Christian Counseling Center



Christian Counseling CenterDr. Angela Corrigan, LPC-S, LMFTTMHI Certified TeleMental Health PractitionerREGISTRATION INFORMATIONThis fully completed document is required as an application for mental health services. Intentionally misleading information will be deemed cause for refusal or termination of services. This document is not considered a valid contract for services until both the client and provider have provided signatures and dates thereof.CLIENT/Client InformationClient Name:____________________________ Date of Birth:_________ SS#:__________________ Phone:home:____________________________ work:________________ cell:__________________ Address:________________________________City_________________ State______Zip________ Employer:______________________________ Job Title:___________________________________Emergency Contact Name, Relation, & Phone:____________________________________________If you wish to communicate regarding appointment scheduling through text: Cell #______________ If you wish to communicate through Email: Email address: _________________________________Use of text and email communication requires client consent. Appropriate disclosures may include scheduling and referral to counseling resources. This communication does not include direct counseling services, which are rendered in the office or through TeleMental Health Practices. Client Marital Status: __Single __Married __Separated __Divorced __WidowedRace (check all that apply)__Black __Hispanic __White __American Indian _Other:__________If client is a minor ADD GUARDIAN; if married or ADD SPOUSE: Name:_______________________________________________Phone_______________________Date of Birth::____________ Employer:________________________Job Title:________________If the client is a minor: A copy of any active Custody/Visitation Order must be provided prior to services rendered. 2nd Legal Guardian Name:________________________________________Address:_____________________________________________Phone________________________ Billing Information__private pay __insurance __eapInsurance Co:_____________________ ID#:_____________________Phone:__________________Subscriber Name:______________________________DOB:_________Group#:________________Subscriber address if different:______________________________Employer:__________________I, the undersigned, assign directly to Dr. Corrigan all medical benefits, if any, otherwise payable to me for services rendered, from any and all existing medical insurance policies held at the time of treatment. I understand I am financially responsible for all charges whether or not paid by insurance, including appointments missed or cancelled without 24 hours notice. I hereby authorize Dr. Angela Corrigan to release all information necessary to secure payment of benefits, by phone, paper and electronic date submission, to the above insurance carrier. I authorize the use of the signature below on all claim submissions.Client Signature________________________________________ Date_____________________Christian Counseling CenterRegistration Informationp.2Authorization to Disclose Protected Health Information (PHI)I, _______________________________________,the undersigned, hereby authorize Dr. Angela Corrigan to disclose my Protected Health Information (PHI), or the PHI of a minor of which I have custodial rights, according to state and federal privacy standards and in the manner(s) that I have checked below and to the people/entities that I have listed below. I completely waive and release any rights of confidentiality I may have regarding such records and information, and agree to hold harmless and indemnify Dr. Angela Corrigan from any and all claims against them in connection with the release of such records or information. Please sign one HIPAA Release of Information Form for EACH entity listed below.Name(s) of entities(s) authorized for PHI disclosure1. Spouse/partner _______________________ __Treatment Planning/Consultation __Appt. Scheduling 2. Physician____________________________ __Treatment Planning/Consultation __Other_________Address:__________________________________Phone:____________________Fax_________________If the client is currently receiving mental health services from any other mental health provider, authorization to disclose PHI is required.3. Counselor_____________________________ __Treatment Planning/Consultation __Records Address:__________________________________Phone:____________________Fax_________________4. Psychiatrist_____________________________ __Treatment Planning/Consultation __Records Address:__________________________________Phone:____________________Fax_________________If Client is a Minor5. School District:___________________________ School Counselor______________________________ Address:___________________________________Phone:___________________Fax_________________6. CPS Case Worker (if applicable) ______________________________________County______________ Address:___________________________________Phone:___________________Fax_________________If Treatment is Court-Ordered7. Ordering Judge:___________________________County____________________Phone_______________8. Attorney________________________________Phone_____________________Fax_________________I understand that I have the right to revoke anyone listed on the authorization and must inform Dr. Corrigan in writing before the revocation can be completed. All revocations will be sent to Angela Corrigan, Ed.D., L.P.C.-S., L.M.F.T., to the attention of the Privacy Officer, and are not effective until received by the assigned Privacy Officer. I fully understand and accept the terms of this authorization. _________________________________________________________________________________ Client (or Guardian if Minor) SignatureDate Christian Counseling Center/Registration Informationp.3Client Background/Personal Data: The following information will not be used in determining appropriateness for service. This information is protected by state and federal law and cannot be disclosed without your written authorization. Please answer all items. This information is considered in the formulation of a treatment plan tailored to your individual health, wellness, experience, and preferences. What is your religious preference, if applicable?__________________________________________________Highest Grade Completed_____ If College; Major_________________ Highest Degree Completed_____Are you currently enrolled in training/education of any kind?________________________________________Cultural values you wish the counselor to be aware of: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________Sexual orientation: __Heterosexual __Homosexual __Bisexual __TransgenderedMedical HistoryCurrent Height:___________ Current Weight ___________ Highest Adult Weight__________Childhood Illnesses:___________________________________________________Age Diagnosed_________________Diagnosed Learning Disabilities:______________________________________________________________________Have you suffered a blow to the head in which you lost consciousness for more than a minute?_______ When?________Major Surgeries_____________________________________________________________________________________Check each of the following that you now or have you ever had and write in the year of diagnosis:High Blood Pressure______ Epilepsy_____ Alcohol Problems______ Drug Problems______ Stroke________ Other Major Illnesses __________________________________________________________Current Medications: _List psychotropic drugs first_______________________________________________________Med:_________________________Dosage_______ MD__________________________Year started_______________Med:_________________________Dosage_______ MD__________________________Year started_______________Med:_________________________Dosage_______ MD__________________________Year started_______________Do you take medications which are not prescribed to you?______ Medication Name:_____________________________How many cigarettes do you smoke in a week?____________ Interested in decreasing/stopping use of cigarettes?______How much do you drink in a typical week?________________ Interested in decreasing/stopping use of alcohol? _______Do you think you, or your partner, or your children, drink or use drugs too much? _____ Who?_____________________Have you ever received drug/alcohol treatment?______ Do you attend AA/NA?____ Do you have a sponsor?____How many stimulant beverages (coffee, tea, caffeinated soda, monster, etc) do you drink in a typically day?___________Have you participated in huffing gas?_______ Paint?_______ Synthetic drug use (k2, spice, etc)?______________Have you ever attempted suicide ________ When?_____________ Treatment Received? yes____ no____ Are you at risk of harming yourself currently?____ Are you willing to commit to not harming yourself?____Prior/Current Mental Health Treatment, both inpatient and outpatientWhere?________________________________________When?__________ For What?___________________________ Where?________________________________________When?__________ For What?___________________________ Where?________________________________________When?__________ For What?___________________________Christian Counseling CenterInformed Consent/Notice of PoliciesDiscussion of the boundaries of a counseling relationship is done out of an ethical commitment to helping you make an informed decision to participate with me in addressing your concerns. In fact, this commitment will carry through our counseling relationship. At any time you may ask me to explain why we are gathering information or prescribing a new approach. I will be glad to explain the purpose behind my techniques. Certain Disorders or client conditions may necessitate a referral to another treatment provider. Certain treatment methods may not be utilized by this provider. The greatest risk of counseling is that it may not by itself resolve your problem or concern. Thus, I’ll do my best to assess progress on a week to week basis. Chronic non-improvement and/or non-compliance will be treated as a reason for referral. Unusual risk inherent in any therapeutic suggestion will be described at the time to the best of my ability and alternatives will be offered. It is important that you understand that treatment may involve discussing relationship, psychological, and/or emotional issues that may at times be distressing but are intended to help you reach your treatment goal. Therapy here is not forced and you may terminate at any point. This is best accomplished in consultation with the therapist. After reading each policy carefully, provide the requested information and place your initials in the space provided to verify your understanding and agreement. If your spouse may attend sessions with you, they must also read and initial the following policy items.You may change your decision at any point by providing written intent of such directly to Dr. Angela Corrigan._______1. The communication between client and counselor is kept strictly confidential and protected Client initials by law. Exceptions to confidentiality occur in the following conditions: If the client is in danger of hurting self or others the Police Dept. or Emergency Medical Services will be contacted.If child or elder abuse is suspected Child or Adult Protective Services will be contacted. In the instance of a subpoena and court order records will be released to the court unless to do so would harm the client or violates rights according to state and/or federal law. With the client’s written authorization records will be released to the named party unless to do so would harm client.Written, oral, or electronic authorization is required for communication through text or email. Texting and email will not be used to discuss therapeutic issues, but may be used for appointment scheduling and to provide resources supplemental to the therapy process.In the instance that a minor attends therapy sessions without the parent/guardian present, the same guidelines of confidentiality may apply and information shared with the guardian regarding those sessions will be done so only if in the child’s best interest. Documentation sent to your insurance company may be determined by the insurance company and may include requirements for precertification, treatment authorization, payment, and utilization review. This documentation may include, but may not be limited to billing forms, treatment plans, progress notes, and treatment reports._______2. Confidentiality rights belong to each adult member involved in family and couple’s counseling.Client initials Complete records may only be released with each member’s authorization. Should one member of the couple/family not authorize disclosure, segments of the file provided by and specific to that member may not be released. When attending individual counseling to reach personal goals, there may be instances when it would be beneficial to have family members attend sessions as a support and enhancement to your therapeutic progress. Family members may offer a special insight as well as an opportunity to practice new skills in the therapeutic environment. Although not required by law, members of a family or couple that attend counseling are encouraged to respect one another’s privacy by not disclosing personal information revealed in session without that person’s permission. Although legal guardians have the right to access confidential counseling records of minors in their care, information from such records that was provided by, and is specific to the home life and/or personal experience of, the guardian’s ex-spouse will not be released, without consent from that party. Records requested may be provided in the form of a treatment summary letter which includes dates of attendance, symptoms, diagnosis, counseling goals and progress toward such goals. In instances that support the need for the entire record, including session notes, records will be forwarded to another mental health professional of the client’s choosing. Texts and emails require written, oral, or electronic authorization._______3. It is understood that the client’s values and beliefs will be respected and utilized as a resourceClient initials during the course of treatment.This includes values and beliefs related to spirituality, religion, and sexual orientation.._______4. In the instance of client death, upon specific request only, records may be released only to Client initials individuals named by the client, in writing, preceding death and specifically authorized by signature and date._______5. The CCC enforces policies protecting against dual relationship, including “no gift” and “noClient initials socializing” policies.Socializing is to be avoided, when possible, and includes, but is not limited to, such situations as serving on the same local committees, visits to each-other’s homes, and attendance of parties at mutual friend’s homes. Inability or refusal to adhere to these policies will result in termination of the counseling relationship and referral. It is prohibited for counselors to participate in personal social media with clients. This includes personal Facebook pages, Twitter accounts, etc._______6. Counseling records are destroyed according to state and federal law. Client initials PHI record are stored for the amount of time required by state and federal law, following which time they are shredded. Should the counselor’s death proceed this time, client records will be kept in the possession of a mental health professional or estate manager, holding a Business Associate Agreement, to be named by Dr. Angela Corrigan and communicated through the executor of Dr. Angela Corrigan’s will, and protected as mandated by state and federal law. _______7. Clients of the CCC are financially responsible for all charges whether or not paid by insurance, Client initials including appointments missed or cancelled without 24 hour notice. Clients will be billed for appointments that are not paid be insurance and those appointments missed (no-shows) or cancelled with less than 24 hour notice. If more than three sessions are missed without prior notification or emergency conditions, therapy may be terminated. Counseling sessions will be billed at $150 for the initial session, $100 for 52 min – 1 hr follow-up sessions, and $85 for 45-51 minute follow-up sessions, unless precluded by sliding scale arrangements or contract agreements with the current insurance plan. Outstanding balances that remain beyond the agreed upon payment schedule will be viewed as reason for non-renewal of services. Services may be terminated following 2 months of no contact, or 2 no-shows, unless otherwise arranged and agreed upon._______8. The Christian Counseling Center may conduct research designed to improve the counseling field.Client Initials Information from confidential counseling records that might be utilized in research include client demographics, symptoms, diagnosis, treatment plan, and interventions. Client names are not revealed nor is information disclosed that might allow readers or co-researchers to determine the identity of clients. Initial the item that best reflects your decision. You may change your decision at any point by providing written intent of such directly to the CCC. ___I DO ___I DO NOT authorize inclusion of data from my confidential counseling record in research. _______9. It is expected that the client disclose any and all current and prior mental health diagnosis, andClient initials treatment provided by qualifiedhealth professionals.It is understood that Dr. Corrigan reserves the right to refer and or decline services based on such diagnosis, competency limitations, and best practice guidelines. Please list in the spaces below any and all mental health diagnosis assigned prior to this date:Diagnosis__________________________ When? ______________ By Whom?_________________Diagnosis__________________________ When? ______________ By Whom?________________________10. Throughout the counseling process, your counselor may recommend that you listen to audio Client initials material, watch videos, or read literature relevant to your situation. Some of these materials are available for temporary use from the counselor’s office, at no charge.. It is expected that all materials provided by the counselor are returned in a reasonable time and without damage. Should materials not be returned or be returned unusable, clients will be charged $20.00 for each item._______11. Licensed Professional Counselor – Interns: Professional Counseling Interns working under the direct supervision of Dr. Corrigan and adheres to the same state and federal laws regarding privacy and the provision of professional counseling plaint Process: An individual who wishes to file a complaint against a Licensed Professional Counselor or Marriage and Family Therapist may write to: The Texas State Board of Examiners of Professional Counselors or The Texas State Board of Examiners of Marriage and Family Therapists 1100 West 49th Street , Austin, Texas 78756-3183or call 1-800-942-5540 Your signature below indicates that you have received, read and comprehend the policies and privacy practices of the Christian Counseling Center and give your full and informed consent for evaluation and treatment, if appropriate, for yourself or a minor child of which you have legal guardianship. ____________________________________ _________________________________________________________Client’s printed name Client Signature (Guardian if the client is a minor) Date ________________________________________________________________________________________________Counselor SignatureDateChristian Counseling CenterNew and Established Client Consent to the Use and Disclosure of Health Informationfor Treatment, Payment, or Healthcare OperationsI, ___________________________________________, understand that as part of my health care, the Christian Counseling Center originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care of treatment. I understand that this information serves as:A basis for planning my care and treatmentA means of communication among the many health professionals who may contribute to my careA source of information for applying my diagnosis and treatment to my billA means by which a third-party payer can verify that services billed were actually provided, andA tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionalI understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that I have the following rights and privileges:The right to review the notice prior to signing this consentThe right to object to the use of my health information for directory purposes, andThe right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operationsI understand that the Christian Counseling Center is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.I further understand that the Christian Counseling Center reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Angela Corrigan, Ed.D., change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S., mail, or, if I agree, email).I wish to have the following restrictions to the use or disclosure of my health information:__________________________________________________________________________________________________________________________________________________________________________________I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.My signature below indicates that I have read and accept the terms of this consent.______________________________________ _________________________________________ Client/Guardian Signature Printed name DateFor office use onlyConsent received by A. Corrigan and added to record on date signed.( ) Consent refused by client, and treatment refused as permitted.( ) I attempted to obtain the client’s signature in acknowledgement on the Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:Date:Initials:Reasons: ASSESSMENT OF FUNCTIONINGClient Name:____________________ Guardian/if Client is a Minor:_______________________CURRENT Emotional/Mental/Behavioral/Relational SYMPTOMS: Mark each symptom you are experiencing to a high degree in the past 2 mths__Relationship difficulties__Parenting difficulties __Lack of emotional support__Sleep problems (Insomnia) __Excessive/rapid weight loss __Excessive Sleeping__Excessive/rapid weight gain __Sadness and/or depressed mood __Poor appetite__Marital Conflict __Family Conflict __Difficulty Saying No__Mania __Nightmares __Flashbacks__Thoughts of death/suicide__Hopelessness/helplessness__Guilt and/or shame__Over-sensitivity __Excessive Jealousy __Lack of Motivation__Low self-esteem__Low energy/fatigue__Difficulties with decisions __Anger problems/irritability__Loss and/or Grief issues__Poor Concentration__Panic attacks __Anxiety and/or excessive worry__Obsessive Thinking__Compulsive Behavior __Racing thoughts__Inability to relax__Stress related problems__Phobias__Sexual problems__Substance abuse __Substance Addiction __Gambling Problems__Sex Addiction __Excessive Eating __Food Binging and Purging__Dishonesty__Stealing __Cheating__Victim of violence and/or abuse__Perpetrator of violence/abuse __Suicide attempt__Problems with Authority __Controlling Others __Communication Problems__Job problems __Learning/School Problems__Loss of interest/Pleasure__Financial Problems__Legal problems__Poor Task Completion __Other:________________________Other:______________________ __Other:________________Mark items you have experienced In the Past 6 Months__Self-mutilation__Threats of suicide __Threats of Homicide __Paranoia __Auditory Hallucinations__Visual HallucinationsC. MARITAL/RELATIONSHIP SYMPTOMS: Mark symptoms you have recently experienced__Victim of Cheating __Lack of affection__Efforts to control partner __Controlling Partner __Perpetrator of Cheating__Threats of divorce__Excessive Criticism __Intrusion from others __Isolation__Lack of quality time__Silent treatment __Insecurity __Accusations of Cheating__Stalking/following __Excessive negativity __Violence __Frequent arguing __Threats of Violence__Frequent Conflict __Lack of Intimacy __Abandonment D. Please mark each of the following LOSSES and TRAUMAS you have experienced __Sexual Abuse as Child__Physical Abuse as Child__Severe Neglect as a Child__Assault __Robbery __Witness of homicide/suicide __Domestic Violence__Kidnapping __Witness of Assault __Rape__Stalking __Homicide Attempt __Extreme Bullying__Loss of Job __Loss of Home __Death of Loved One__Ongoing Discrimination__Ongoing Emotional Abuse__Divorce __Loss of Custody of Children __Loss of Parental Rights __Exposure to Graphic Violence/Death/Dismemberment (such as first responder experience) __Other_________________________ __Other_______________________________________________Client/Guardian Signature______________________________________Date________________Outpatient Treatment PlanThe following plan provides focus and goals for your therapeutic work with Dr. Angela Corrigan. A Treatment Plan is a “living document” in that it can be modified as needed to incorporate changes in direction for the therapeutic process.Client/Client Name: ___________________________________ Date:________________ Guardian name if client is a minor:____________________________________________It is expected that counseling will result in the client(s) attaining certain goals related to the improvement of mental health. Appropriate goals are related to the symptoms experienced and the area(s) of life that the symptoms are causing difficulty in. The goal is to improve the problem areas by replacing the negative symptoms with positive functioning.DIAGNOSIS/PROBLEM AREA_________________________________________History of Symptoms __< 1 month __1 – 6 months __7 – 11 months __12 months or moreCurrent Functioning __Slight __Mild __Moderate __Severe __Very Severe __ ProfoundTreatment Modality __Individual __Marital __Family __Group Treatment Environment (s) __Office __Home __TeleMental HealthCOUNSELING GOALSImprovement in one area can automatically result in improvement in another area. For example, irrational thinking can result in poor relationships, depressed mood, low self-esteem, etc. Therefore, cognitive restructuring can improve all of these areas. Check all areas that will positively impact the presenting problem.__Develop and maintain support network __ Identify and utilize resources__ Improve Communication __Cognitive Restructuring (replacing irrational thinking) __Diagnosis/Problem Area Education __Improve Self Esteem__Assertiveness/limit setting __Conflict resolution skills__Anger management skills __Improve Social Skills__Improve Task Completion__Improve Impulse Control__Improve Concentration__Utilize effective problem solving __Grief Process Skills __Develop and utilize depression mgmt plan __Identify mood triggers __Gain personal insight__Develop and utilize anxiety mgmt plan __Effective coping skills __Goal Setting Skills__Behavior Modification __Relaxation/stress management skills__Improve Boundaries__Maintain appropriate eating patterns __Maintain adequate sleep __Appropriate exercise__Obtain evaluation by MD __Comply with treatment/medication regime__Manage time/money__Values Clarification __Spiritual Growth __Others: _____________________________ ___________________________ __ ___________________Expected Outcome & Prognosis __Return to normal functioning __Expect improvement, anticipate less than normal functioning __Relieve acute symptoms, return to baseline functioning __Maintain current status, prevent deteriorationYour signature below certifies that the information on this document contains no willful misrepresentation and that the information given is true and complete to the best of your knowledge. It is understood that any willful misrepresentation is cause for refusal or termination of treatment.______________________________________________ ____________________________________________________Client (Guardian) Signature Date Counselor Signature Date TeleMental Health Services AgreementDBA Christian Counseling Center Dr. Angela Corrigan, LPC-S, LMFT, TMHI Certified TeleMental Health PractitionerOfc: 903-737-6959 Fax: 844-737-0431 acorrigan@Informed Consent for Counseling ServicesRendered Through Electronic Real Time VideoClient Name:____________________________________ Date:_____________TeleMental Health Service involves the delivery of counseling services through the means of internet-based electronic videoconferencing using advanced communication technologies. It is to be used when the counselor and client are unable to meet face-to-face. Both counselor and client must be physically in the state of Texas when TeleMental health services are rendered. As a TMHI Certified TeleMental Health Practitioner, Dr. Angela Corrigan has been trained in the unique features of counseling through videoconference. When unable to travel to our office in person you have the option of meeting with your provider from a distant location, using your own computer and enjoying the privacy you create and maintain. In addition, when both you and the provider are unable to physically meet at the provider’s office, you may both utilize technology from a distant site to meet for a TeleMental health counseling session.Dr. Angela Corrigan adheres to the standards of the American Telemedicine Association as well as the Texas State Board of Examiners Codes of Ethics for Licensed Professional Counselors and Licensed Marriage and Family Therapists.Our Commitment to Confidentiality Video conferencing software meets federal guidelines for privacy. Computers have up-to-date antivirus software active and a firewall installed.Videoconferencing software is capable of blocking the provider’s caller ID when requested.Point-to-point encryption meeting recognized standards is used to ensure security of audio and video transmission. FIPS 140-2 (Federal Information Processing Standard) lists AES (advanced Encryption Standard) as providing acceptable levels of security.Provider mobile devices require a passphrase or equivalent security to access the device. Access to client contact information will be adequately restricted. Multifactor authentication will be used if available. Mobile devices will be configured to utilize a timeout function that requires re-authentication to access the device after the timeout threshold has been exceeded. This timeout will not exceed 15 minutes. Mobile devices will be kept in the possession of the provider when traveling or in an uncontrolled environment. Unauthorized persons will not be allowed to access sensitive information stored on the device. Providers will utilize devices in which they have capability to wipe their mobile device in the event it is lost or stolen.Videoconferencing software will not allow multiple concurrent sessions to be opened by a single user. Should a second session attempt to be opened, the system shall either log off the first session or block the second session from being opened. Emergency Plan RequirementThe client shall provide the provider the name and contact information for a Client Support Person of their choosing. The provider may contact this person in case of an emergency.Emergency Medical Services will be contacted in the instance of medical or mental crisis situation.The name and location of the nearest hospital will be in the record to be utilized as needed for admission in the instance of an emergency.The provider will report to persons/services contacted the nature of the crisis and immediate needs.Documentation and Storage of RecordsSession logs will be stored securely. Access to logs shall only be granted to authorized users.Any Protected Health Information that is stored digitally shall only be backed up or stored on secure data storage locations. Cloud services unable to achieve compliance shall not be used.Clients will be informed if the provider intends to record services and how this information will be used and how privacy will be protected. Clients may not record or store video-conference sessions or in-person sessions.The provider may monitor whether any of the videoconferencing transmission data is intentionally or inadvertently stored on the client or professional’s hard drive. If so, the hard drive of the provider should use whole disk encryption to the FIPS standard to ensure security and privacy. Preboot authentication will also be used.Required Technical Conditions Both audio and video capabilities must be available for each session. In the event of technical difficulties the session will be paused until technical issues are resolved. Should they not resolve in a timely manner, the session will be rescheduled to a time when all technical functionality is resumed. Should technology fail completely, the counselor will phone the number provided by the client to work toward a resolution and plan for continuation of the session.ConnectivityBandwidth must be 384 Kbps or higher. A link test may be used prior to the session to ensure the link has sufficient quality to support the session.A minimum of 640 x 360 resolution at 30 frames per secondTo ensure the most reliable connection, where wired connections are available, they should be used. Videoconferencing software should be able to adapt to changing bandwidth environments without losing the connection.Coordination of CareClients shall sign authorization for disclosure of Protected Health Information to their primary care physician and any/all behavioral health providers currently providing service to the client.Contact between sessionsContact between sessions may be made by telephone, or other previously agreed upon methods, to address scheduling and other needs. Videoconferencing may not be utilized for any other purpose than the therapy session. Session reminders and notifications will be sent to the email address provided by the client.Termination and/or ReferralShould the provider come to believe that the TeleMental Health Service environment is not conducive to therapeutic progress, a referral will be provided for in-person counseling. Should the client or provider lose the ability to utilize videoconferencing for the counseling sessions, the client may request that a referral be provided to another TeleMental health provider or that an in-office appointment be scheduled..Should the agreed upon standards of practice defined in this document be violated, the provision of TeleMental Health Services will be terminated.Payment for sessions must be provided at, or before, the time of service for all TeleMental Health Services provided.Expectations for EACH TeleMental Health SessionPhysical Setting Each party must present themselves in a setting appropriate to the services provided. Dress and environment must be appropriate to an in-office visit. Seating, lighting and camera must allow for a clear image of each party’s face. Full dress and an upright body position are required.Maintain privacy Entry of any other individual into the area of service for either the client or professional must be agreed upon by both the client and professional and be part of the agreed upon treatment plan. The presence of individuals unapproved by both parties will be considered reason for termination of the session. Verification of Identity When the identity of the client is in question, verification will be provided through the provision of legal proof of identity such as an ID card or Texas Driver’s License. A valid ID will be presented by the client during the informed consent process and copied for the client file.Verification of Location and Contact Information The client shall disclose the physical address of the location for which the TeleMental health session at the time the appointment is scheduled. No session shall occur in which the counselor is unaware of the physical location of the client. The client shall also provide a phone number at which the client can be reached during the time of the session should the connection be dropped.Client Support Person Identification The client shall inform the provider of any changes in their identified support person or emergency management protocol. Client signature below indicates that the client has read this entire document and consents and agrees with the standards outlined for the provision of TeleMental Health Services. It is understood that violation of this agreed may be seen as termination of services._________________________________________ ______________________________________Client/Guardian Date Counselor DateTeleMental Health Services Dr. Angela Corrigan, LPC-S, LMFT, TMHI Certified TeleMental Health Practitioner3420 W Houston St, Paris, TX 75460 2279 FM 728, Jefferson, TX 75657 Ofc: 903-737-6959 Fax: 844-737-0431Client Location Based Emergency Contacts The client confirms that the contact information below is accurate and up-to-date and authorizes the provider to utilize this information in the event of a medical or mental emergency, as deemed necessary to protect the client from danger to self or other.Client Name:_________________________________________________ Phone to be used for text appointment notification and reminders:__________________________ Email Address to be used for appointment notification and reminder:______________________ Client physical location (address) during TeleMental Health counseling sessions:__________________________________________Texas________________________________StreetCityStateZipLandline Phone #Phone number to be used in the instance internet connection fails_________________________Client Support Person: (name)_____________________________________________________(address)_______________________________________________________________________Relationship_____________________(phone/cell) _____________________________________Local Police Department: (phone)___________________________________________________Local Hospital: (name) _________________________________(phone) ____________________(address) _______________________________________________________________________Primary Care Physician: (name) __________________________(phone) ____________________(address) _______________________________________________________________________ (fax) __________________________Psychiatrist: (name) ____________________________________(phone) ___________________(address) _______________________________________________________________________(fax) __________________________The signatures below indicate contractual agreement to all terms outlined in this document._____________________________________________________________________________Client Printed Name (Guardian if minor)SignatureDate _____________________________________________________________________________Counselor/Provider Date ................
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