New Client Paperwork – SFISD

Service Expectations:

• Individual Counseling/Psychotherapy
  I understand that, in general, the goal of psychotherapy is to help my child to learn to cope independently with stressful demands of life and/or remove obstacles to success or healthy relationships with others. Depending upon the needs of the student, the duration of therapy varies. To ensure maximum effectiveness, the student’s assigned therapist will discuss goals of therapy in early sessions and periodically review progress thereafter.
• Group Psychotherapy
  I understand that in group counseling, my child will learn to deal with issues through sharing with peers who are experiencing or have experienced similar issues and problems. Counselors examine potential coping strategies, relational approaches, and encourage peer support under the supervision and facilitation of a trained provider.

In All Modalities:

I am aware that, in the initial stages of counseling, there is the possibility that my student may experience short-term reactions in response to underlying issues that naturally come to the surface before their therapist can assist in developing effective coping skills and resolutions. Potential short-term symptoms include increased stress, emotional discomfort, and/or the disruption of current interpersonal and family relationships. Once goals are established and the work begins in earnest, these effects typically subside rather quickly.

Confidentiality:

The provider and Innovative Alternatives, Inc. follow all applicable laws, rules, regulations, guidelines, as well as codes of ethics and codes of conduct concerning privacy and those related to the client/therapist relationship regarding psychotherapy sessions and the storage of records. Please remain aware, that there are legal exceptions to your expectation of privacy regarding psychotherapy sessions and the records documenting these sessions. Exceptions to confidentiality involve situations in which the provider is obligated, by law, to disclose information, including instances involving:

• Abuse or neglect of minors;
• Abuse, neglect, or exploitation of elderly or disabled persons;
• Abuse, neglect, illegal, unprofessional, or unethical conduct in an inpatient mental health facility, residential school, a chemical dependency treatment facility, a hospital providing comprehensive medical rehabilitation services, or of any client in nursing facilities;
• Sexual exploitation of any client by a mental health service provider; or a service provider's improper conduct with a client
  2which rises to the level of unethical practice according to the provider's governing licensing Board;
• A client who presents a danger to self or others in the best judgment of the provider;
• Court orders or DistrictAttorney subpoenas for disclosure of information or records;
• Parents of a minor client requesting information or records, unless such a release presents a danger or potential harm to the child or may have a negative influence on the child's mental or emotional state or create potential harm to the treatment relationship between child and provider. In such cases, Health & Human Service laws instruct providers to prepare a 'Treatment Summary' for parents which only discloses dates of service, whether the child is participating in treatment, and whether the child is making progress in treatment, but the provider is not required to relay any other content of sessions with that child; Health & Human Service laws instruct providers to prepare a 'Treatment Summary' for parents which only discloses dates of service, whether the child is participating in treatment and whether the child is making progress in treatment, but is not required to relay any other content of sessions with that child;
• Funding agencies audit Innovative Alternatives, Inc. or its programs. This is only possible for Victim Assistance & SF Resiliency Center Programs, but in 3 decades of service, client records have not been requested from IA by this funding agency, only financial records. They do reserve the right to audit charts;
• Requests for your child’s records after signing a 'Release of Information Form' asking us to disclose certain information to other physicians, employers, court, family members, or other medical or mental health providers. Once the information is out of our hands, IA has no responsibility for securing your child’s privacy. After having been voluntarily released by you, the guardian, if you wish to limit the scope of what is released, you must define which items we should release and items to keep confidential;
• Voluntarily giving a testimonial or consent to participate in research or evaluation activities conducted by IA. While information of this kind is always de-identified, recognition of your general story by others is beyond our control. It is best not to write such testimonials or to participate in research if you feel your circumstances are unique enough for recognition by persons who know you;

By signing below, you acknowledge your understanding that expectation of privacy is limited, that client/provider communications and therapist records are sometimes disclosed to third parties under the circumstances above, and that you are aware of the HIPAA Notice of Privacy Practices employed by Innovative Alternatives, Inc. I am also aware that, at any time, I may receive a copy of the HIPAA Notice upon request or can review it in IA's office or on the IA website at www.innovativealternatives.org

Treatment Team Approach:

By signing below, you are permitting discussion of your child’s case with a program clinical supervisor and/or treatment team within this agency. Information is shared among staff treatment providers and clinical supervisors only as appropriate to ensure the highest professional quality and coordination of service.

As the parent of a minor client, IA desires to collaborate with you in your child’s treatment. You also have the right and are welcome to, call at any time to schedule a phone or in-person consultation with your child’s provider, for any reason, or simply to receive updates on their progress. The provider may periodically call you for information about your child’s mood/behavior at home or may wish to share techniques to use at home to assist in coping with trauma or other symptoms.

Court Involvement of a Psychotherapist:

I understand that IA charges for all time spent and all expenses incurred by a therapist or other representative of IA inresponding to any subpoena, whether for an in-person court appearance, preparation of documents in my chart aboutme or my child, regardless of whether the subpoena was requested by me,by an attorney on my behalf, or at times by an opposing counsel, if you as the client or guardian wish for yours or your child’s provider to appear in court. Services subject to billing include, but are not limited to, time preparing for testimony, telephone contacts, review of any correspondence related to the case, review of records, duplication of records, waiting to testify and testifying, traveling, parking expenses and meals if at the courthouse during or adjacent to customary mealtimes.

I agree to provide a $1,500.00 advance retainer as soon as a subpoena is received by a therapist. Time is charged at an hourly rate of $175.00. All expenses are charged against the retainer as they are incurred. I agree to pay all such amounts promptly upon receipt of a phone call requesting payment via credit card from IA staff or receipt of a bill. I agree that waiting to inform the counselor until the last minute that I need them in court does not obligate this agency or the provider to go through extraordinary efforts to meet such deadlines. I am hereby informed that this is often a basis upon which this agency can file a 'motion to quash the subpoena for insufficient preparation time. I agree to work collaboratively and to strongly encourage my attorney to work cooperatively with IA and my provider for the benefit of my case and to prepare my provider adequately for court appearances. IA agrees to prompt reimbursement of any unused portion of the advance retainer. I agree to make payment of court fees owed to IA regardless of the outcome of court proceedings and whether or not the testimony of the psychotherapist helps or hurts my case.

Grievance Procedure or Complaints against a Psychotherapist:

The relationship between the provider and the client is considered a professional one. The provider’s professional code of ethics prohibits any other relationship between the provider and the client while the professional relationship exists and extends for sometime, thereafter, prohibiting any non-counseling activity initiated by either the provider or the client to establish a nontherapeutic relationship of any kind.

If you have a complaint against a licensed or credentialed provider of this agency, we ask that you follow this complaint procedure:

• Discuss the issue with your provider, if possible, and let them know how they can better meet your needs. All providers at IA are happy to help you find a good match and will not take offense if the issues are best addressed by a change in treatment provider.
• f the request for a new provider is based on more than simply match preference, please request another provider from the Intake personnel in the front office of IA. Please let us know what you felt the first provider did or did not do that made it difficult for you todo your work, so we can require more coaching or training and prevent future issues of the same sort for other clients. We are happy to arrange this time outside your session time without charge to you if preferred. Call or place your complaint in writing to the President & CEO of IA at 713-222-2525 or sbayus@innovativealternatives.org
• f this action is still not satisfactory, or the complaint is about the President & CEO, you may submit your complaint in writing to the Board of Directors of IA. Address your complaint to the Chair of the Board of Directors. The current Chair can be found by calling IA at713-222-2525 or on our website at: www.innovativealternatives.org
• Anyone who wishes to file a complaint against a healthcare professional in this state may call the Health Professions Council toll-free complaint referral system: 1-800-821-3205. This automated, statewide number routes a complainant to the appropriate licensing agency.

Agreement of all Counseling Clients:

By signing below, I acknowledge that I have read, understood, and agree to everything in this Consent for Service to myself or my child. Further, if the client is a minor, I acknowledge, represent, and warrant that I have the legal right to agree to the services on behalf of the child named below and will present court documents on request following a divorce to demonstrate this right.