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Click on the link below: Informed Consent for Assessment & Treatment HIPAA Notice of Privacy Practices |
Click Here For A Printable Copy INFORMED CONSENTThank you for choosing Nadine Rosen, M.A., L.P.C., N.C.C. Today’s appointment will take approximately 50 minutes. The decision to start counseling is a major one and you may have many questions. This document is intended to inform you of my policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and I will try my best to give you all the information you need. I hold a Master’s Degree from the Adler School of Professional Psychology, which was received in 1993 and have been practicing counseling and psychotherapy for over 15 years. I have a current License as a Professional Counselor in the state of North Carolina. I am also a Nationally Certified Counselor and a Certified Clinical Hypnotherapist. I take an eclectic approach to counseling. That is, I will borrow techniques from various schools of thought, such as, Alfred Adler’s Individual Psychology, Aaron Beck’s and Donald Michenbaum’s Cognitive-Behavioral Therapy, and Acceptance and Commitment Therapy (ACT) The decision as to which treatment technique to use will depend on several variables including the success rate of a particular treatment. The counseling process will require that we develop a therapeutic contract or treatment plan stating goals, methods, and time frame. This plan may need to be re-evaluated and redesigned after periodically evaluating your progress. Please note that it is impossible to guarantee any specific results regarding your counseling goals. However, together we will work to achieve the best possible results for you. CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process claims, b) information you and/or you child or children report about physical or sexual abuse; then, by North Carolina State Law, I am obligated to report this to the Department of Children and Family Services, c) where you sign a release of information to have specific information shared, d) if you provide information that informs me that you are in danger of harming yourself or others, e) information necessary for case supervision or consultation and f) or when required by law. If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for those services. Signature(s)_______________________________________ Date_____________
FINANCIAL/INSURANCE ISSUES: As a courtesy I will bill your insurance company, HMO, responsible party or third party payer for you, if you wish. I ask that at each session you pay your co-pay or co-insurance. In the event that you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. In the event that an account is overdue and turned over to my collection agency, the client or responsible party will be held responsible for any collection fee charged to my office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to Nadine Rosen, M.A., L.P.C., N.C.C. I have received a copy of my fee schedule_______________ (initial) I agree to have my insurance company reimburse my provider directly___________(initial) Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed at the hourly rate. I sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested. Signature(s)_______________________________________ Date_____________
COORDINATION OF TREAMENT: It is important that all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. Please understand that you have the right to revoke this authorization, in writing, at any time by sending notice. However, a revocation is not valid to the extent that we have acted in reliance on such authorization. If you prefer to decline consent no inform will be shared. _______You may inform my physician(s) _______I decline to inform my physician PHYSICIAN NAME:____________________________________ CLINIC:______________________________________________________________ADDRESS:__________________________________________ PHONE:____________________________________________ Signature(s)_______________________________________ Date_____________
NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I/We have read and received a copy of the, Notice of Privacy Practices and Client Rights document. Signature(s)_______________________________________ Date_____________
CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS: I/We consent that _____________________________________ maybe treated as a client by Nadine Rosen, M.A., L.P.C., N.C.C. At times it may be necessary to schedule appointments during school hours. I ask for your cooperation to provide the most timely treatment for you and your children. Signature(s)_______________________________________ Date_____________
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