Informed Consent and Service Agreement

INFORMED CONSENT AND SERVICE AGREEMENT
Emilee Scruggs, LISW-CP, C-ASWCM
107 E. Park Ave
Greenville, SC 29601
(864) 376-6634
PLEASE READ THIS CAREFULLY
I will answer any questions you might have. You should not consider your communication with me legally protected or
confidential until you are told by me that your communication is protected or until you are told that you are a client.
Please discuss any questions with me before you sign or agree to the terms of this document.
SERVICES AGREEMENT This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new client rights with regard to the use
and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care
operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of
PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal
health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided
you with this information at the end of the first session if possible. Although these documents are long and sometimes
complex, it is very important that you read them carefully before our next session. We can discuss any questions you
have about the procedures at that time. When you sign this document, it will also represent an agreement between us.
You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action
in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims
made under your policy; or if you have not satisfied any financial obligations you have incurred.
Treatment Information
• Services Provided. Services provided include therapeutic assessments, psychological evaluations, assessment based
interventions, crisis intervention, counseling, psychotherapy and client education. No service will be provided without
your consent. Consultation and education may also be provided for school, educational placements and sports related
activities.
• Treatment is Optional and Not Required. Counseling, psychotherapy and crisis intervention services are not required. I
do not work with people who are forced to seek treatment by others. You are free to limit or end treatment at any time,
although it is preferable to discuss ending therapy several weeks prior to discontinuation as a means of “ending well.”
• Consultation. From time to time your provider may find it necessary or helpful to consult with other professionals
about their work with you. I believe in using a team approach when necessary. I will discuss this possibility with you in
advance. Your provider will do this in order to insure that we are providing the best service possible. Consultations are a
routine part of professional practice and are considered confidential unless you are not a client. I may provide your
name to people I consult with. They will be bound by the same laws and ethical standards. Please tell your provider
immediately if you have any questions or if you do not want your provider to consult with outside resources or experts.
• Service Orientation and Approach. My approach in working with clients is primarily evidence-based psychotherapy
and counseling to anxiety, depression and couples issues. I believe that problem solving, skill building, education and
information is the foundation to make decisions, achieve goals and to make changes in our lives and the lives of others.
My services are designed for each client or client's needs. I provide information, recommendations and a therapeutic
environment intended to give my clients meaningful choices.
• Health Insurance. I will bill your insurance for you in the event that I am credentialed by your insurance company. You
may want to contact your insurance company to see if we are a listed provider. Should your insurance company not reimburse for services you will be responsible for payment. I do not provide paper work requested by insurance companies, treatment codes or reports regarding your history or treatment without your authorization. A separate authorization
form signed by you will allow me to bill your insurance company with date/s of service, diagnosis, and fee applied together with a copy of your insurance card.
• Methods. Services provided include individual, group, couples, marital, crisis and education. The focus of services is
primarily educational and interpersonal with some interpretation directed to providing insight. Cognitive, Behavioral,
Grief therapy and Positive Psychology methods are used to guide services.
• Multiple Relationships. Greenville SC is technically a small city. You may know one or more of my clients. It is possi-
ble that you may "bump" into a friend, neighbor, employer, family member, colleague or business partner coming in or
out of an appointment. I do not acknowledge working with anyone without their permission. I do not discuss anyone
without their
permission and without a purpose that would be helpful in their case. It is also very possible that I may also be involved
in community activities such as church, community services, consultation with agencies or a
business that does business with you or your employer. I can not anticipate when or where you might see or interact
with me. It is my policy to not harm a client, to not exploit a client relationship and to ensure that I can provide a reasonable standard of care.
• Time Parameters. Traditional mental health services offer 45 and 50 minute appointments the frequency, i.e.; twice a
week, once a week, every other week, will be determined between therapist and client. The initial assessment (first
meeting) and treatment planning will take 1 or 2 hours, and this will usually be in the first and may include the second
appointment. Group therapy is traditionally 1 1/2 or 2 hour appointments. If you experience a crisis and need to talk
with someone immediately and cannot get in touch with me or it is after hours please call the Crisis Hotline provided by
the county you live in. You may also contact your physician or the emergency room. If I am not be available for an extended period due to illness or prior commitments or planned vacations, I encourage you to utilize the services provided
by your county. If a planned absence by me does occur I will make a reasonable effort to notify you in advance.
• Cancellations and Missed Appointments: Know that I have put considerable thought and researched this issue in
order to implement a fair and reasonable process. I have taken into account that life throws unexpected curveballs, such
as work obligations, family emergencies and car breakdowns and have structured the fee scale accordingly. Nonetheless,
please keep in mind that regardless of your understandable reason for cancelation, the fee structure will apply. These
fees are not covered by insurance. The only exception is severe weather. If driving conditions are such that you do not
feel safe driving to the office, please call as soon as possible and you will not be charged. If you do not call, the charge
will stand.
FIRST late cancel charge: $35.00
FIRST missed appointment charge: $50.00
SECOND late cancel charge: $50.00
SECOND missed appointment charge: $75.00
Subsequent late cancel charge: $75.00
Subsequent missed appointment charge: $90.00
If you are late canceling or missing more than 2 appointments in 6-12 months, consider whether you are at a crossroads
in counseling or not ready/able to prioritize time for counseling sessions. I welcome sorting this through with you and
understand if you decide to end counseling. Please let me know if this is your decision. You are always welcome back
if/when you choose.
• Electronic Transmissions. I may rely on e-mail to keep in touch with you. I believe private (not an employer's) e-mail
system is at least as secure as regular mail or the telephone. However, it is harder to tell if an e-mail has been opened.
Be cautious, in some cases an employer can monitor, keep copies and open your e-mail. You are not required to use email.
• Legal Issues. I do not provide legal advice or forensic services. I may bring up issues for you to consider, but recommend you seek legal opinions. Without mutual agreement and a contract for services, I do not provide assessments or
recommendations in support of legal actions such as child custody, competency evaluations, law suites or criminal
charges. Please notify me immediately if you are involved or may become involved in a legal or criminal matter.
• Contacting Your Provider. Due to my work schedule, I am often not immediately available by telephone. While I am
usually in my office between 9 AM and 5 PM, I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by a voice mail system that only I can access. I will make every effort to return your call
on the same day you contact me. If you are difficult to reach, please inform me of some times when you will be available. I will also protect your confidentiality, therefore in returning your telephone call please indicate on my voice-mail
if I can leave my name and number on your answering machine or with someone other than yourself who may receive
my call. In emergencies, please contact your county’s crisis hotline. In Greenville County, please contact Mental
Health America of Greenville County. The number is: CRISISline at 864.271.8888. You can also contact your family
physician or the nearest emergency room and ask for assistance regarding a mental health emergency.
• Professional Records. You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in
two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for
seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we
set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past
treatment records that I receive from other providers, reports of any professional consultations, your billing records, and
any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances
that involve danger to yourself and others (for which I will provide you with an accurate and representative summary of
your Record), you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because
these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so
you can discuss the contents. There will be a $1.00 per page charge together with mailing expenses if necessary. The
exceptions to this policy are contained in Exception to Professional Records Notice Form. If I refuse your request for
access to your Clinical Record, you have a right of review, which I will discuss with you upon request. In addition, I
sometimes keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include
the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also
contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical
Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your
signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor
penalize you in any way for your refusal. You may examine and/or receive
a copy of your Psychotherapy Notes unless I determine that such disclosure would be injurious to you.
Client Rights. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions
on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of
protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in
your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and
procedures. I am happy to discuss any of these rights with you.
Fees and Payment Policy
I will bill insurance companies for you (see Health Insurance paragraph). If you do not have insurance coverage the fee
will be discussed with you as you make an appointment. Payment for service is by cash or personal check or Visa/MC
made out to Emilee Scruggs LISW-CP and is due prior to each appointment on the day of the appointment. The Person
Responsible for Payment is financially responsible for paying funds prior to or at the time services are provided. If
services are terminated and treatment is no longer necessary, any balance of funds for services will be refunded, typically within 30 days. If you become involved in legal proceedings that require your provider's participation, you will be
expected to pay for all of my professional time, including preparation and transportation costs, even if called to testify
by another party. Because of the difficulty of legal involvement, I charge $150 per hour for preparation and attendance
at any legal proceeding.
Confidentiality. Confidentiality is a legal protection and assurance of your right to privacy to the fullest extent allowable
by Federal and South Carolina state statutes. Psychotherapy, counseling, assessment and associated services that are
related to diagnosis, evaluation and treatment services provided by professionals are confidential and protected in accordance with state law pertaining to that license. This means that the client has legal rights and effective steps he or she
can take to keep their records and treatment relationship private. Confidentiality does not apply if you are not a client.
Please ask your provider or your attorney if you have any questions. Confidentiality applies to an established service
relationship. Confidentiality does not apply until you are told that you are a client.
Limits of Confidentiality. The reasons client/s visit my office are not revealed to anyone without your permission.
Greenville, SC is a small town. It is possible that someone in the area or waiting room may recognize you. Please tell
me if you have concerns regarding confidentiality, privacy or whether or not someone may recognize you. I can only
release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. With your signature on a proper Authorization form, I may disclose
information in the following situations: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other
professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about
these consultations unless I feel that it is important to our work together. I may employ administrative staff. In most
cases, I need to share your protected information with these individuals for both clinical and administrative purposes,
such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of
confidentiality. All staff members will be given training about protecting your privacy and have
agreed not to release any information outside of the practice without the permission of a professional staff member.
There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and your clinical record is subpoenaed I must submit your information to them. I cannot provide any information without your (or your personal or legal representative’s) written
authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney
to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide records for them.• If a client files a
complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend
myself. • If a client files a worker’s compensation claim, he/she automatically authorizes me to release any information
relevant to that claim.
Limits of Confidentiality: There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a
client’s treatment. • if there is any admission of child abuse and/or neglect by law I must report such activities to
the proper authorities. If the abuse and/or neglect is or has been perpetrated by the client I will support and encourage the client to make the report (call) her/himself. If the client knows of a previous offender of child abuse/
neglect and is aware of the offender being in contact with children currently, this too shall be reported either by
the client or me. I will divulge information stated to me under confidence if there is a suspicion, known threat of
harm, or past offense of abuse/neglect to those unable to protect themselves whether due to age or mental capacity. This also pertains to the aged unable to defend and/or care for themselves and to the mentally ill unable to
defend and/or care for themselves in their protection.
• If I believe that a client presents a clear and substantial risk of imminent, serious harm to another person, I
may be required to take protective actions. These actions may include notifying the potential victim, contacting
the police, or seeking hospitalization for the client. • If I believe that a client presents a clear and substantial risk
of imminent, serious harm to him/her self, I may be obligated to seek hospitalization for him/her, or to contact
family members or others who can help provide protection. If such a situation arises, I will make every effort to
fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and I am not an attorney. In situations where specific advice is required, formal
legal advice may be needed.
To File a Complaint. I hope you would first discuss any concerns with me. I will do my best to resolve any miscommunications or any other problems. If you feel we are not a good fit working together, please let me know and I would be
happy to provide you with referrals that may better suit your needs. If this does not feel comfortable for you, know that I
am a licensed professional in the state of South Carolina. Please contact:
South Carolina Board of Social Work Examiners
Synergy Business Park Kingstree Building 110 Centerview Dr. Columbia, S.C. 29210. (803)896-‐4470
or online at: http://www.llr.state.sc.us/POL/SocialWorkers/index.asp?file=complaint.htm
I hereby confirm that I have carefully read, and that I understand and agree to the entire content of this Services
Agreement.
______________________________________________
Printed First and Last Name
______________________________________________
Signature and Date