As a client of A New Hope with Saffrone, you have the following rights:

1. You have the right to be treated with courtesy and respect by your counselor and all staff.

2. You have the right to receive service regardless of your race, marital status, sex, age, color, religion, national origin, income, or sexual orientation.

3. You have the right to participate in the development of an Individualized Service Plan designed to address your specific treatment needs.

4. You have a right to privacy. In a group service situation, it is up to each member to protect the privacy of all participants. You have the right to expect that all communication and records pertaining to your service are confidential. These records cannot be released without your written permission or a Court Order. If there is a court order requiring information to be shared, we require releases to be signed prior to sharing the information. Information will be limited to dates of Sessions ONLY.

5. You have the right to current information concerning your service.

6. You have the right to refuse services, discuss grievances regarding your service, and to terminate service at any time.

7. You have the right to know if A New Hope with Saffrone wants to include you in research studies, and you have the right to refuse to participate in such projects.

8. If you inform us of a suicidal or homicidal intent, or of abuse in which the safety of self or others is threatened, we must take action and contact the proper authorities. In addition, if you (or your child) become volatile and potentially harmful while on the premises of your treatment location, we will contact law enforcement. We will not, however, under any circumstance perform any type of physical hold or restraint on you or anyone on our premises.

9. If you are a minor or a person over the age of 65 and the victim of a crime, we are required by law to report that information to the state abuse hotline.

10. You have the right to review your case records which consist of SESSION DATES ONLY and request correction of inaccurate information.

YOUR RESPONSIBILITIES AS A CLIENT

Your first appointment will consist of gathering information and determining an understanding of what brought you in for services.

YOUR ROLE:

1. Help me understand your history as well as your current situation/difficulties.
2. Be open and as complete as possible in your disclosure.
3. Any interaction (phone/email/texting) with legal representatives is billed at $122 per (30 minutes or any part there of).
4. Keep scheduled appointments or call 48 hours in advance to cancel an appointment if needed. There is a $100 penalty for canceling within 24 hours of your session.
5. Pay a NO SHOW fee of $153, if you do not attend your scheduled session, before rescheduling will be allowed.

Individual or family therapy usually requires 8-12 sessions to be effective. While the actual length of treatment will vary based on a number of factors, an estimate of the length of your treatment will be discussed. You may be asked to complete "homework" assignments between visits in order to maximize the benefit of treatment, there is no penalty for not doing homework. Many patients choose to use therapy as part of their self care routine and continue with Sessions Indefinitely.

RISKS AND BENEFITS:

RISKS: Therapy can be a challenging process in which a person may temporarily feel more
vulnerable and/or more emotional while working through difficulties.

BENEFITS: Therapy can be successful in helping you reach your personal goals for
change, healing, and growth while also decreasing problematic symptoms.

I understand the evaluation/intake procedures, respective roles, risks, and benefits of participating in the therapy process.

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the before signing this consent.


1. The patient understands and agrees to allow this office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care.


2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is obligated to agree to those restrictions only to the extent they coincide with state and professional regulations.

3. A patient's written consent need only be obtained one time for all subsequent care given.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

5. Our office may contact you periodically regarding appointments, treatments, products, services, or charitable work performed by our office. You may choose to opt-out of any marketing or fundraising communications at any time.


6. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.


7. Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by their clinician.

8. Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains. You will be provided with a new notice at your next visit following any change.

9. This notice is effective on the date stated below.

10. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the therapist has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

If you have further questions regarding this notice, please contact your counselor at (321) 501-8006.

CONFIDENTIALITY: Everything you say is these sessions and the written notes I take are confidential and may not be released to anyone without your written permission except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED BY LAW: Disclosure is required or may be required by law when there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to me that the you present a danger to others. Disclosure may also be required by the courts. I will not release records to any outside party unless I am authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

EMERGENCY: If there is an emergency during therapy or after therapy, and I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or other third party payer in order to process the claims. Only the minimum necessary information will be communicated to the carrier.

RECORDS AND YOUR RIGHT TO REVIEW THEM: The law requires that I keep treatment records for at least 6 years. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I feel that releasing such information might be harmful in any way. Upon your request, I will release information to any agency/person you specify unless I feel that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact me between sessions, please call A New Hope with Saffrone at 321-501-8006. If we do not answer, we will return your call as soon as possible. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call 911 or go to your nearest emergency room.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Therapy can affect you in many ways. You may resolve the problem you came in for, but it takes effort on your part. For the best results it helps to be open and honest. We may also talk about unpleasant events, which may cause you discomfort and I may challenge some of your ways of thinking. You must also know that while we expect change, there is no guarantee that this therapy will yield a positive result. Change will sometimes be easy and swift, but more often it will be slow and even frustrating at times. I am likely to draw on various psychological approaches. These approaches may include, behavioral, cognitive-behavioral, Solution Focused, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. I do not prescribe medication.

TREATMENT PLANS: On approximately your second visit, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives, and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy or about the treatment plan, please ask and I will explain it to you. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: After the first meeting, I will assess how I can be of benefit to you. I do not accept clients who, in my opinion, I cannot help. In that a case, I will give you a number of referrals whom you can contact. If at any point during therapy you are non-compliant, I will terminate treatment. In such a case, I will give you a number of referrals that may be of help to you. And upon your request, I will provide her/him with the essential information needed.

You have the right to terminate therapy at any time.

DUAL RELATIONSHIPS: Not all dual or multiple relationships are unethical or avoidable. Therapy never involves any dual relationship that impairs the therapist’s objectivity, clinical judgment or can be exploitative in nature. It is important to realize that in some areas multiple relationships are unavoidable. I will never publicly acknowledge working with you, without written permission. I will not accept you if I feel a significant dual or multiple relationship exists. It is your responsibility to advise me if any dual or multiple relationship becomes uncomfortable for you in any way. I will always listen carefully and respond to your feedback and will discontinue the dual relationship if you find it is or may interfere with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

SOCIAL NETWORKING AND INTERNET SEARCHES: I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.

I have read the above policies. I understand them and agree to comply with them.

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