We welcome you to Still Waters Professional Counseling Services, Inc. (SWPCI)!
Upon entering treatment and receiving any services at SWPCI, you (or the person legally representing you) have signed a consent form and agreed to the following terms.
These terms include several subjects such as:
Participant’s Rights and Responsibilities
Privacy Practice Notice
Consent to Treat
Financial Responsibility
We encourage you to fully understand all of your rights and our expectations as it relates to your experience with us.
You have been given a card with the link to this page for a reference. Feel free to refer back to these terms anytime you like.
If you have any questions about these terms please feel free to ask questions to either the management staff or your counselor.
Participant’s Bill of Rights and Responsibilities
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 through 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)
Privacy Practice Notice
1. SWPCSI 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. SWPCSI required 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. SWPCSI 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. SWPCSI will endeavor to answer any question you have regarding your privacy rights.
13. SWPCSI reserves the right to change these practices without notice.
Consent to Treat
Individual’s Rights and Terms with Respect to Treatment:
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 make 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 person I legally 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 agree to play an active role in this process. I understand that no promises have been make 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 person I legally 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-party 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 my child(ren) 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 consent signature on Still Waters Consent Form S9 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.
Financial Responsibility Agreement to Pay
As part of the registration process prior to appointments, I understand that Still Waters Professional Counseling Services, Inc. (SWPCI) will determine if I (or the individual I represent) will be billed via insurance or “self-pay” methods.
Self-Pay:
I understand that if it is determined that I (or the individual I represent) a “self-pay” that I may request a review for a sliding scale fee.
Sliding Scale Discount:
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 applications 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 SWPCI 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, SWPCI will require a minimum payment of $20 per visit regardless to 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 SWPCI 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, SWPCI staff will contact me to establish a payment plan. Also that if is determined that that there has been insufficient PAYMENT activity to pay in full the balance due, an account may be turned over to a collection agency.
Minimum Payment:
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 SWPCI 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 SWPCI staff will request and expect payment at time of visit and that if payment is not rendered that SWPCI 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 SWPCI 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.
Bundling of 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 that bundled services are non-refundable.