Behavioral Health Informed Consent

I hereby consent to engaging in Behavioral Health Telemedicine and/or In Office visits in an office with a licensed Behavioral Health Provider or Supervisee in Social Work through the Community Health Center of the New River Valley. I understand that my participation is completely voluntary, and I may terminate the therapeutic relationship at any time. If I am out of services for 30 days without consulting with my therapist, it will be assumed that I am no longer interested in services and I will be considered terminated from the behavioral health program.

Confidentiality: I understand that all information regarding services is confidential and will not be released to any other agency or individual without my knowledge and consent, except when required by law. I understand that the Center and my therapist are required to report knowledge of abuse and/or neglect of a person who is presently a minor, elderly or disabled. I also understand that the Center and my therapist may break confidentiality if there is a serious intent to harm myself or others. I further understand that my therapist may consult with other organizations, mental health professionals or medical care providers to provide the best services possible for me. I understand that my therapist will provide the minimum necessary clinical information to my insurance provider and/or managed care organization to both protect my confidentiality and authorize services as needed. I understand that if I see a therapist that is a “Supervisee In Social Work”, that my information will be shared with their clinical supervisor(s), Ally Yeatts or Erin Shaffer. I understand that I can contact Ally Yeatts or Erin Shaffer with any concerns or questions related to my care by calling the Christiansburg Center at (540) 381-0820.

Telemedicine:I understand that Behavioral Health Telemedicine includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of mental health data, and education using interactive audio, video, or data communications. I understand that the recording or dissemination of any personally identifiable images or information from the Behavioral Health Telemedicine interaction shall not occur without my written consent.

I understand that there are risks and consequences from Behavioral Health Telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my medical or mental health information could be disrupted or distorted by technical failures; the transmission of my medical or mental health information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or limited ability to respond to emergencies.

If the telemedicine call becomes disconnected, your provider will attempt to contact you via phone. If needed, your provider may leave you a detailed voice message at the number provided during the session.

In addition, I understand that Behavioral Health Telemedicine-based services and care may not be as complete as face-to-face services.

No Show/Cancellation Policy: I understand that I need to call to cancel or reschedule any appointments within 24 hours of my appointment time. The Center allows for 3 No Shows within a calendar year. If I have 3 no shows for appointments within the Center, which includes same day cancellations or rescheduled appointments, I will be required to meet with the Director of Behavioral Health Integration prior to being able to schedule any follow up appointments. If I continue to No Show or have late cancellations/reschedules after this meeting, I may be discharged from the practice. I understand that it is important to arrive on time for my appointments with my Behavioral Health Provider to ensure I receive full benefit from counseling. If I arrive to my appointment more than 10 minutes late, I may be asked to reschedule my appointment.

Legal Fees: I understand that if I am involved in or anticipate being involved in legal or court proceedings, I will let my therapist know as soon as possible. In situations requiring court involvement, I understand that the fee is $500 per half day and $1,000 per day for court appearances. In addition, $150 per hour will be charged per hour spent for preparation for court testimony including, but not limited to, consulting with attorneys, reviewing the file and report/letter writing. In the event of a settlement or cancellation of the trial/hearing with less than 24 hours’ notice, a charge will be levied for those hours originally set aside for the trial/hearing. These services are not reimbursable by medical insurance. I understand that if I need to talk with the Center staff when the office is closed, I may call and leave a message on the voice mail or send a message through the patient portal. I understand that my therapist may not be able to respond immediately. I should use the patient portal for routine scheduling or to request a call from my therapist. Patient portal should not be utilized for urgent or emergent matters. If I have an emergency, I understand that I should contact ACCESS, 911 or go the nearest hospital emergency department.

I understand that my emergency contact and/or appropriate authorities may be contacted in the case of emergency.