Client Intake Form

    Your Choice Behavioral Electronic Signature Disclosure and Consent

    This Electronic Signature Disclosure and Consent (“Consent”) sets forth the terms and conditions governing my consent to sign documents electronically through, and my use of, the YourChoiceBehavioral.com (YCB) Electronic Signature System (System).

    Effect of My Consent

    By agreeing to this Consent, I understand that (i) electronically signing and submitting any document(s) to Your Choice Behavioral legally binds me in the same manner as if I had signed in a non-electronic form, and (ii) the electronically stored copy of my signature, any written instruction or authorization and any other document provided to me by Your Choice Behavioral, is considered to be the true, accurate and complete record, legally enforceable in any proceeding to the same extent as if such documents were originally generated and maintained in printed form. I agree not to contest the admissibility or enforceability of Your Choice Behavioral’ electronically stored copy of this Consent and any other documents. By using the System to electronically sign and submit any document, I agree to the terms and conditions of this Consent.

    Client Information

    FemaleMale

    SingleMarriedWidowedDivorcedOther

    YesNo

    YesNo

    Home PhoneWork PhoneCell PhoneEmail


     

    Primary Insurance Information (if applicable)

    YesNo


     

    Secondary Insurance Information (if applicable)


     

    Responsible Party Information

    FemaleMale


     

    Emergency Contact Information


     

    Additional Information


     

    Client Information & Responsibility

    Consent for Treatment

    By digitally singing this agreement, you are giving voluntary consent to participate in treatment with Your Choice Behavioral Services (YCB). This permission is given with the understanding that the mission of Your Choice Behavioral Services is to facilitate healthy relationships and increased family functioning. Treatment services may consist of counseling, therapy and teaching specific skills to assist individuals in dealing with personal issues, which affect the individual and family. Such issues may include grief and loss, anger management, parenting skills, self-esteem, family separation, reunification, and many more.

    Treatment Providers
    The clinical staff at Your Choice Behavioral Services is comprised of Licensed Marriage and Family Therapists, Licensed Clinical Social Workers, Interns, Master’s Degree and Bachelor’s Degree Providers. The professional level of the provider assigned is dependent upon the needs of the individual and family.

    Confidentiality
    Privacy and confidentiality are your rights which are protected by state and federal laws. Therefore, all information disclosed in your sessions will be kept strictly confidential unless you provide written authorization to release information. However, Your Choice Behavioral Services is mandated by law to disclose confidential information to appropriate authorities under the following circumstances: 1) if there is reasonable suspicion of child abuse or neglect or abuse or neglect of a dependent elderly.; 2) when a court order is issued for records; or 3) when the client or another is in clear and immediate danger. If you threaten to harm yourself or someone else, or the property of others, your treatment provider is required to call the proper authorities and to take reasonable steps to warn the potential victim and prevent the threatened harm. In these cases, only the minimal amount of information necessary will be shared with the appropriate family members or authorities to ensure your safety and that of others. Additionally, when submitting claims to Medicaid or other insurance carriers, information such as presenting symptoms, diagnoses and treatment progress notes must be included to have the services authorized.

    Participation in Treatment
    As a client of YCB, you have the right to be involved in the treatment planning which will identify specifics goals, objectives and various therapeutic interventions to help resolve those issues. Likewise, you have the right to be informed regarding your progress. Keep in mind that progress occurs at different rates for different individuals and symptoms may initially increase when addressing painful issues. However, if at any time, you are experiencing significant distress or dissatisfied with your progress or the services you are receiving, or is important to discuss this with your treatment provider to ensure appropriate closure and to provide you with any necessary referrals. As a client of YCB you have the right to select a qualified Medicaid provider of your choosing. Services provided are designed to reduce the duration and intensity of care to the least intrusive level of care possible while sustaining the recipient’s overall health.

    Appointments/ Cancellations
    Appointments are mutually arranged between you and the treatment provider and to be most effective attendance should be regular and consistent. If you are unable to keep your appointment which reserved for you, please contact the provider at least 24 hours in advance. Do not assume that your appointment time will automatically be rescheduled. Repeatedly missing or cancelling appointments many indicate a lack of commitment to treatment and may result in the termination of services.

    I have been fully informed and understand the information contained in this Consent for Treatment. I acknowledge that I am providing voluntary consent for services and understand that I may withdraw my consent with Your Choice Behavioral Services at any time.


     

    Confidentiality

    Information shared during counseling session is confidential and may not be discussed with others without the client’s written consent. If it becomes clinically helpful to share the information with other providers Your Choice Behavioral Services will discuss the information and is relevance with you and have you sign a release of information. Note: The law does require the release of confidential information regarding a client in the following circumstances: suspected child abuse or neglect, an apparent threat of physical harm to self or others, or when requested by court order.

    I have read and understand the information above.


     

    STATEMENT OF CLIENT'S FINANCIAL RESPONSIBILITY

    Thank you for choosing Your Choice Behavioral Services (YCB) as your mental health provider. We are committed to providing you with the highest quality care. We ask that you read and sign this form to acknowledge your understanding of our client’s financial policies.

    YCB will bill your insurance carrier on your behalf. However, many insurance companies have additional stipulations that may affect your coverage. If your insurance carrier denies any part of your claim, you will be responsible for your balance in full.

    You are responsible for any deductible and co-payment/co-insurance as directed by your insurance carrier.

    If you are uninsured, you are responsible to pay in full for services rendered at time of service.

    I fully understand that I am ultimately responsible for all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court costs, attorney fees and any other charges incurred in the collection of any balance due.


     

    Informed Consent for Teletherapy

    I agree to participate in a telemedicine evaluation. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by provider/ therapist and other persons involved in my mental health care.

    Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small.

    I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a teletherapy/telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation.

    I understand that as with any technology, teletherapy does have its limitations. YCB will assist with troubleshooting problems that may arise during a teletherapy session.

    I understand that medical records of telemedicine services will be kept at the consulting site facility.

    If clinical information regarding HIV status is included in my medical record for purposes of the telemedicine/teletherapy evaluation, I agree to the collection of these data for research purposes.


     

    Authorization for Release of Information

    I understand that this authorization is voluntary. I understand that my health and mental information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal Regulations, Parts 160.and 164), the Federal Rules for Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Code of Federal Regulations, Chapter I, Part 2), and/or state laws. I understand that my health and mental information may be subject to re-disclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or treatment care provider, the released information may no longer be protected by the Federal privacy regulations.

    I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality, and may contain confidential HIV/AIDS related information. I further understand that by signing below, I am authorizing the release or exchange of these records to the parties named below. I also understand that my Behavioral Health information may be released to the Court and Probation Officers for review per their requests. The Health plan may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form, except for certain eligibility or enrollment determinations prior to my enrollment in its health plan, and for health care that is solely for creating protected health information for disclosure to a third party.

    I understand that I may revoke this authorization at any time by notifying YCB in writing, but if I do, it will not have any effect on any actions YCB took before it received the revocation.

    Verbally onlyWritten form onlyBoth verbally and written

    Exchange withRelease toObtain from the parties indicated below

    Person/Organization receiving/communicating the information:


     

    YCB Authorization for Release of Information

    **YOU MAY REFUSE TO SIGN THIS AUTHORIZATION**

    All Treatment Plan(s)Claims Outpatient Progress ReportsEligibility/BenefitsClinical records used to make benefit determinations (may include HIV/AIDS and/or Substance Abuse information)All records relating to a Disability claimOther

    To allow the clinically appropriate management and coordination of the Member’s mental health and/or substance abuse treatment and/or coverage under the Member's health benefit plan (Care Management and Coordination)Benefit Management Administration of a Worker's Compensation claimClaims Administration/Payment Administration of a Disability claimEmployer Mandated Treatment Referral Subpoena or other legal process to release physical records described above


     

    Release of Information for School

    Behavioral concernsTest/assessment resultsClassroom progressAttendance recordsSocial SkillsIBP summaryOther


     

    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE INFORMS YOU ON HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY YCB AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

    I. IT IS OUR LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
    • By law we are required to ensure that your PHI is kept private. Your PHI constitutes information created or noted by YCB that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. YCB is required to provide you with this Notice about our privacy procedures. This Notice must explain when, why, and how YCB would use and/or disclose your PHI. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice; PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we are always legally required to follow the privacy practices described in this Notice.
    · Please note that YCB reserves the right to change the terms of this notice and the agency privacy policies at any time as permitted by law. Any changes will apply to PHI already on file with YCB. Before we make any important changes to YCB policies, we will immediately change this Notice and post a new copy of it in our offices and on our website. You may also request a copy of this Notice from YCB, or you can view a copy of it in YCB offices.

    HOW YCB WILL USE AND DISCLOSE YOUR PHI.
    • We may use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples.
    A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. We may use and disclose your PHI without your consent for the following reasons:
    1.) For treatment. We can use your PHI within our practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns. We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care.
    2.) For health care operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Examples: Quality Control - we might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services.
    3.) To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: we may send your PHI to your insurance company or health plan to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, or claims processing companies, to process health care claims for our office.
    4.) Other disclosures. Examples: Your consent isn't required if you need emergency treatment if we attempt to get your consent after treatment is rendered. If we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI.
    B. Certain Other Uses and Disclosures Do Not Require Your Consent. We may use and/or disclose your PHI without your consent or authorization for the following reasons:
    1.) When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: we may make a disclosure to the appropriate officials when a law requires us to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
    2.) If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.

    3.) If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
    4.) If disclosure is compelled by the patient or the patient's representative pursuant to Nevada Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
    5.) To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public (i.e., adverse. reaction to meds).
    6.) If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.
    7.) If disclosure is mandated by the Nevada Child Abuse and Neglect reporting law (NRS.432B). For example, if I have a reasonable suspicion of child abuse or neglect.
    8.) If disclosure is mandated by the Nevada Elder/Dependent Adult Abuse Reporting law. For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse.
    9.) If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence.by you against a reasonably identifiable victim or victims.
    10.) For public health activities. Example: in the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.
    11.) For health oversight activities. Example: We may be required to provide information to assist the
    government during an investigation or inspection of a health care organization or provider.
    12.) For specific government functions. Examples: We may disclose PHI of military personnel and veterans
    under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States.
    13.) For research purposes. In certain circumstances, we may provide PHI to conduct medical research.
    14.) For Workers’ Compensation purposes. We may provide PHI to comply with Workers' Compensation laws.
    15.) Appointment reminders and health related benefits or services. Examples: We may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.
    16.) If an arbitrator or arbitration panel compels disclosure. When arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
    17.) If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations.
    18.) If disclosure is otherwise specifically required by law.
    C. Certain uses and Disclosures Require You to Have the Opportunity to Object
    1.) Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.
    D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that we haven't taken any action subsequent to the original authorization) of your PHI by YCB.
    III. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI. These are your rights with respect to your PHI:
    A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in possession of YCB, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, we may deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have the denial reviewed. If you ask for copies of your PHI, we will charge you not more than .25¢ per page. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
    B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in
    emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or permitted to make.
    C. The Right to Choose How We Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (via email instead of by regular mail). We are obliged to agree to your request providing that we can give you the PHI, in the format you requested, without undue inconvenience. We may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.
    D. The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years. We will respond to your request for an accounting of disclosures within 60 days of receiving your request, The list we give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period, The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure, We will provide the list to you at no cost, unless you make more than one request in the same year, in which case we will charge you a reasonable sum based on a set fee for each additional request.
    E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than YCB. The denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and the denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made, and will advise all others who need to know about the change(s) to your PHI.
    F. The Right to Get This Notice by Email. You have the right to get this notice by email & you have the right to request a paper copy of it.
    IV. HOW TO COMPLAIN ABOUT PRIVACY PRACTICES.
    • If you think we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of' the Department of Health and Human Services at: 200 Independence Avenue S.W. Washington, D.C. 20201.
    PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT YCB PRIVACY PRACTICES. If you have any questions about this notice or any complaints about YCB’s privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, PLEASE CONTACT THAT OFFICE.
    • This notice went into effect by law on: April 14, 2003.