for an online synchronous chat, audio, or video conference and we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, contact me to schedule a new session time.

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I have read and agree to the terms listed above in the Informed Consent. I understand that S Hinds is a Licensed Chemical Dependency Counselor and a Distance Credentialed Counselor who follows the laws and professional regulations of the State of Texas (USA). I understand the psychotherapy treatment will be considered to take place in the state of Texas (USA) unless the client resides in another state. If a client resides in a state where distance treatment is not provided, the counselor will get written permission from the Board of Examiners in that state before providing services. I understand that telephone/online psychotherapy is not a substitute for medication under the care of a psychiatrist or doctor. I understand that online and telephone therapy is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. In case of emergency situations, I will contact the resources listed in the Telephone & Emergency Procedures above.

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I understand my signature is an agreement for psychotherapy services conducted by Discover and Recover Counseling, Services. LLC.

TELE-BEHAVIORAL HEALTH

Do not share information about the meeting room used for online classes and/or password with anyone. This is to ensure your confidentiality. If this information is compromised, you must inform your counselor immediately so changes can be made for the privacy of those on the call.

When you are in your session, it is imperative that you are in a secluded place where your video screen cannot be viewed by others. There must not be any other people around you. You should be in a place free from noises or distractions during class.

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CLIENT ORIENTATION CHECKLIST

• Consent to Receive Telehealth Services
• Consent to Receive Appointment Reminders
• Program Guidelines and the consequences of non-compliance
• Client Rights
• Notice of Privacy
• Client Grievance Procedures

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If you have any issues with submitting this form after you uploaded a copy of your ID or the size of the image is > 25mb, then please submit the form without the ID and send the copy of your ID by email to s.hinds@discoverandrecover.net.