Initial Counseling, Initial Counseling Form, Consent to Treatment, Christian Treatment Center

JC Christian Counseling

1821 Oregon Pike Suite 212 / Lancaster, PA 17601 / Office: (717) 278-8326 / Fax: 1- 866-285-7198

customer service software technical support

Live Chat

Request A Call Back

New Client? Act Now!

Letter from the Director

Employment

ON-LINE CONSENT TO TREATMENT

1. I hereby voluntarily consent to receiving counseling services at JC Christian Counseling including such diagnosis and therapeutic methods deemed necessary or advisable by our counselors.

2. I am aware that the practice of counseling is not an exact science and I acknowledge that no guarantees have been made to me regarding the results of my treatment! counseling care. I am aware that I may refuse the counseling offered to me and terminate my treatment.

3. I hereby authorize JC Christian Counseling to retain, preserve, and use for research or teaching purposes information provided in the sessions without disclosure of my name or any other personal identification.

4. I understand that referrals may be made to other professionals (such as psychiatrist, psychologist, etc.) by my counselor. JC Christian Counseling (which includes the referring counselor) is not responsible for payment to other professionals on my behalf or the client receiving counseling care.

Click Here to Sign

Signature of Client or Responsible Party

Date

If signed by Responsible Person, complete one of the following:

a.) Client is unable to consent because he/she is a minor,

years of age.

b.) Client is unable to consent because

ON-LINE COUNSELING POLICY

INITIAL SESSION EVALUATION

All new clients are seen initially as a consultation for the purpose of evaluating the nature of personal needs and difficulties, discovering the desirability of counseling or referral, and recommending the type(s) of counseling. In some cases, the counselor may suggest a psychiatric or psychological evaluation for which a referral will be provided. Initial sessions for adolescents are to be attended with an adult who is the responsible party.

INITIAL INFORMATION FORMS

Each client is asked to provide information to the Counselor that will be documented on an Intake Form; this provides information helpful to the counselor and basic information for administrative purposes. In addition, this Counseling Policy, Consent for treatment and the Fee Policy must be signed prior to services. This information is kept strictly confidential.

APPOINTMENTS AND CANCELLATIONS

All appointments and cancellations of appointments are made directly through the office. If one is unable to keep a scheduled appointment, the Office must be notified at least 24 hours in advance, to RESCHEDULE your appointment. This can be accommodated by leaving the office a message on the voice mail system or by sending an email.Clients will be charged one-half of their fee for cancellations made with less than 24 hours notice. Unforeseen emergency situations will be taken into account.

TERMINATION

On-Line Counseling Sessions are paid for prior to receiving the service. Therefore; if you decide that you would not like to receive Online counseling services with us at JC Christian Counseling after your payment has been made, then contact the office within three days prior to your scheduled appointment or three days after the initial intake process (via telephone call, or email), sign the refund form and receive a full refund. If you contact us after the three day refund period then you will receive a partial refund. If you contact us on the day of your scheduled appointment, no refund will be provided.

If a client does not make contact with the office within 24 hours of the appointment time and does not attend their appointment, lack of communication that will be considered a "no-show". Two consecutive no-shows may result in inunediate termination of services, at the discretion of the counselor, and no refund will be provided.

If a client makes the decision to terminate counseling, it is requested that a termination session be scheduled with the client's counselor (rather than termination by phone or email).This is to allow time to draw closure to the therapeutic process and to provide adequate aftercare.

EMERGENCIES

On-Line Counseling does not provide "emergency services". Ifa client has an urgent concern, call the office and we will try to schedule an appointment with your counselor as soon as possible. Please contact your local Crisis Intervention Center for emergencies,or 911.

CONFIDENTIALITY

The relationship between the counselor and the client is held in strict confidence. It is legally and ethically
forbidden for the counselor to share information about a client (outside of JC Christian Counseling staff) without
prior written authorization from the client. However, in the event that there is concern that the client will or has
caused harm to themselves or others (particularly towards children) becomes apparent, the counselor is legally and
ethically required (as a mandated reporter) to report this knowledge to the appropriate entities.

NOTIFICATION OF REFERRING PERSON

There are times when professionals may refer clients to this office (physician, probation officer, clergyperson, etc.), and it is our belief that open communication is essential; therefore, our policy is to notify the referral source of only the fact that the client has started therapy and/or has terminated therapy. This is a matter of professional courtesy. No other information other than that can be divulged unless given written permission by you.

I AGREE TO ABIDE BY THE POLICIES ON THIS STATEMENT AND CONFIRM THAT THE INFORMATION WITHIN HAS BEEN EXPLAINED TO ME AND THAT I UNDERSTAND THE INFORMATION CONTAINED HEREIN. I HAVE ALSO RECEIVED A COPY OF THIS POLICY.

CLIENT'S SIGNATURE

Date

COUNSELOR'S SIGNATURE

Date

IN THE EVENT OF AN EMERGENCY, WHO MAY WE CONTACT?


Name	Relationship	Telephone

MAY WE CONTACT YOU BY TELEPHONE TO REMIND YOU OF/OR CHANGE YOUR
APPOINTMENT:

AT HOME?

Yes

AT WORK?

Yes

Please provide another telephone number to where you can be reached if you dont check both of the boxes:~

MAY WE SEND INFORMATION ADDRESSED TO YOU TO YOUR HOME ADDRESS:

YES

CLIENT'S INITIALS

PRIVACY NOTICE

To Clients of JC Christian Counseling:

JC Christian Counseling is committed to providing excellent quality of care to all individuals as well as to abiding by federal, state and local law (Health Insurance Portability and Accountability Act of 1996 (HIPAA). Confidentiality is regarded very seriously here at JC Christian Counseling to ensure the safety and privacy of information for each client.

With your Consent, certain Protected Health Information (PHI) may be disclosed for the purpose of carrying out treatment,
payment, or health care operations on your behalf. JC Christian Counseling will disclose only the minimum amount of
information required for these purposes.

PHI that may be disclosed:

Name, Address, Telephone Number, Social Security Number
Past, present, or future physical or mental health or condition, i.e., diagnosis
Dates and times of sessions
Treatment provided and progress or outcome
Past, present, or future payment for the provision of health care services

For example, PHI may be disclosed to staff within this office in the course of professional supervision to ensure appropriate and
quality treatment. PHI may be disclosed to your health insurance company to ensure reimbursement for treatment. PHI may be
disclosed to appropriate personnel to make and confirm appointments, to review medical record completion, or any other
medical/personal related information that they may need access to in order to fulfill their job description. Also, with your
Consent, your name, address and phone number may be used to develop a mailing list so you may receive newsletters or
materials about other related benefits and services that may be of interest.

PHI may be disclosed without your consent: a) in the event that an emergency; b) in the event that you may be a threat to
yourself or others; c) in the event that it is required by federal, state or local law. All other disclosures of PHI will be made only after written Authorization has been obtained from you. You may revoke authorization, in writing, at any time, except to the extent that JC Christian Counseling has already acted on the authorization.

In reference to PHI, you have the right:

1. To request restrictions on certain uses and disclosures of PHI, although JC Christian Counseling is not
required to agree to your requested restrictions.
2. To receive confidential communications of PHI;
3. To inspect and copy PHI;
4. To amend PHI;
5. To obtain a paper copy of this Notice from JC Christian Counseling upon request.

JC Christian Counseling is required by law:

1. To maintain the privacy of PHI and provide you with this Notice of its legal duties and privacy practices
with respect to PHI;
2. To abide by the terms of the Privacy Notice currently in effect;
3. To provide a revised Privacy Notice, in the event that JC Christian Counseling changes its privacy practices,
This notification will be sent to you via the email address that you have provided within our records.

At any time, if you believe that your privacy rights have been violated; You may enter a complaint to JC Christian Counseling or
to the Secretary of Health and Human Services. A complaint may be filed with JC Christian Counseling by contacting us in
writing. JC Christian Counseling will respond to your complaint, in writing, within two weeks of receiving your complaint. JC
Christian Counseling will not retaliate against any person for filing a complaint.

For questions concerning this Notice, please contact JC Christian Counseling by phone at 717-278-8326.

I have been notified of my rights to confidentiality, privacy (according to HIPAA) and the protection of health information.


Client Signature or Responsible Party	Date

ON-LINE FEE POLICY

I		agree to provide payment at the time in which
the counseling appointment is scheduled for either myself or for the individual in which I am signed as the responsible party.

Credit Card Option:

I authorize JC Christian Counseling to run the credit card that I have provided each time that I schedule my appointment, unless I terminate counseling care or provide an alternative of payment. (Appointments that are rescheduled will follow the counseling policy)

Adolescent Client

(the parenti responsible party), am the legal

guardian! responsible party for

and is aware that

payment is required at the time the appointment is scheduled. If an organization (such as a Church, Children Services or Child Welfare agency) is providing payment for services; Please contact JC Christian Counseling to discuss payment details and authorization.