MINORS

Parent Authorization for Minor’s Mental Health Treatment

In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.

If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements, or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.

Individual Parent/Guardian Communications with Me

In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately
or together. Please be aware, however, that, at all times, my client is your child – not the parents/guardians
nor any siblings or other family members of the child.

If I meet with you or other family members in the course of your child’s treatment, I will make notes of that
meeting in your child’s treatment records. Please be aware that those notes will be available to any person or
entity that has legal access to your child’s treatment record.

Mandatory Disclosures of Treatment Information

In some situations, I am required by law or by the guidelines of my profession to disclose information,
whether or not I have your or your child’s permission. I have listed some of these situations below.

Confidentiality cannot be maintained when:

• Child clients tell me they plan to cause serious harm or death to themselves, and I believe they have
  the intent and ability to carry out this threat in the very near future. I must take steps to inform a
  parent or guardian or others of what the child has told me and how serious I believe this threat to be
  and to try to prevent the occurrence of such harm.
• Child clients tell me they plan to cause serious harm or death to someone else, and I believe they have
  the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the
  threatened harm [and the police].
• Child clients are doing things that could cause serious harm to them or someone else, even if they do not
  intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed or abused in the past. In this situation, I am [may be] required by law to report the alleged abuse to the appropriate state child-protective agency.
• I am ordered by a court to disclose information.

Disclosure of Minor’s Treatment Information to Parents

Therapy is most effective when a trusting relationship exists between the therapist and the client. Privacy is
especially important in earning and keeping that trust. As a result, it is important for children to have a “zone of
privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be
immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.

It is my policy to provide you with general information about your child’s treatment, but NOT to share specific
information your child has disclosed to me without your child’s agreement. This includes activities and behavior
that you would not approve of — or might be upset by — but that do not put your child at risk of serious and
immediate harm. However, if your child’s risk-taking behavior becomes more serious, then I will need to use my
professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your
child is in such danger, I will communicate this information to you.

• Example: If your child tells me that he/she has tried alcohol at a few parties, I would keep this information
  confidential. If you child tells me that he/she is drinking and driving or is a passenger in a car with a driver who is drunk, I would not keep this information confidential from you. If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I would not keep that information confidential.
• Child clients tell me, or I otherwise learn that, it appears that a child is being neglected or abused--physically, sexually or emotionally--or that it appears that they have been neglected I will not keep this information confidential.
• Example: If your child tells me that he/she is having voluntary, protected sex with a peer, I would keep
  this information confidential. If your child tells me that, on several occasions, the child has engaged in
  unprotected sex with strangers or in unsafe situations, I will not keep this information confidential.

You can always ask me questions about the types of information I would disclose. You could ask in the form of
“hypothetical situations,” such as: “If a child told you that he or she were doing ________, would you tell the
parents?”

Even when we have agreed to keep your child’s treatment information confidential with them, I may believe that it
is important for you to know about a particular situation that is going on in your child’s life. In these situations, I
will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with
you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you
know how to be more helpful to your child.

Disclosure of Minor’s Treatment Records to Parents

Although the laws of Florida may give parents the right to see any written records I keep about your child’s
treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in
their meetings with me, and you agree not to request access to your child’s written treatment records.

Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation

When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for
everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You
agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me
to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion
about parental fitness or custody/visitation arrangements. Such letters are not “within my scope” of expertise.
Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do
so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either
parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or
parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is
provided, but I will not make any recommendation about the final decision(s). Furthermore, if I am required to
appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my
participation agrees to reimburse me at the rate of $150 per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.

Child/Adolescent Client: ** For very young children, (12 and under) the child’s signature is not necessary.

By signing below, you show that you have read and understood the policies described above. If you have any
questions as we progress with therapy, you can ask me at any time.

Parents/Guardian of Minor client:

Please agree to each line below and then sign, indicating your agreement to respect your child’s privacy:

I will refrain from requesting detailed information about individual therapy sessions with my child. I understand
that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy
sessions as needed.

Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT
to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.

I understand that I will be informed about situations that could endanger my child. I know this decision to breach
confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted
above.

As a client(s) of the Palm Harbor Counseling Team Inc, you have the following rights:

1. Services shall not be denied to any person on the grounds of race, ethnicity, age, color, religion, gender, nationality, sexual orientation, handicap, or developmental disability.
2. To be treated with courtesy and respect by all staff.
3. To receive appropriate mental health care or to be provided with a referral to another qualified provider, if necessary.
4. To participate in the planning of your treatment throughout the counseling process.
5. To ask questions and learn about the counseling process, and the qualifications of your provider(s).
6. As a competent individual, consent to or refuse treatment.
7. To confidentiality of your records and the right to inspect your records.
8. To be informed of your condition and to know the costs of services.

And the following responsibilities:

1. To make your payment at the time of service (whether self or co-payment or deductible).
2. To have your insurance company billed for covered services. You are responsible for all co-payments, deductibles, and/or coinsurance payments as required by your insurance policy.
3. To schedule and keep appointments. Should you need to cancel or reschedule an appointment, we require at least 48 hours’ notice when possible. Should you not provide this notice, or not show for an appointment, you will be charged $55. We will automatically bill this to the credit card you list in the payment policy form below.
4. To not come to any appointment under the influence of any mood-altering substances, unless prescribed and only as prescribed by a physician. If you do, you will be asked to reschedule and charged $45.
5. To give your treatment provider the necessary information about you, and to be involved in the planning of your treatment.
6. To follow the recommendations of your treatment provider, including those for psychiatric evaluations for medication therapy and testing, and to follow the agreed upon treatment plan.

I agree and understand that by typing (or drawing) my Signature electronically, that this electronic signature is the legal equivalent of my manual/handwritten signature.

Consent to Email or Text Usage for Appointment Reminders and Information Communications

Palm Harbor Counseling Team clients may be contacted via email and/or text messaging to remind you of an appointment and/or to provide general information (therapist illness, loss of power, weather safety alerts, etc.) If at any time I (the client) provides an email or text address to Palm Harbor Counseling Team or my therapist at which I may be contacted, I consent to receiving appointment reminders and other relevant communications/information at that email or text address.

Risk of using email/texting

The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:

1. Email/texts can be circulated, forwarded, stored electronically, on paper, or broadcast to unintended recipients.
2. Email/text senders can easily misaddress an email or text and send the information to an undesired recipient.
3. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted their copy.
4. Emails/texts can be intercepted, altered, forwarded or used without authorization or detection.
5. Email/texts can be used as evidence in court.
6. Emails/texts may not be secure, and it is possible the confidentiality of such communications may be breached by a third party. The Clinician and PHCT cannot be held responsible for this type of breach.

I consent to receive text messages from PHCT or my therapist at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/ information unless I request a change in writing (see revocation section below).

PHCT does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan

*Revocation: I understand the Revocation of Consent to texting or email can be submitted at any time by means of providing a written signed request to my therapist.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

I agree and understand that by typing (or drawing) my Signature electronically, that this electronic signature is the legal equivalent of my manual/handwritten signature.

Voluntary Consent to the use of Telehealth:

Thank you for choosing us as your mental health provider. We are committed to providing you with quality and affordable care. Because some of our clients have had questions regarding client and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request

1. Insurance. We participate in most insurance plans. If you are not insured by an insurance plan, we do business with, payment in full is expected at each visit. If you are insured by a plan, we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co- payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by your insurer. You must pay for these services in full at the time of visit.
4. Proof of insurance. All patients must complete our client information form before seeing a therapist. We must obtain a copy of your current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Insurance providers will not pay any claims submitted 90 days after date of service.
5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
7. Nonpayment. If your account is over 90 days past due. Please be aware that if a balance remains unpaid, we may have to discharge you from this practice. If this is to occur, you will be referred to another counseling agency. If there is mental health crisis during the referral process, our agency will provide interim emergency services only.
8. Missed appointments. Our policy is to charge a 55-dollar fee for missed appointments that are not canceled 24 hours in advance. There are common sense exceptions such as sudden illness, family emergencies, severe weather warnings or other public emergencies, however you are still expected to contact your therapist or the intake office and notify them. Otherwise, these charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.
9. Recurring Credit Card Payment Authorization. It is our policy to obtain credit or debit card information from each patient. This is to ensure that all payments will be collected according to the conditions within our payment policy. By completing the following information, you authorize Palm Harbor Counseling Team LLC to charge the credit card indicated in this authorization form according to the terms outlined above.

This payment authorization is for the goods and services described above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this care.

For tele behavioral health services, I understand that Palm Harbor Counseling Team LLC providers cannot verify the card in person as would be standard for n-site, in office treatment and accept the process for card charges.

NOTE: If you are using EAP benefits, LEAVE THIS CREDIT CARD SECTION BLANK and simply sign at the bottom indicating you have read the policy.

NOTE: The form below is protected by SSL security encryption. You can safely transmit your credit card details using this form.

Parent/Legal Guardian Signature