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Notice of Privacy Practices

I understand that information disclosed about myself in the process of treatment at Anchorpoint Counseling Ministry can only be used for:
1. Planning my care
2. Seeking payment through a billing agent for services rendered

3. Insuring quality improvement of services
4. And as described in detail on the Notice of Privacy Practices in Detail paper that I have received.

I know that I have a right:
1. To request a restriction on certain uses of my information
2. To revoke my consent, and,
3. To file a complaint when I feel my rights have been disregarded.

I acknowledge that I have received a copy of the Notice of Privacy Practices and also, I was given the opportunity to have any part of the Notice of Privacy Practice explained to me.

Have you read all of the above information?

Yes

Client Bill of Rights

Clients have the right to be treated with consideration and respect.
Clients have the right to expect that a licensed counselor or supervised intern has met the minimal qualifications as required by State law.
Clients have the right to expect that we will respond to their request for service to the best of our ability. These services include evaluation, treatment and, if treatment needs cannot be met, referral to another agency or facility in a responsible manner.
Clients have the right to expect that we will explain to them or to an appropriate person on their behalf, current information regarding diagnosis, treatment and prognosis.
Clients have the right to obtain a copy of the Code of Ethics published by the National Association of Social Workers and/or American Association for Marriage and Family Therapy which are the ethical guidelines of this agency.
Clients have the right to be informed of costs for professional services before receiving service.
Clients have the right to information about their case record, and to have the information explained clearly and directly.
Clients have the right, if no legal conflict is involved, to refuse treatment following an explanation of the consequences of this action and the receiving of alternative treatment referrals.
Clients have the right to expect that all communications and records pertaining to their care are treated as confidential, except as required by law.*

*Reporting of a situation which shows “clear and imminent danger” to self or another, reporting of neglect, or the physical, or sexual abuse of a minor child, and the examination of records by the court through subpoena.

Have you read all of the above information?

Yes

Therapeutic Relationship Policy

In your best interest, and following APA (American Psychological Association) standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever be a close friend to or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.

I cannot see you for therapy if you, at some point, expect me to become involved with the courts in a legal, divorce or custody dispute. I want you to understand that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because of our therapeutic relationship; and (2) the testimony might affect our therapy relationship and I must keep our therapeutic relationship first.

I must protect the therapeutic relationship, and thus we do not go to court for any legal issues including, but not limited to DUI/criminal cases, divorce, or custody disputes.

I understand and agree to this policy.

Have you read all of the above information?

Yes

Communication with Primary Care Physician

I would like Anchorpoint Counseling Ministry to inform my Primary Care Physician that I am receiving psychological counseling services.

Yes

Consent to Treatment

Welcome to Anchorpoint Counseling Ministry. Our goal is to provide you with quality mental health care. Your informed participation is essential. It will benefit you and our effort to help you. The following statements describe our agreement regarding services: (Please put your initials after each section, once you’ve read and agreed to the information given.)

I understand that the information discussed during sessions is confidential and that only under the following conditions can information be released without my permission:

If there is clear and imminent danger of harm to myself or another, steps will be taken to insure the safety of all.
If it is learned that there is a situation of neglect, physical or sexual abuse of a minor child, the elderly, or persons with disabilities, steps will be taken to insure the safety of that person.
My name, address and telephone number and diagnostic code is given to the Anchorpoint billing agent and if applicable, with your insurance provider.
Any other use of this information will require a written authorization from me before it is shared with others.

I have been given and read, understand and agree to the:

Information Packet

Notice of Privacy Practice
Client Bill of Rights
Payment Policy
Therapeutic Relationship Policy
Communication Letter to Primary Care Physician

I understand that all services provided and all disclosures by Anchorpoint Counseling Ministry are in accordance with the Notice of Privacy Practices given to me prior to beginning services. I understand that all information maintained by Anchorpoint Counseling Ministry is protected by State and Federal regulation and mandated by the Health Insurance Portability and Accountability Act (HIPAA) regarding the confidentiality of client records.

I have read and was given the opportunity for further explanation and clarifications for any of the forms I was given.

Have you read all of the above information?

Yes

Please Confirm full name and signature.