Consent to Treat
SOUL EMINENCE CENTER : CONSULTING INFORMED CONSENT
BEHAVIOR AND MENTAL HEALTH CONSULTING INFORMED CONSENT
Welcome to Soul Eminence Center. This document contains important information about consulting services and business policies. When you sign the consulting agreement it will represent an agreement between you and Soul Eminence Center. We can discuss any questions you have when you sign the agreement or at any time in the future.
Consulting is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. Behavior and Mental Health Consultants are not licensed mental health care or medical professionals. Consulting services are meant to help you identify the areas in you or your family's life that may be standing in your way. Consulting is not professional mental health care or medical care.
As a client you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of.
I understand that the consulting services I will be receiving from my Consultant are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Consultant is not acting as a mental health counselor or a medical professional.
I understand that consulting is, at present, an unregulated industry and that my Consultant is not licensed by the State of Arizona or any other state. I also understand that for all legal purposes, the services provided by my Consultant will be considered to be provided in the State of Arizona.
I understand and agree that I am fully responsible for my well-being during mine or my family’s consulting sessions, and subsequently, including my choices and decisions.
I understand that consulting is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy.
I understand that all comments and ideas offered by my Consultant are solely for the purpose of aiding me or my family in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my Consultant to assist me in achieving such goals.
I understand that to the extent our work together involves career or business, my Consultant is not promising outcomes included but not limited to increased clientele, profitability and or business success.
GOALS OF CONSULTING
There can be many goals for services. Some of these will be long-term goals such as improving the quality of your life. Others may be more immediate goals such as decreasing strong emotional reactions, developing healthy relationships, changing behavior or decreasing undesirable behavior. Whatever the goals are, they will be set by the clients according to what they want to work on. Our consultants may make suggestions on how to reach that goal but you decide where you want to go.
RISKS/BENEFITS OF SERVICES
Consulting is an intensely personal process that can bring unpleasant memories or emotions to the surface. Some undesirable behaviors may increase as a result of interventions being used. There are no guarantees that services will work for you, your child, and family. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Behavior change requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of services.
However, there are many benefits that can help you, your child, and family develop coping skills, make behavioral changes, reduce symptoms of mental and behavioral health disorders, improve the quality of your life, learn to manage anger, and many other advantages.
Appointments will ordinarily be 50 minutes in duration, once per week, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, please let us know within 24 hours before the appointment. If you miss a session without canceling, or cancel with less than 24-hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. You are responsible for coming to your appointment on time, if you are late, your appointment will still need to end on time.
If you are unable to keep an appointment, please notify us immediately by phone, email, or text (610) 653-4021. If an appointment is canceled or missed without 24 hours prior notice, (24 hours does not include weekends) you will be billed for the late cancelled or missed in-office session at the rate of $50 and $75 for a late cancelled or missed in-home/school session. Third and subsequent late cancellations will be billed the full fee.
You are responsible for paying at the time of your appointments unless prior arrangements have been made. Payment must be made by credit card or cash. If you refuse to pay your debt, Soul Eminence Center reserves the right to use an attorney or collection agency to secure payment. If you anticipate becoming involved in a court case, we recommend that you discuss this fully before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required.
RELEASE OF LIABILITY
I hereby release, waive, acquit and forever discharge Soul Eminence Center, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Consultant as a result of the advice given by my Consultant or otherwise resulting from the consulting relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.
Soul Eminence Center will make every effort to keep your personal information private. If you wish to have information released, photograph taken, and sessions recorded you will be required to sign a consent form before such information will be released.
CONFIDENTIALITY FOR MINORS
If you are seventeen years of age and under the guardianship of your parents, they have the right to review your records. We try to work with parents to limit what is disclosed to them at your request, but ultimately they are able to access your records.
LIMITS TO CONFIDENTIALITY
You have the right to have your privacy protected in keeping with federal and state regulations.
Clients can expect that any information, verbal or written, is kept confidential. No information about you will be released without your written authorization except:
During the service authorization and quality assurance process provided by the Soul Eminence Center Multidisciplinary Team.
During required record audits conducted by Soul Eminence Center, licensing authorities, and other contracted agencies.
When we receive a court order to release your records and/or the verbal or written testimony of your service provider.
When an emergency exists and withholding information puts you or someone else in danger.
When there is a reported incidence of child abuse or neglect.
When County, State and Federal regulators require us to summarize client or service information, but in a way that ensures that clients are anonymous.
If you are being seen in conjunction with your spouse and/or other family members, written authorization must be obtained from all adult participants before any information will be released about the services provided. If only one member authorizes release of information, information will be redacted from the record pertaining only to the individual authorizing the release.
CONFIDENTIALITY AND GROUP SERVICES
The nature of group services makes it difficult to maintain confidentiality. If you, your child, and family choose to participate in-group services, be aware that Soul Eminence Center cannot guarantee that other group members will maintain your confidentiality. However, Soul Eminence Center will make every effort to maintain you, your child, and family’s confidentiality by reminding group members frequently of the importance of keeping what is said in-group confidential. Soul Eminence Center also has the right to remove any group member from the group should they discover that a group member has violated the confidentiality rule.
CONFIDENTIALITY AND TECHNOLOGY
Some clients may choose to use technology in their services. This includes but is not limited to online services via Skype, Go to Meeting, telephone, email, text or chat. Due to the nature of online treatment, there is always the possibility that unauthorized persons may attempt to discover your personal information. Soul Eminence Center will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used. Should a client have concerns about the safety of their email, Soul Eminence Center can arrange to encrypt email communication with you.
Soul Eminence Center requests client’s email addresses. Clients have the right to refuse to divulge their email address. Soul Eminence Center may use email addresses to periodically check in with clients, send updates on progress with client consent, and send newsletters with valuable information.
Soul Eminence Center keeps records of your services. This includes intake paperwork, progress notes, and other documentation. These records are kept to ensure progress is being made. They will not be shared except with respect to the limits to confidentiality discussed in the confidentiality section. Should the client wish to have their records released, they are required to sign a release of information that specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically or in a paper file and stored in a locked cabinet in the office.