Cathexis Tucson, LLC.
Psychotherapy and Counseling Service Agreement and Client Rights
This document also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient/client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully and discuss and questions or concerns with your therapist.
By signing this Agreement, you are consenting to enter into a therapeutic relationship with Cathexis. You can revoke this Agreement at any time. If you decide to end the treatment relationship, please consult with your therapist about your desire to do so. That revocation will be binding on Cathexis unless this agency has taken action in reliance on it, if there are obligations imposed on this agency by your health insurance in order to process or substantiate claims made under your policy or if you have not satisfied any financial obligations you have incurred. This consent to treat will expire 12 months from the date of signature, unless otherwise specified.
Similarly, Cathexis. has the option to terminate this Agreement if: a) it is determine that we are unable to meet your treatment needs; b) it is determine an ethical conflict exists; c) it is determine you need a higher level of care. Should this occur, the termination will be clearly discussed with you and the counselor may provide you with a written Termination of Services and appropriate referrals, if applicable. If at any point, Cathexis staff safety is threatened or that of their office or family, therapy will be terminated immediately. Should that occur, Cathexis will offer appropriate referrals if deemed appropriate.
Counseling and psychotherapy are not easily described in general statements and varies for each client depending on the issues presented at the beginning and during the course of treatment. Cathexis counselors employ various methods and incorporate various theoretical orientations. Psychotherapy and counseling require your active participation, in session and out of session. Counseling and psychotherapy can have both benefits and risks. Since counseling and psychotherapy often involve discussing difficult and sometimes painful aspects of your life, you may experience unpleasant feelings and disruptions in your daily life. Conversely, counseling and psychotherapy have been shown to have benefits such as improved relationships, improved self-esteem and a reduction in unpleasant symptoms. Much depends on your intentions and investment in the process. As with any counseling and psychotherapy process, there are no guarantees as to the results.
The relationship between therapist and client is important and requires time to develop. The first few sessions may involve an informal evaluation of your needs. If you decide to continue and you determine you would benefit from working with Cathexis, the counselor will provide you with his/her impressions of what your work will include and develop a treatment plan with you. You can revise the treatment plan at any time. Counseling and psychotherapy require a commitment of time, money and energy and due to the nature of the treatment relationship, choosing the appropriate therapist is important. If at any time during our work together you have questions about your process or the manner in which the therapist works, please bring your questions to session.
You are encouraged to ask questions about anything that happens in therapy. Your counselor is committed to discussing the process, techniques or theory or anything else that may arise. You may ask the counselor to try something you think may be helpful. You may ask about the counselor’s training, impressions and the process. You may request a referral to someone else if you feel your work together is not an appropriate fit for you.
Meetings, Financial Obligations and Fees
Insurance Clients: Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. You will be responsible for any charges not covered by insurance, including co-payments and deductibles. The Administrative staff will make every attempt to determine out of pocket expenses and notify you as soon as possible. However, insurance policies continue to grow in complexity, and it may not be possible to determine accurate out of pocket expenses until the claims have been finalized by the payer. If it is the case that out of pocket expenses are more than were anticipated, you will be responsible to pay the full amount in which they are responsible. Fees are available upon request.
Private Pay Clients 24 Hour Cancellation Policy: Once an appointment has been scheduled, you are expected to pay for the session unless you have given your assigned therapist 24 hours advance notice of cancellation either by phone or email. Cathexis will keep your credit card information on file and will automatically bill your card the full price of your session if you do not give your therapist notification of intent to cancel your scheduled session within 24 hours prior to the appointment time. There are occasions where emergency events outside of your control do occur; if we determine this to be the case, you will not be required to pay for the session.
Minors and Parents/Guardians
Clients under the age of 18 years of age and their parents should be aware that the law may allow parents/guardians to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes Cathexis’s policy to request an agreement from parents that they consent to relinquish access to their child’s records. If parents/guardian agree, during treatment Cathexis will provide general information about the child’s treatment and progress. Any other communication will require the child’s authorization unless it is believed that the child is in danger or is a danger to someone else in which case Cathexis will notify the parents/guardian of the concern. Before giving parents any information, Cathexis will discuss this matter with the child and, if possible, handle objections. Additionally, such information may be released and discussed during a conjoint session.
Privacy, Records, Confidentiality and Limits on Confidentiality (Privacy Statement)
The psychotherapy and counseling relationship is confidential and private. The law protects the privacy of all communications between a client and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. Some situations require only that you provide written advance consent. Your signature on this Agreement provides consent for the following situations:
1. Cathexis participates in a process where selected cases are discussed with other professional colleagues to facilitate our continued professional growth and to get you the benefit of a variety of professional experts. While no identifying information is released in this peer consultation process, the dynamics of the problems and the people involved are discussed, along with the treatment approaches and methods. To ensure your privacy, we do abide by HIPPA regulations in the handling of confidential information. Please note that if your therapist is a licensed associate counselor they currently work under direct supervision and will discuss your case and treatment with either Cathexis’s Clinical Director, Tim Mills MC/MFT LPC (email@example.com, 520-303-8394) or staff member Leonard Corte, LCSW (520-744-3839). More information may be given to these individuals than in the peer consultation process.
2. If a third party payor, such as an insurance company, is providing payment, Cathexis will release only that information relevant to financial obligations and balances.
There are some situations where Cathexis is permitted or required to disclose information without either your consent or Authorization:
A. If you are involved in a court proceeding and a request is made for information concerning the profession services Cathexis provides, such information is protected by the therapist-client privilege law. Cathexis cannot provide any information without you or your legal representative’s written authorization or a court order. If you are involved in or are contemplating litigation, consult with your attorney to determine whether a court would be likely to order Cathexis to disclose information.
B. If a government agency is requesting the information for health oversight activities, Cathexis may be required to provide requested information.
C. If a client files a complaint or lawsuit against a Cathexis therapist, Cathexis may disclose relevant information regarding the client in order to defend the staff member if necessary.
D. If a client files a worker’s compensation claim and Cathexis is providing services related to the claim, Cathexis must, upon appropriate request, provide reports to the Worker’s Compensation Commission or the insurer.
There are some situations under which Cathexis is legally mandated to take actions which are necessary to protect others from harm. Should a mandated situation arise, Cathexis may be required to reveal some information about a client’s treatment. These situations are unusual.
a. If a client threatens to harm herself/himself, Cathexis may be obligated to seek hospitalization for her/him or to contact family members or others who can help provide protection.
b. If Cathexis has reason to believe that a child under 18 is or has been the victim of injury, sexual abuse, neglect or deprivation or necessary medical treatment, the law requires that Cathexis file a report with the appropriate government office (usually Department of Child Safety). Once a report is filed, Cathexis may be required to provide additional information.
c. If Cathexis has reason to believe that any adult client who is either vulnerable and/or incapacitated and whom has been the victim of injury, abuse, neglect or deprivation or financial exploitation, the law require that Cathexis file a report with the appropriate government office. Once a report is filed, Cathexis may be required to provide additional information.
d. If a client communicates an explicit threat or imminent serious physical harm to a clearly identified or identifiable victim and Cathexis believes that the client has the intent and ability to carry out such threat, Cathexis must take protective actions that may include notifying the potential victim, contacting law enforcement or seeking hospitalization for the client.
If such a situation arises, Cathexis will make effort to fully discuss the situation with you before taking any action and my disclosure will be limited to that information necessary for safety. While this written summary of exceptions to confidentiality should prove helpful in understanding my legal obligations, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be complex, and some situations may require formal legal advice.
Keep in mind that your records are property of Cathexis, and will remain in our confidential care. A written request with signature and date is required if you desire access to yours or your child’s records.
The laws and standards of our profession require that Cathexis keeps Protected Health Information about you or your child in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you only request these records in extenuating circumstances and that you initially review them in your counselor’s presence or have them forwarded to another mental health professional so you can discuss the contents. In most situations, Cathexis is allowed to charge a copying fee of $.07 per page.
In addition, your counselor also keeps a set of Progress Notes. These notes are for the therapist’s use and are designed to assist him/her in providing you with the best treatment. While the contents of Progress Notes vary from client to client, the content typically consists of the conversations during session, the counselor’s assessment of the session and the plan or impact on your therapy. The Progress Notes may include sensitive information that is not part of your Clinical Record. Progress Notes are not released to other parties (i.e. doctors, insurance companies) without explicit written consent and direction from you. You may examine and/or receive a copy of your Progress Notes unless Cathexis determines that such access is clinically contraindicated.
YOUR RIGHTS AND RESPONSIBILITIES AS A CLIENT OF CATHEXIS
When you receive services from Cathexis you have the right to:
– Receive high-quality service
– Be treated with respect and courtesy
– Have your information kept private and confidential except as described in Cathexis Privacy Statement
– Be listened to and have staff work with you to make a plan to address your concerns and needs
– Receive service in offices that are safe, clean and accessible, and respectful of your individuality, choices, strengths and abilities
– Get information and support to help you make decisions to improve your situation
– Be served without harassment or discrimination based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis
– Discuss your service with staff to identify if it is working for you and express any questions or complaints that you may have; at any time you have the right to refuse counseling
– Request a change of staff member if there is another staff person available who can address your issues and your request is reasonable — you should know that discriminatory requests will not be considered. Patient also has the right to request a referral to another health care institution if you feel the care you are receiving from Cathexis is not improving your situation
– To participate, or have your legal guardian participate in the development of, or decisions concerning the counseling provided at Cathexis.
– To participate or refusal to participate in research or experimental treatment
– To receive from family, legal guardian or others individuals assistance in understanding and exercising your patient’s rights.
– Have the ability to review, upon written request, patient’s own medical files or financial records.
– It is not Cathexis’ usual practice to photograph our clients, but in the event that a circumstance arises, patient has a right to accept or decline in writing.
This is what we ask from you:
– Treat the staff and others at Cathexis with courtesy and respect
– Let your assigned counselor or Cathexis staff know when you will not be able to keep a scheduled appointment at least 24 hours in advance. Please understand that for most of our counselors are on site for scheduled appointments only. As a courtesy to your counselor, please give them ample notice of cancellation.
– Should you have concerns or complaints regarding the care you have received from Cathexis, we ask that you follow the Patient Complaint Process described in the following section.
Patient Complaint Process Policy and Procedures
Cathexis values and encourages the feedback of its clients regarding the programs and practices of the organization. Complaints can provide important opportunities for improving service. A complaint may be defined as an expression of dissatisfaction or unmet expectation. A complaint can be made by the patient with support if necessary. The complaint can relate to any aspect of the organization’s programs and services. A patient or legal guardian who believes they have experienced discrimination at Cathexis can file a claim about this facility with the Arizona Department of Health Services by utilizing the Medical Licensing Online Complaint Form, found at https://app.azdhs.gov/Is/online_complaint.aspx, or by contacting the department at 602-542-1025 or 150 N 18th Ave, Phoenix, AZ 85007.
The Privacy Officer for Cathexis is the Chief Administrative Officer, Susie Mills, who can be contacted at 520-271-0628.
Cathexis is committed to listening to patient complaints and responding in a fair, timely and respectful manner. All complaints will be given due consideration without reprisal or discrimination. Language support for non-English speaking patients will be provided.
Cathexis actively informs patients of their right to register complaints (verbal or written) and seek resolution. This information is accessible and publicized in Cathexis Client Rights and Responsibilities, and is available on our website or by request. Patients who speak languages other than those covered by the latter documents or who have reading difficulties are encouraged to have this policy explained to them by a Cathexis staff person at the beginning of service. Cathexis will assist persons with disabilities to register their complaints and seek resolution.
All aspects of a complaint will be handled in confidence. However, if the complaint involves allegations of illegal or unethical behavior, information may need to be shared with external authorities.
All complaints are documented. The maintenance of complaint files is the responsibility of the Chief Administrative Officer.
Complaints deemed a risk to the organization are brought forward to the Chief Administrative Officer or the Chief Executive Officer/Clinical Director, who will review the details of the situation and decide on the appropriate and immediate action. The Chief Executive Officer/Clinical Director will record the details of the complaint and actions taken to resolve the issue, and will be revisited at the shareholder Cathexis Quality Management Program Annual Review Meeting. Clients with questions, comments or complaints about Cathexis privacy policies and procedures or about the collection, use or disclosure of their personal information will be directed to the Privacy Officer.
As the goal of Cathexis is to give sufficient local authority to meet patient needs, complainants will be encouraged, but not required to work through the lines of authority within the organization.
To provide maximum support to the staff-patient relationship, the complaint resolution process begins with the involvement of the staff person who provided service, unless this is not in the best interests of the service user or community member.
STEP 1: Receiving a Complaint
a. If the person providing service receives the complaint the patient should be offered the earliest opportunity to discuss their concern(s).
b. If the complaint is received by any staff member or volunteer of the organization other than the person providing service the patient should be directed to the person providing service with an explanation of Cathexis policy. If the complainant is reluctant to speak directly to the person providing service they should be referred to that person’s immediate manager. The person providing service should be alerted to the existence of the complaint.
c. In hearing a complaint the person providing service may decide to involve or consult their manager at any stage. This option should be taken if the service user brings a friend or advisor.
d. If the complaint is handled to the mutual satisfaction of the complainant and the person providing service, the complaint and resolution is documented on the Complaint Form and a copy is forwarded to the manager of the person providing service and the department director.
STEP 2: Discussion with the Chief Administrative Officer
a. If the person providing service is unable to resolve a complaint, the complainant is offered the opportunity to speak with the Chief Administrative Officer (Susie Mills, 520-271-0628,firstname.lastname@example.org).
b. The preferred method is to have the Chief Administrative Officer call the patient. This affords the staff person the opportunity to discuss the matter with the manager prior to any further action or outreach to the complainant.
c. The Chief Administrative Officer calls the patient as soon as possible after consulting with the staff who provided the service.
d. If a patient calls the Chief Administrative Officer to complain about the person providing the service or about the service provided, the manager should hear the complaint, but offer no action without discussing the matter with the staff person involved.
e. From the point the Chief Administrative Officer takes a call from a patient or calls a complainant about a complaint, a meeting between the manager and complainant should be offered within five working days.
f. The staff person(s) and Chief Administrative Officer should jointly plan the response to the service user’s or community member’s complaint. Whenever possible the plan should support the integrity of the service user/community member/staff relationship and unless clearly contraindicated, the staff person will be present at any meeting between the manager and complainant.
g. The role of the Chief Administrative Officer is to resolve the matter to the satisfaction of the patient and staff person(s) or, failing this, to inform the complainant of their right to seek resolution through a meeting with the Chief Executive Officer/Clinical Director (Tim Mills, 520-303-8394, email@example.com).
h. A letter must be sent to the patient within two weeks of the meeting. The Chief Executive Officer/Clinical Director is informed of the complaint and the resolution or lack of resolution.
STEP 3: Meeting the Chief Executive Officer/Clinical Director
a. If the patient is not satisfied with the response from the Chief Administrative Officer the complainant may take the complaint to the Chief Executive Officer/Clinical Director and should be informed of the name and phone number of the Chief Executive Officer/Clinical Director.
b. The Chief Executive Officer/Clinical Director should be alerted immediately if a call is anticipated and a copy of the completed Complaint Form should be provided.
c. If requested, the Chief Executive Officer/Clinical Director will meet with the patient within two weeks and attempt to resolve the matter.
d. Prior to this, the Chief Executive Officer/Clinical Director will inform the Chief Administrative Officer and the staff person(s) of the approach and seek any necessary consultation.
e. Whenever possible the Chief Executive Officer/Clinical Director will involve the staff person(s) and Chief Administrative Officer in the planning process and may invite one or all of them to the meeting.
f. Prior to the meeting the Chief Executive Officer/Clinical Director will ensure that a letter bearing his/her signature is sent to both the patient and the Chief Executive Officer/Clinical Director outlining the complaint and all the steps taken to resolve the complaint.
g. Within two weeks of meeting the service user or community member, the Chief Executive Officer/Clinical Director will send a letter to the complainant setting out any agreement reached, or failing this, the Chief Executive Officer/Clinical Director ‘s decision regarding the complaint. The person(s) providing the service and those at the first level of authority will be kept informed throughout all attempts to resolve complaints. In instances where there is an allegation of criminal or serious ethical breach of conduct by Cathexis personnel, the Chief Executive Officer/Clinical Director may waive the requirement to inform personnel until legal and/or police advice is sought and may continue to refrain from informing the person during the course of an investigation providing there is no breach of a legal or contractual standard. While every attempt should be made to achieve a positive resolution with the complainant, the integrity of Cathexis policies and the integrity and safety of Cathexis personnel and other service users or community members must be maintained.
All complaints received from a patient are initially documented by the staff person who received the complaint using the Complaint Form. A flag noting that a complaint has been received is placed in the client or community member’s record. A copy of the complaint is forwarded to the staff person’s manager.
The complaint file (includes all documentation, correspondence, resolution and follow up) is maintained separately from the patient’s client record in the appropriate directors office.
A record of the complaint will be made available to the complainant on request except in the case where the confidentiality of another patient may be breached. These records will be retained for the same period of time as the client or community member record (currently this period is 10 years).