HIPAA PRIVACY INFORMATION
IF THIS IS AN EAP (Employee Assistance Program):
IF MANDATED BY THE LEGAL SYSTEM:
(court, probation, attorney, DFCS, etc), the rates are:
Assessment: $75, Group: $25, Individual: $35, Family session: $45
Informed Consent: I give my permission for Coastal Counseling Center to provide information to my insurance/EAP company for the purpose of billing for services provided. I also agree to pay any copay required by my insurance company. I further authorize the release of any information applicable regarding my care as required by the third-party payer.
CONSENT FOR TREATMENT: I hereby give my consent for treatment by Coastal Counseling Center clinical staff. I affirm that I am of legal age and competent to give such consent for behavioral health treatment. If not; however, the person who co-signs this consent represents me as parent, legal guardian, or person otherwise allowed by law to consent for my treatment.
CONFIDENTIALITY: I acknowledge that in accordance with state & federal laws, information about me at Coastal Counseling Center will be protected from unauthorized disclosure. No information will be sent to my employer, family, friends, or anyone else unless it is discussed with me ahead of time and written authorization is obtained.
Confidentiality may be broken, however, in certain situations that may endanger my health & safety as well as the health & safety of others (e.g., suspected suicide, homicide, abuse, neglect, and domestic violence).
Federal laws do not protect information about a crime committed by a client either at the Center or against any person who works for the Center or about a threat to commit such a crime.
Information regarding alcohol & drug abuse in a client’s medical record is protected by federal laws & regulations. Generally, the Center cannot disclose that a client is participating in a program or disclose information to anyone outside the Center unless: (1) the client consents in writing; (2) the disclosure is allowed by court order; or (3) disclosure is made to medical personnel in a medical emergency.
NO-SHOW/LATE CANCELLATION POLICY: Our policy is to charge a fee when people do not show for scheduled appointments or cancel within a few hours of their appointment. Reminders are sent (with your approval) by text, email or phone call to prevent missing a scheduled appointment.
DISCHARGE: Treatment is solution-focused and brief in nature, with a goal of successful discharge. Should a client have a sixty (60) day gap in services (e.g., no contact in this 60 days), the client’s medical record will be closed. He or she may contact the Center for re-admission after that period, provided all fees are up to date.
INVOLVEMENT IN TREATMENT: I hereby give permission for the following persons to be involved in my treatment at Coastal Counseling Center. It is noted that these persons do not have access to my medical record or Protected Health Information; they may participate with me and have or give information on a very limited basis:
Authorized Concent for Treatment of a Minor by Parent/Guardian
I give my consent for assessment and treatment and understand the conditions of this informed consent and agree to its provisions:
Finally, thinking about a plan for your counseling experience:
Please type your name below to indicate consent to treatment.
THIS IS A SECURE FORM. CLICK SUBMIT.