Client Information and Consent for Services

Saratoga Center for the Family (SCFF) is a private, not-for-profit agency serving Saratoga County New York and surrounding communities. SCFF is committed to strengthening, empowering and improving the emotional wellbeing of children, families and the community. SCFF is committed to reducing the incidence and impact of child abuse and neglect.

This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

THE THERAPY PROCESS

Therapy is a collaborative process where you and your Provider, Saratoga Center for the Family, 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 Provider 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 Provider. 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. Therapy can cover a range of topics depending on the purpose for seeking treatment.  There are no physical risks associated with therapy, although an increase in emotional distress can occur as issues and topics are discussed through the process.  Please speak to your provider if you have any concerns.  Therapists at Saratoga Center for the Family are professionals holding masters or doctoral degrees in social work, mental health counseling, psychology or related human service degree.  From time to time SCFF acts as a training site for master level/doctoral interns who are pursuing an advanced degree in their field.   All therapists including interns employed by Saratoga Center for the Family are under supervision of a licensed supervisor, director or other professional. For professionals holding a New York state license specifically an LMSW or LMSW-LP, the supervisor (LCSW or LCSWR) is responsible for the diagnosis and practice of the LMSW.  For MHC-LP therapists, the supervisor (either LMHC, LCSW or LCSWR) is responsible for the diagnosis and practice of each client. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional.

You will discuss with your provider what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. Together, you and your Provider 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 Provider may edit your treatment plan to be sure it describes your goals and steps you need to take.

After the intake process, you will attend regular therapy sessions at your Provider's office or through video and/or audio, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

FINANCIAL POLICY

Payment for services is the responsibility of each client.

You will need to decide if you want health insurance to pay your fees depending on your plan's benefits or qualify for a grant or sliding scale consideration. Financial assistance is available to qualifying clients (according to federal income guidelines). Please speak to our office staff if you would like more information about the financial assistance available through Saratoga Center for the Family.

Your health insurance contract is between you and your insurance company – it is your responsibility to understand your insurance plan including your co-insurance, deductible, and co-payments. Saratoga Center for the Family cannot provide you with information surrounding your specific insurance plan or benefits. Contact your insurance company to find out whether the mental health provider is in network with your specific insurance plan or if you have any other questions about your insurance benefits. Saratoga Center for the Family cannot advise you as to whether our mental health providers are in network with your insurance. If your insurance terminates or changes, you are responsible for informing SCFF and you will assume any fees not paid by your insurance company. This includes fees associated with deductibles, co-insurance, co-payments and out of network charges including lapse in coverage.  If timely payment is not received, SCFF may utilize collection agencies for unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) would not be disclosed in this process. Unpaid debts may be reported to credit agencies, and the client’s credit report may state the amount owed, the timeframe, and the name of the clinic or collection source.

If you choose to use insurance benefits to pay for services, you may be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

You have the option to keep a valid credit or debit card on file. This card can 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.

THERAPY THROUGH TELEHEALTH SERVICES

To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

•  I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.
• I understand that I may opt out of the telehealth visit at any time.
• I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of New York at the time of this service.
• I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
• I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
•  It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
• Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
• Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
• I agree that information exchanged during my telehealth visit will be maintained by my therapist, doctors, other healthcare providers, and healthcare facilities involved in my care.
• I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).
• I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
• The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.
• I agree to provide a safe, private setting for my child(ren) to receive telehealth without interference.
• I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.
• I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.
• I understand and agree that a mental health evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including crisis intervention, further diagnostic testing, such as psychiatric or psychological testing, and/or follow up with an in-office visit.
• I understand that electronic communication may be used to communicate highly sensitive mental health information.
• I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I know that I will have to inform the healthcare provider of any information I do not wish to be transmitted through electronic communications.
• I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when behavioral health care is provided.
• To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.
• I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the existing emergency 911 services in my community.
• I understand that I may be asked to share personal information with the telehealth platform to create an account, such as my name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards
• It may be difficult for your Provider to provide immediate support during an emergency or crisis. Your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

OTHER SERVICE GUIDELINES

Custody: The therapists at SCFF are not trained in custody evaluation nor do they provide supervised visitation between family members. You must seek outside providers for these services. If called to appear in court, we will not speak to custody or visitation issues.  If applicable, SCFF requests that you provide current custody orders at the time of initiation of services particularly as it pertains to consent for services for you or your child(ren).

Court Appearances:  SCFF staff will only appear in court for testimony if a signed judicial subpoena is received for that testimony.

Judicial Subpoena: There is a chance, however slight, that you, or your child(ren)’s HIPAA protected PHI including confidential documentation, clinical records, intake information supplied by you, progress and or psychotherapy notes,  assessments,  other documents, emails, texts or any other means of communication could be subject to a subpoena by a judge.  While every effort will be made to keep mental health records confidential, you should be aware of the possibility.  You will be notified if your or your child(ren)’s records are subpoenaed.  

 Recording of Psychotherapy Sessions:  Recording audio or visual images during psychotherapy sessions is strictly prohibited without prior written permission from both parties.  While occasional audio or visual recording of some segments of psychotherapy sessions may be beneficial to enhance therapeutic outcomes or for training purposes, without proper consent from both parties, it is a violation of confidentiality and the policies of SCFF.  Any violation of confidentiality may be grounds for action up to and including discharge from counseling services.

Modes of Communication and Correspondence with client(s), families and third party Entities:  You have the right to decide how to communicate with your Provider outside of your sessions. We ask that you limit your communication to scheduling, cancellations, weather issues etc. Secure communications are the best way to communicate personal information, though no method is entirely without risk. You can utilize communication services such as email, fax and intermediary phone text messaging services. However these services are not necessarily private or confidential means of communication, correspondence, nor are they all fully HIPAA compliant (Health Insurance Portability and Accountability Act of 1996, Public Law 104-191).  Please be advised if you correspond with the staff at SCFF or allow by consent SCFF employees to communicate/correspond with you or third parties, there are risks involved.  If you chose to use one of the above modes, then you, as the client, are assuming the risk, though slight, that identifying information communicated could be read accidently, or otherwise inadvertently intercepted by a third party. While SCFF puts safeguards in place to ensure your privacy and to avoid such an interception, nothing is 100% foolproof.  It is not illegal to correspond with clients via non-encrypted modes as a consumer of services from SCFF, however you are being informed of the assumed risks of communicating/corresponding using these modes.  By signing this document, you attest that you understand the risks involved and are consenting to  communicating and/or corresponding with SCFF employees and third party entities via email, fax and intermediary phone text messaging services if you so choose.

Social Media/Review Websites:  If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy. Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider or if you see your Provider on any form of review website, they will not follow you back and it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact of your posts and on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

Record Requests: You have the right to request your medical and billing records. A signed release of information form is required and available at the main office reception desk or on the agency website.   Although every effort is made to accommodate your request in a timely manner, SCFF has 60 days to fulfill your request. The fee for the preparation of records is .75 per page. Once your records are prepared, we will contact you with the final cost. You can pick up your records at the reception desk during the Center’s posted business hours.   Payment for records will be expected at the time of pick up.

ENDING SERVICES

No-show and Late Cancellation Policy: The staff at SCFF strives to provide the best services possible. Therefore, your appointment time is reserved especially for you or your child. If you have to cancel your appointment, call the center at 518-587-8008 no less than 24 hours before your appointment.  If you miss two (2) appointments without notifying us, SCFF may choose to discharge you from treatment. If you have three (3) same-day cancellations, SCFF may choose to discharge you from treatment. If discharged due to no-shows or cancellations, and you request future mental health services, your name will be placed back on the wait list and you will be required to undergo the intake process again.

Automatic Discharge Policy: Automatic discharge from mental health services will be initiated for a client who exhibits physical violence, verbal abuse, harassment, bullying, threats toward staff or other clients, spreading false or unsubstantiated information about staff or clients or sharing HIPAA protected health information about any client particularly on social media platforms or in any other manner. Immediate discharge of any client or client’s family members carrying weapons, threatening harm or engaging in illegal acts while in the building at SCFF, in a school-based office, or during communication with staff. Discharge will be considered if a client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. Clients are notified by mail of non-voluntary discharges. The client may appeal this decision with the Clinical Director or request to reapply for services.

Voluntary Discharge: A client may end services at any time. Clients are strongly encouraged to discuss this decision with their Provider.

CLIENT RIGHTS

 Releases of Information: You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different other than the address on file, you must provide this information in writing.

Suggestions and feedback: Are welcome for changes or additions in any aspect of the services we provide.

Civil rights: Your civil rights are protected by federal and state laws as applicable. https://www.hhs.gov/ocr/index.html

Cultural/spiritual/gender issues: You may request services from someone with training or experiences from a specific cultural, spiritual, or gender orientation. If these services are not available, we will help you in the referral process to other services.

Treatment: You have the right to take part in formulating your treatment plan.

Medical/legal advice: We encourage you to discuss your treatment with your doctor and/or attorney.

Disclosures: You have the right to receive an accounting of disclosures of your protected health information that you have not authorized. Request this in writing.

CRISIS SERVICES

 SCFF does not provide crisis services.  If you or someone you know is at risk for serious harm: CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM.    You can also contact The National Suicide Prevention Lifeline by calling or texting 988 for help 24 hours/7 days a week.

After Hours Contact: SCFF does not provide emergency after hours contact. For non-urgent matters, you may leave after hours voice mail messages for your therapist by calling the main number at 518-587-8008 and follow the menu prompts.

SARATOGA CENTER FOR THE FAMILY ETHICAL OBLIGATIONS

• We dedicate ourselves to serving the best interest of each client.
• We are committed to providing care in a manner that supports and protects the personal dignity of each client.
• We are committed to providing care that reflects ‘best practices’ and evidence-based treatments.
• We will not discriminate against clients or professionals based on age, race, creed, disabilities, handicaps, preferences, or other personal choices or concerns.
• We maintain an objective and professional relationship with each client.
• We respect the rights and views of other mental health professionals.
• We will appropriately terminate services or refer clients to other programs if deemed necessary.
• We will continuously evaluate the agency’s limitations, strengths, biases, and effectiveness for the purpose of self-improvement.
• We highly value the attainment of further education and training to enhance and improve services.

CLIENT RESPONSIBILITIES

• You are responsible for your financial obligations to SCFF as outlined above.
• You are responsible for following the policies of SCFF.
• You are responsible for treating staff and fellow patients in a respectful, cordial manner in which their rights are respected and not violated through harassment or threat.
• You are responsible to provide accurate information about yourself, your child and/or family.

COMPLAINTS
Speak with your Provider.

If discussion with your therapist does not resolve the problem, please contact:

Clinical Director (Center and Community Services), 518-587-8008 or

Clinical Director (School Based Services), 518-587-8008

If discussion with one of the SCFF’s Clinical Directors does not resolve the issue, you may contact the Executive Director at 518-587-8008

If your concern is not adequately addressed via these avenues, please direct your concerns to the following agencies:

NYS OFFICE OF MENTAL HEALTH COMMISSION ON QUALITY OF CARE

99 Washington Avenue, Suite 1002, Albany, NY 12210

General Phone: 518-473-4090 or 1-800-624-4143

Customer Relations Service: 1-800-597-8481 or En Espanol: 1-800-210-6456

TDD (for those who are deaf/hearing impaired): 1-800-597-9810

or

NYS OFFICE OF VICTIM SERVICES:  

New York State Office of Victim Services

80 South Swan St, Suite 1035

Albany, New York, 12210

Or NYS Office of Children and Family Services: Bureau of Protective Practice main line number: 518-473-9495

The NYS Office of Victims Services process for registering complaints against an entity such as SCFF who receive U.S. Department of Justice federal grant funds from OVS states the following for redress of grievances:

Any person who has reason to believe that they have been unlawfully discriminated against or experienced discriminatory harassment based on religion, race, color, national origin, age, sex, height, weight, marital status, disability, or genetic information by the sub-recipients of federal funds may contact the Office of Victim Services by going to the link: https://www.ojp.gov/program/civil-rights-office/filing-civil-rights-complaint

IMPORTANT NOTICE – PLEASE READ

Filing a complaint with the New York State Office of Victim Services is voluntary. OVS is not your attorney or advocate. OVS may or may not forward this complaint to U.S. Department of Justice, Office of Justice Programs, Office for Civil Rights (OCR) or other agencies for investigation. OVS does not take responsibility for your notifying your employer of a discrimination or retaliation claim, nor for filing this complaint with the appropriate agency or court, within the appropriate time-periods for doing so.

CONFIDENTIALITY
Saratoga Center for the Family as your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.

• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed.

There are a few times that your Provider may not keep your personal information confidential:

• If your Provider 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 Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider 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 Provider will work with you to discuss other options to keep you safe.

RECORD KEEPING

Saratoga Center for the Family 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.

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. Further, I consent to use an electronic signature to acknowledge this agreement.

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