Consent Form New

I UNDERSTAND that if it is determined that I (or the individual I represent) is a “self-pay” that I may request a review for a sliding scale fee.

I UNDERSTAND that if I (or the individual I represent) apply for the sliding scale fee discount program, and that I must provide written verification of monthly income and family size. Which can include examples such as: Prior year’s W-2 forms or the two most recent pay stubs.

I UNDERSTAND that my eligibility for the sliding scale fee discount program will be reviewed every six months and that once approved, the application's 6 month life will start with the date of the submission of the form.

I UNDERSTAND that I am obligated to notify Still Waters immediately if my (or the individual I represent) income or household status changes before the 6 months has expired for any Sliding Scale Discount application on file.

I UNDERSTAND that in the event, I (or the individual I represent) do not have a way to provide written verification, in special circumstances, I (or the individual I represent) may do a “self-declaration” and this will entail
providing a signed statement of income, and why(s) I (or the individual I represent) are unable to provide independent verification and that this statement will be presented to Still Waters management for review and final determination as to the sliding scale discount fee percentage.

I UNDERSTAND that as a “self-declared individual’ I (or the individual I represent) will be responsible for 100% of the charges until management determines the appropriate category.

I UNDERSTAND that, Still Waters will require a minimum payment of $20 per visit regardless of the status of any Sliding Scale Discount Fee application that may be being reviewed.

I UNDERSTAND that my (or the individual I represent) Sliding-Scale discount fee accounts are handled in a manner consistent with payment and collection policies offered by other businesses that extend credit
and that I (or the individual I represent) on the sliding-scale fee will be billed at least monthly.

I UNDERSTAND that all accounts must be kept current, and Still Waters Financial Counselors will work with me (or the individual I represent) to establish payment plans.

I UNDERSTAND that after 30 days of no payment activity on my (or the individual I represent) account, Still Waters staff will contact me to establish a payment plan. Also that if is determined that there has been insufficient PAYMENT activity to pay in full the balance due, an account may be turned over to a collection agency.

I UNDERSTAND that if I (or the individual I represent) documentation qualifies me (or the individual I represent) for the Minimum Payment category, I am expected to apply for publicly available insurance through Medicaid.

I UNDERSTAND that the Minimum Payment category is considered a
temporary eligibility category until Still Waters receives verification of
Medicaid eligibility. If positive verification is received, those visits become insured. If negative verification is received, the visits remain at the Minimum Payment category. If the application is pending, related visits will remain at the Minimum Payment category.

I UNDERSTAND that Still Waters staff will request and expect payment at time of visit and that if payment is not rendered that Still Waters staff will reserve the right to reschedule my (or the individual I represent) session but that exceptions will be made for crisis situations.

I UNDERSTAND that consistent non-payment for Still Waters services is grounds for termination of non-emergent services and that if my (or the individual I represent) balance exceeds $250 that I (or the individual I represent) may be asked to stop using services, or may be required to pay all outstanding balances in full before receiving further services.

I UNDERSTAND that if interested, I may purchase a bundle of services (6 counseling sessions and one psychiatric visit) at a 20% discount. This discount cannot be combined with the sliding scale fee discount and bundled services are non-refundable.

I do hereby seek and consent to take part in the treatment
provided by this agency. I understand that developing a
treatment plan with this therapist and regularly reviewing our
work toward the treatment goals are in my best interest.

I agree to play an active role in this process. I understand that
no promises have been made to me as to the results of treatment
or of any procedures provided to me by this therapist.

I am aware that I (or the individual I represent) may stop treatment with this therapist and/or program at any time. I understand that I
may lose other services or may have to deal with other problems
if I stop treatment. (For example, if my treatment has been
court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel or
do not show up, I may be charged for that appointment, except in
cases of extreme emergency.

I am aware that an agent of my insurance company or other
third parties may be given information about the type(s),
cost(s), and providers of any services I receive. I understand
that any fees not covered by insurance or other third-party payers are my responsibility. If payment is not made, for the services I receive here, services will be terminated and my account could be referred to a collection agency.

I may be assigned to a student who is a Counselor in training
or a staff member who is working towards obtaining licenser. I understand that if I am assigned to a Counselor in training any
conference, evaluation, or relevant information may be observed
by and/or discussed with the appropriate supervisor.

I understand that counseling services are confidential and my
records and/or my child’s are protected by state and Federal laws. However, in circumstances concerning threat or danger to
self or others, confidentiality may be disregarded for my safety
and welfare or that of others. By law, we are mandated reporters
in cases of child abuse and neglect for persons under eighteen (18) years old as well as the elderly.

I grant permission for audio and/or video recording of part or all of my counseling sessions solely for the purpose of professional training, consultation, and/or service evaluation.

As part of therapy, transportation may be provided to outside
activities and/or functions. I grant permission for the individual I represent to be transported by a staff member of Still Waters Professional Counseling Services, Inc.

I understand that services are voluntary and that I may
choose another agency to provide services if I am unhappy
with Still Waters Professional Counseling Services, Inc.. I
understand that if I behave in a vulgar and/or threatening
way, such behavior will not be tolerated and services will be
terminated.

I understand that after the three missed appointments without prior notice, services will be terminated and my case
will be closed.

I authorize and consent to Psychiatric Services and Treatment.

I have read, understand the risks, rights, and terms listed
regarding Treatment. All of my questions have been answered to
my satisfaction.

My signature shows that I have reviewed the rules for participation and agree to comply with them. I understand failure to comply with result in termination of services.

1. The participant has the right to make informed decisions
regarding his/her care and participate in decisions
regarding care, including the development and revisions of
the plan of treatment (COA: G.1.02.e).

2. The participant shall receive information necessary to
make decisions regarding his/her care and is expected to
work with staff toward set service plan and goals (COA:
G1.1.02.a).

3. Right to be informed about plan of treatment and to
participate in the planning, as able; (O.C.G.A. § 26-5-6)

4. Right to be promptly and fully informed of any changes in
the plan of treatment; (O.C.G.A. § 26-5-6)

5. Staff will communicate in a language or form the client can
reasonably be expected to understand (COA: G1.1.01).

6. Whenever possible, the company shall provide special
needs participants with the assistance necessary to obtain
special devices, interpreters or other aids to facilitate
communication (COA: G1.1.01.e)

7. The services will be provided at a time that is mutually
determined by the staff and participant. Services will be
provided during standard business hours, as well as evening
and weekend hours (as needed). Staff are available by
phone 24 hours a day, 7 days a week, including home visits
as necessary (COA: G1.1.02.b)

8. It is the expectation that participants make every effort
to keep scheduled appointments. Missed appointments
(without adequate rationale) will result in a warning that
can be followed by termination of services. Any blatantly
offensive, threatening or violent behavior could result in
termination of services. (COA: G1.1.02.c).

9. The participant is informed of any responsibilities he/she
may have in the services provided (COA: G1.1.02.a). The
responsibilities of the participant will be determined by the
Clinician’s assessment of the problem and goals that are
mutually determined for the plan of services.

10. The participant shall be provided information concerning
the Clinician’s assessment of the family problem that relates
to the services to be provided.

11. The participant may refuse all or part of his/her services to
the extent permitted by the law and shall be informed of
the expected consequences of such action (COA: G1.1.03).

12. The participant does not participate in research (COA:
G1.7.01).

13. The participant shall be informed at the beginning of
the services of charges and policy concerning payment
for services. When a participant is referred to another
organization, the participant is informed of any financial benefit to the referring organization.

14. The participant shall receive care appropriate to his/her
needs in a timely manner. There shall be continuity in the
care provided.

15. The participant shall be informed in a timely manner of the
need to transfer to another organization and/or level of
care and of the alternative, if any to such transfer.

16. The participant shall be informed in a timely manner of
pending discharge continuing care requirements, and other
available services if needed.

17. Right to confidentiality of client records; (O.C.G.A. § 26-5-6)

18. All information concerning participant services shall be
treated confidentially within the confines of Georgia law.
As required by law, staff members are mandated reporters
and are required to report situations in which an individual
is a danger to themselves or others. Information will not
be released to any organizations/individuals (outside of the referring agency) without the written consent of the
participant (COA: G1.5.03).

19. The participant shall be informed upon admission
a mechanism for receiving, reviewing and resolving
complaints. A participant Concern Form can be requested
by contacting Still Waters Professional Counseling.
(COA: G1.1.02.f).

20. The participant shall be given the opportunity to voice
grievances and recommend changes in policies and services
without coercion, discrimination, reprisal or unreasonable
interruption of services (COA: G1.1.02.d)

21. The participant has the right to insert a statement, in
their own words, into their case record. If staff inserts a
statement in response the participant has the right to
review such a response (COA: G1.6.03).
22. The participant will not present under the influence of
alcohol or illicit drugs. Alcohol, undocumented prescription
medication, or illegal substances are not allowed on the
premises. Tobacco products are only allowed outside and
must be extinguished and disposed of properly.
23. The participant will receive a Privacy Practices Notice and
the opportunity to ask for additional information.
24. The participant will have access to the Consumer Handbook
or may receive a copy on request.
25. Right to a humane treatment or habilitation environment
that affords reasonable protection from harm, exploitation,
and coercion; (O.C.G.A. 26-5-5, 26-5-6)
26. Right to be free from physical and verbal abuse; (O.C.G.A.
26-5-5, 26-5-6)
27. Right to be free from the use of physical restraints and
seclusion unless it is determined that there are no less
restrictive methods of controlling behavior to reasonably
insure the safety of the client and other persons; (O.C.G.A.
26-5-5, 26-5-6)
28. Right to be informed about plan of treatment and to
participate in the planning, as able; (O.C.G.A. 26-5-5,
26-5-6)
29. Right to be promptly and fully informed of any changes in
the plan of treatment; (O.C.G.A. 26-5-5, 26-5-6)
30. Right to accept or refuse treatment, unless it is determined
through established authorized legal processes that the
client is unable to care for himself or is dangerous to
himself; (O.C.G.A. 26-5-5, 26-5-6)
31. Right to be fully informed of the charges for treatment;
(O.C.G.A. 26-5-5, 26-5-6)
32. Right to confidentiality of client records; (O.C.G.A. 26-5-5,
26-5-6)
33. Right to have and retain personal property which does not
jeopardize the safety of the client or other clients or staff
and have such property treated with respect; (O.C.G.A.
26-5-5, 26-5-6)
34. Right to be informed of the program’s complaint policy and
procedures and the right to submit complaints without
fear of discrimination or retaliation and to have them
investigated by the program within a reasonable period of
time; (O.C.G.A. 26-5-5, 26-5-6)
35. Right to have access to their own client records and to
obtain necessary copies when needed; (O.C.G.A. 26-5-5,
26-5-6)
36. Right to receive a written notice of the address and
telephone number of that state licensing authority, i.e. the
department, which further explains the responsibilities of
licensing the program and investigating client complaints
which appear to violate licensing rules; (O.C.G.A. 26-5-5,
26-5-6)
37. Right to obtain a copy of the program’s most recent
completed report of licensing inspection from the program
upon written request. The program is not required to release
a report until the program has had the opportunity to file a
written plan of correction for the violations as provided for
in these rules. (O.C.G.A. 26-5-5, 26-5-6)
38. Right to obtain a copy of the program’s most recent
completed report of licensing inspection from the program
upon written request. The program is not required to release
a report until the program has had the opportunity to file a
written plan of correction for the violations as provided for
in these rules; and
(b) Such policies and procedures shall also include
provisions for clients and others to present complaints,
either orally or in writing, and to have their complaints
addressed and resolved as appropriate in a timely manner.
(O.C.G.A. § 26-5-6)
39. Right to converse privately, have convenient and reasonable
access to the telephone and mails, and to see visitors,
unless denial is necessary for treatment and the reasons
are documented in the client’s treatment plan; (O.C.G.A. §
26-5-6)

1. Still Waters limits the use of Protected Health Information (PHI)
that is held or transmitted in any form or media, whether
paper, electronic, or oral.

2. PHI will be released to the consumer without authorization,
with the exception of Psychiatric or Psychological reports.

3. PHI will only be released for treatment, payment, health care
operations, related to another permitted use, public interest,
and limited data for research or public health without the
consumer’s authorization.

4. PHI will obtain authorization for release of PHI for any reason
that is not considered for treatment, payment, and or health
care operations.

5. Still Waters requires a signed Release of Information
Authorization to disclose information to a third party. This
release will be specific in terms of to whom and what information shall be released.

6. The general Release of Information Authorization covers
most of your PHI and the information in your file, with the
exception of Psychiatric or Psychological reports.

7. HIPAA has additional requirements for Psychiatric or
Psychological reports. We require a separate Authorization to
release this information due to content.

8. You have the right to review and obtain a copy of any release
of your PHI.

9. You have the right to restrict use and/or disclosure of your PHI.

10. You have the right to request how we communicate your PHI
with you by designating an alternate address or other means.

11. Still Waters has and applies sanctions against employees who
violate our Privacy Practices. You have the right to file a complaint if you feel we have violated your rights. We will provide you a Privacy Complaint form on request or you may obtain one at: http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf

12. Still Waters will endeavor to answer any question you have
regarding your privacy rights.

13. Still Waters reserves the right to change these practices without
notice.

All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient- identifiable images or information for this telehealth interaction to researchers or other entities shall not occur without your consent.

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telehealth consultation.

You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

You agree that any dispute arriving from the telehealth consult will be resolved in Georgia, and that Georgia law shall apply to all disputes.

You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above.

I had an opportunity to review the Consumer Handbook, or have been provided a copy.

I (or the individual I represent) accept full financial responsibility for services rendered by Still Waters as defined by the
(A) FINANCIAL RESPONSIBILITY AGREEMENT TO PAY.

I have reviewed the rules for participation and agree to comply with them as defined on the (B) CONSENT TO TREAT.

I have reviewed and have been offered a copy of the (C) PARTICIPANT’S BILL OF RIGHTS AND RESPONSIBILITIES

I have reviewed and have been offered a copy of the (D) PRIVACY PRACTICE NOTICE

I have reviewed, filled out, and consent to the (E) STATEMENT OF FAMILY PARTICIPATION.

I have reviewed, filled out, and consent to (F) PSYCHIATRIC SERVICES giving authorizations as indicated.

I have reviewed, filled out, and consent to (G) PSYCHIATRIC SERVICES - TELEPSYCHIATRY (TELEHEALTH). giving authorizations as indicated.

I have reviewed, filled out, and consent to (H) TELEHEALTH SERVICES.

I attest that I am legally authorized to act on behalf of myself or represent the individual listed above as the “Individual Receiving Services”.