The Center for Holistic Healing
Consent for Services Information
As a client of CHH You will recieve a copy of this Form
to keep and to sign in your client portal
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 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.
POLICY ON APPOINTMENTS AND FEES
Office hours are by appointment, and every effort is made to accommodate varying schedules, if possible. Appointments for psychotherapy are either scheduled for 45 minutes or extended sessions are 53-60 minutes long. Lengths of appointments vary for other services. The appointments begin on time, unless we have some unforeseen circumstance or crisis. When you arrive, please check in with the receptionist, or have a seat in the waiting room if the receptionist is unavailable, and your treatment provider will be out to get you. If you have a telehealth appointment, please sign into your telehealth platform at the scheduled time.
If you need to cancel a psychotherapy appointment, we require 24 hours notice so that the time may be given to someone else who needs the appointment. If you cancel an appointment with less then 24 hours notice or do not show up for an appointment, there is a $50 charge. Please talk to your practitioner if you have questions about this.
Groups/Classes: Space is limited in our groups and classes. When you sign up, you are reserving a space for yourself. Therefore, if you sign up for a class, we ask for a minimum of 24 hours notice if you can not attend. If you cancel with less then 24 hours notice or do not show up for a group/class, you will be charged the fee for that group/class.
Fees are due at the time of service. Fees for psychotherapy services are: The initial session is $195, and subsequent sessions are $185 for an extended session, $150 for a 45 minute session and $110 for a 30 minute session. We accept cash, personal checks, and credit cards for payment. There is a $25 charge for any returned checks. Fees for other services vary based on the type of service and the length of the appointment. If you have a balance exceeding $150, you will be required to pay the balance before you can attend another appointment. Exceptions to this are at the discretion of your practitioner, and require a plan to pay the balance.
You can self-pay or use your insurance. If you decide to use your insurance, we will ask for your co-payment/deductible/coinsurance at each session and file claims to your insurance company for the remaining balance. We are on most, but not all, insurance panels. As a courtesy, we will contact your insurance company to check your benefits. However, the information we receive is not guaranteed to be accurate and is subject to change without notice.
Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
You are responsible for any unpaid balance that is indicated on the Explanation of Benefits that we (and you) will receive from your insurance carrier.
Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy.
• When your Provider is out-of-network, they do not have a contract with your insurance company, and the cost to you may be higher then an in-network provider.
Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will 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.
Please be advised that insurance will not cover expenses associated with expert witness testimony. Should your therapist receive a subpoena to appear and testify as an expert witness in any legal proceeding on your behalf, separate charges will apply at a fee of $185 per hour starting from the time your therapist leaves the office until they arrive back, plus mileage and parking fees. Please consult with your therapist for further details.
There is a charge of $25 for writing any letters or correspondence that you may request. There is also a charge per page for any information that you would like us to send to other parties, .75 pages 1-25, .50 pages 26-100, .25 over 100 based on NC Statutes. We can be available by phone if needed for emergencies. There is a charge for phone calls based on fees above and insurance most often does not cover phone sessions.
It is the policy of The Center for Holistic Healing to prohibit the carrying of weapons, concealed or otherwise, on its premises. While state statutes permit residents to obtain licenses to carry concealed weapons, employers may prohibit the carrying of concealed weapons on business premises. The Center for Holistic Healing has an obligation to safeguard all its employees and guests, and therefore has chosen to prohibit the carrying of weapons, concealed or otherwise, on its premises.
Each treatment provider is licensed/certified in their field of practice. Please talk with your treatment provider about their training and qualifications. If you have any questions about these policies, please discuss them with your treatment provider.
By signing this form, I acknowledge I have read and agree to the terms of this policy. I authorize The Center for Holistic Healing P.C. to provide information about my care to my insurance carrier(s) in order to file claims and receive payment. Additionally, I authorize The Center for Holistic Healing to provide my treatment.
IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.
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:
Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your 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.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and 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.
Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
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 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
Your Provider 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.
COMMUNICATION
Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
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 on any platform, they will not follow you back.
• If you see your Provider on any form of review website, 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 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.
COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.
THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider 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.
POLICY ON APPOINTMENTS AND FEES
Office hours are by appointment, and every effort is made to accommodate varying schedules, if possible. Appointments for psychotherapy are either scheduled for 45 minutes or extended sessions are 53-60 minutes long. Lengths of appointments vary for other services. The appointments begin on time, unless we have some unforeseen circumstance or crisis. When you arrive, please check in with the receptionist, or have a seat in the waiting room if the receptionist is unavailable, and your treatment provider will be out to get you. If you have a telehealth appointment, please sign into your telehealth platform at the scheduled time.
If you need to cancel a psychotherapy appointment, we require 24 hours notice so that the time may be given to someone else who needs the appointment. If you cancel an appointment with less then 24 hours notice or do not show up for an appointment, there is a $50 charge. Please talk to your practitioner if you have questions about this.
Groups/Classes: Space is limited in our groups and classes. When you sign up, you are reserving a space for yourself. Therefore, if you sign up for a class, we ask for a minimum of 24 hours notice if you can not attend. If you cancel with less then 24 hours notice or do not show up for a group/class, you will be charged the fee for that group/class.
Fees are due at the time of service. Fees for psychotherapy services are: The initial session is $195, and subsequent sessions are $185 for an extended session, $150 for a 45 minute session and $110 for a 30 minute session. We accept cash, personal checks, and credit cards for payment. There is a $25 charge for any returned checks. Fees for other services vary based on the type of service and the length of the appointment. If you have a balance exceeding $150, you will be required to pay the balance before you can attend another appointment. Exceptions to this are at the discretion of your practitioner, and require a plan to pay the balance.
You can self-pay or use your insurance. If you decide to use your insurance, we will ask for your co-payment/deductible/coinsurance at each session and file claims to your insurance company for the remaining balance. We are on most, but not all, insurance panels. As a courtesy, we will contact your insurance company to check your benefits. However, the information we receive is not guaranteed to be accurate and is subject to change without notice.
Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
You are responsible for any unpaid balance that is indicated on the Explanation of Benefits that we (and you) will receive from your insurance carrier.
Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy.
• When your Provider is out-of-network, they do not have a contract with your insurance company, and the cost to you may be higher then an in-network provider.
Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will 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.
Please be advised that insurance will not cover expenses associated with expert witness testimony. Should your therapist receive a subpoena to appear and testify as an expert witness in any legal proceeding on your behalf, separate charges will apply at a fee of $185 per hour starting from the time your therapist leaves the office until they arrive back, plus mileage and parking fees. Please consult with your therapist for further details.
There is a charge of $25 for writing any letters or correspondence that you may request. There is also a charge per page for any information that you would like us to send to other parties, .75 pages 1-25, .50 pages 26-100, .25 over 100 based on NC Statutes. We can be available by phone if needed for emergencies. There is a charge for phone calls based on fees above and insurance most often does not cover phone sessions.
It is the policy of The Center for Holistic Healing to prohibit the carrying of weapons, concealed or otherwise, on its premises. While state statutes permit residents to obtain licenses to carry concealed weapons, employers may prohibit the carrying of concealed weapons on business premises. The Center for Holistic Healing has an obligation to safeguard all its employees and guests, and therefore has chosen to prohibit the carrying of weapons, concealed or otherwise, on its premises.
Each treatment provider is licensed/certified in their field of practice. Please talk with your treatment provider about their training and qualifications. If you have any questions about these policies, please discuss them with your treatment provider.
By signing this form, I acknowledge I have read and agree to the terms of this policy. I authorize The Center for Holistic Healing P.C. to provide information about my care to my insurance carrier(s) in order to file claims and receive payment. Additionally, I authorize The Center for Holistic Healing to provide my treatment.
IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.
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:
Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your 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.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and 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.
Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
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 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
Your Provider 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.
COMMUNICATION
Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
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 on any platform, they will not follow you back.
• If you see your Provider on any form of review website, 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 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.
COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.