Professional Documents
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Individual Counseling, Individual Counseling Services, Individual Counseling in Lancaster
Individual Counseling, Individual Counseling Services, Individual Counseling in Lancaster
JC CHRISTIAN COUNSELINGt\it
1821 Oregon Pike, Suite 212, Lancaster, PA 17601 Phone: (717) 278-8326, FAX: 1-866-285-7198
1. I hereby voluntarily consent to receiving counseling services at JC Christian Counseling including such diagnosis and therapeutic methods deemed necessary or advisable by our counselors. 2. I am aware that the practice of counseling is not an exact science and I acknowledge that no guarantees have been made to me regarding the results of my treatment! counseling care. I am aware that I may refuse the counseling offered to me and terminate my treatment.
3. I hereby authorize JC Christian Counseling to retain, preserve, and use for research or teaching purposes information provided in the sessions without disclosure of my name or any other personal identification. 4. I understand that referrals may be made to other professionals (such as psychiatrist, psychologist, etc.) by my counselor. JC Christian Counseling (which includes the referring counselor) is not responsible for payment to other professionals on my behalf or for the client receiving counseling care.
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Witness Signature
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*If signed by Responsible Person, complete one of the following: a.) Client is unable to consent because he/she is a minor, b.) Client is unable to consent because ----,years f age. o '
JC CHRISTIAN COUNSELING1;a
1821 Oregon Pike, Suite 212, Lancaster, PA 17601 Phone: (717) 278-8326, FAX: 1-866-285-7198
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CONFIDENTIALITY Legally and ethically, the relationship between counselor and client is of a confidential nature. This means that any and all information which is given to the counselor during any session cannot be divulged by the counselor without the client's written consent. However, in the event that a clear and present danger of physical harm to the client and/or others (particularly towards children) becomes apparent, the counselor is legally and ethically required to inform those who have a direct need to know.
NOTIFICATION OF REFERRING PERSON If a client is referred to this office by a professional person (physician, clergyperson, etc.), it is this office's policy to notify the referral source of the facts of that individual's commencing and terminating therapy. This is a matter of professional courtesy and is important to the client's on-going relationship with that person.
IN THE INTEREST OF OUR WORKING tOGETHER, I AGREE TO ABIDE BY THE POLICIES ON TIDS STATEMENT AND SIGNIFY THAT I HAVE RECEIVED AND UNDERSTAND mE INFORMATION CONTAINED HEREIN.
CLIENT'S SIGNATURE
DATE
COUNSELOR'S SIGNATURE
DATE
IN THE EVENT WE MUST CONTACT YOU BY TELEPHONE TO REMIND YOU OF, OR CHANGE, YOUR APPOINTMENT, MAY WE CONTACT YOU: YES AT HOME? AT WORK? NO
0 0
0 0
_
CLIENT'S
INITIALS
0 YES 0 NO
CLIENT'S INITIALS
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HRISTIAN COUNSELING
JC CHRISTIAN COUNSELINGlja
1821 Oregon Pike, Suite 212, Lancaster, PA 17601 Phone: (717) 278-8326, FAX: 1-866-285-7198
I,
the counseling appointment is scheduled for either myself or for the individual in which I am signed as the responsible party. Credit Card Option: I authorize JC Christian Counseling to run the credit card that I have provided each time that I schedule my appointment, unless I terminate counseling care or provide an alternative of payment. (Appointments that are rescheduled will follow the counseling policy)
Adolescent Client
payment is required at the time the appointment is scheduled. If an organization (such as a Church, Children Services or Child Welfare agency) is providing payment for services; Please contact JC Christian Counseling to discuss payment details and authorization.
Client Signature
Date
Witness
Date
Responsible Party
Date
CHRISTIAN COUNSELING
JC CHRISTIAN COUNSELINGtlja
1821 Oregon Pike, Suite 212, Lancaster, PA 17601 Phone: (717) 278-8326, FAX: 1-866-285-7198
'"THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO TIDS INFORMATION."" "PLEASE REVIEW IT CAREFULLY.""
NOTICE
EFFECTIVE DATE: 8/17/09 To Clients of JC Christian Counseling: JC Christian Counseling is committed to providing the highest level of service possible to our clients as well as to abiding by federal, state and local law (Health Insurance Portability and Accountability Act of 1996 (HIPAA). Confidentiality between JC Christian Counseling and clients is necessary to develop the trust and confidence important for therapeutic intervention. With your Consent, certain Protected Health Information (PHI) may be disclosed for the purpose of carrying out treatment, payment, or health care operations on your behalf JC Christian Counseling will disclose only the minimum amount of information required for these purposes. PHl that may be disclosed: Name, Address, Telephone Number, Social Security Number Past, present, or future physical or mental health or condition, i.e., diagnosis Dates and times of sessions Treatment provided and progress or outcome Past, present, or future payment for the provision of health care services For example, PHl may be disclosed to staff of this office in the course of professional supervision to ensure appropriate and quality treatment. PHl may be disclosed to your health insurance company to ensure reimbursement for treatment. PHl may be disclosed to appropriate personnel to provide you with appointment confirmation. Also, with your Consent, your name, address and phone number may be used to develop a mailing list so you may receive newsletters or materials about other related benefits and services that may be of interest. pm may be disclosed without your consent: a) in the event of an emergency, and after attempts have been made to contact you; b) in the event that you might pose a threat to yourself or society; c) in the event that it is required by federal, state or local law. Other uses or disclosures of PHl will be made only after written Authorization has been obtained from you. You may revoke authorization, in writing, at any time, except to the extent that JC Christian Counseling has already acted on the authorization. In reference to pm, you have the right: 1. To request restrictions on certain uses and disclosures ofPHl, although JC Christian Counseling is not required to agree to your requested restrictions. 2. To receive confidential communications ofPHl; 3. To inspect and copy PHl; 4. To amend PHl; 5. To obtain a paper copy of this Notice from JC Christian Counseling upon request. JC'Christian Counseling is required by law: 1. To maintain the privacy of PHI and provide you with this Notice of its legal duties and privacy practices with respect to PHl; 2. To abide by the terms ofthe Notice currently in effect; 3. To provide a revised Notice -- in the event that JC Christian Counseling changes its privacy practices, which practices will apply to all PHI maintained by JC Christian Counseling -- by sending an email to you've provided in our records the revised Notice. You may enter a complaint to JC Christian Counseling or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. A complaint may be filed with JC Christian Counseling by contacting in writing. JC Christian Counseling will respond to your complaint, in writing, within two weeks of receiving your complaint. JC Christian Counseling will not retaliate against any person for filing a complaint. For questions concerning this Notice, please contact JC Christian Counseling by phone at 717-278-8326. I have been notified of my rights to confidentiality, privacy (according to HlPAA) and the protection of health information.
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