The following Consent for Treatment documents will be provided electronically to be signed via Headway or Sessions Health before the first therapy session. Headway's privacy policy can be found here.
Embedded Files
Informed consent
Welcome
Welcome
Welcome to the Therapy Practice of Charis Chase, LCSW. The therapy relationship is a unique and personal one, and the process of psychotherapy requires your active participation. An investment in this process will likely involve exploring complex life issues, which takes courage and commitment. As we engage, I promise to listen without judgment, value your time, honor your autonomy, respect your strengths, and maintain your confidentiality (subject to the provisions of the attached HIPAA Notice).
Consent to Treatment
Please carefully read the following informed consent agreement. This document also contains important information about our professional services and business policies. When you sign this document, it will become an enforceable agreement between us. Please do not sign this informed consent unless you fully understand and agree to its provisions.
Credentials and Qualifications: I am a Licensed Clinical Social worker. My experience includes providing Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) based therapy for the past 10+ years. CBT helps provide clients with the tools to recognize and redirect negative and unproductive thoughts. DBT can help clients find ways to accept themselves, feel safe, and manage their emotions. Both Therapies help regulate feelings associated with anxiety, depression, grief, loss, stress, and potentially destructive or harmful behaviors. During our sessions, we may discuss past events and how they continue to affect you, analyze your underlying beliefs, and how these beliefs impact your functioning and openness to change. We will also discuss how you might use specific emotional, cognitive, and behavioral tools and techniques that may help you progress toward your goals. I will endeavor to create a warm, empathetic, and non-judgmental environment where you can feel safe, open up, and begin the healing process. There is no one-size-fits-all approach. Together we can build trust, set goals, explore your insights, and find the tools you need to manage life's problems with confidence.
Voluntary Participation: All clients voluntarily agree to treatment and, accordingly, may, without penalty, terminate at any time. Counseling involves a large commitment of time, money, and energy, so you should be thoughtful about the therapist you select. In the first couple of sessions, you should decide whether I am the right therapist for you. If you feel I am not a good match, I will be happy to assist you in finding a new therapist.
Therapist Involvement: As we engage in the counseling process, I promise to attentively listen without judgment, value your time, honor your autonomy, respect your strengths, be supportive in meeting your treatment goals, work hard to help you resolve your problem areas, and subject to the provisions of the attached HIPAA Notice, maintain the confidentiality of the information you choose to share.
Client Involvement: Counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you are encouraged to work on things we talk about both during our sessions and at home. Clients are expected to show up to appointments on time, prepared to focus on and discuss their treatment goals and issues. You are expected to be open and honest so that I can assist you with your goals. Inconsistent attendance can negatively affect your progress.
Risks of Therapy: Just as medications sometimes cause unexpected side effects, counseling can stimulate painful memories, unanticipated changes in your life, and uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions. In some cases, your symptoms may become worse during therapy. Another risk of therapy is that you may reach a point of change where you no longer feel you are the same person as you were when you entered therapy. These feelings can be unsettling.
Benefits of Therapy: The benefits of therapy can include: new insights into yourself, improved self-esteem, more effective means of communicating in relationships, a greater level of functional coping, solutions to specific problems, reduced stress and distress, and other symptomatic relief.
Guarantees: Although therapy offers no guarantee of positive change, many people do find that it provides the safe space they need to explore, address, and alleviate problematic patterns in behavior, mood, and thoughts. Even so, no therapist can guarantee or reliably predict results such as: becoming happier, saving relationships, ending substance abuse or other problematic behaviors, becoming less depressed, and so forth.
Colleague Consultation: In keeping with standards of practice, I reserve the right to consult with other mental health professionals regarding the care and management of cases. The purpose of these consultations, should they occur, is to ensure the quality of your care and will protect your identity by not using real names or any identifying information.
Sessions and Length of Therapy: Appointments are typically scheduled using HIPPA compliant telehealth system such as Sessions Health, Headway or Google Meet. The frequency of our sessions will vary depending on your needs and the limitations your insurance carrier may impose. Typical sessions last between 55 and 60 minutes. The frequency and duration of our sessions will vary based on your needs, your motivation, and any insurance constraints. Many people find their needs are addressed in 10-25 sessions, but this can vary.
Confidentiality and Privilege: The information you share in therapy is privileged and confidential and will not be shared with anyone without your written consent, except as outlined in the HIPAA Notice.
Disputes and Complaints: Any disputes or complaints that we are unable to resolve between us can be referred to: the New Jersey State Board of Social Work Examiners
Phone Availability and Therapy Interruptions: I provide outpatient services to individuals. I DO NOT offer crisis or emergency services. I do not answer the phone during therapy sessions or provide unscheduled therapy support. All sessions are by appointment only. When unavailable, please leave a voice message. Except for weekends and holidays, I will endeavor to return your call within 24 hours of when you called. If you are difficult to reach, I encourage you to leave me times when you will be available. When I am on vacation or plan to be unavailable, If requested, I will provide you with the name and number of another therapist you can contact with questions or schedule as needed. In the event of a long term interruption of therapy I will make appropriate referrals as needed.
Crisis and Emergencies:
In case of a mental health or substance abuse emergency, please contact:
National Suicide & Crisis Lifeline: Call or text 988
After-hours crisis service: Call 1-800-273-TALK (8255)
Termination: Either of us may end therapy at any time. If we feel you are no longer benefiting from our sessions, we will discuss the benefits and risks of termination. I will also provide you with a referral if you desire additional counseling. As a courtesy, please provide notice of termination in writing (a text or email is fine)
Financial Agreement and Terms
Insurance: Most of my clients rely on health insurance to help pay for the therapy services I provide. If you have indicated you will be using insurance for your therapy sessions. Please note that it is your responsibility to know and understand your mental health benefits, including any co-pays, co-insurances, or deductibles. As a courtesy, I have verified your mental health/insurance benefits, should there be any discrepancies, any owed amount is your responsibility. Any estimates provided are non-binding and subject to change once claims have been processed. Please inform me of changes in your insurance or medical assistance eligibility. You will be responsible for charges incurred if your coverage has changed or lapsed.
Professional Fees: I will perform an initial diagnostic session which is more expensive. Follow-up therapy sessions are less expensive. Headway provides a break down of fees If you are utilizing health insurance benefits, your health plan may have negotiated a contracted rate with me or the Practices through which I provide my services that differ from the usual and customary fees listed in my fee schedule.
Copays, Coinsurance, Billing, and Payments: You are expected to make payment arrangements with me (or with the Practices through which my services are provided) to pay for all (or your copayment share) for each therapy session at the time the session is conducted. Keep in mind that it is you (not your insurance company) that is responsible for the full payment of my fees. Therefore, if you utilize health plan benefits, understand that you are responsible for any amount (co-pay or co-insurance, deductibles) that insurance does not cover. You are responsible for knowing your benefits and the estimate of benefits provided is not a guarantee of coverage. If you are unclear on what your insurance covers it is recommended that you contact your insurance directly to confirm.
Cancellations and Missed Appointments: Please understand that when you make an appointment, I set aside that date and time specifically for you. I adjust my schedules and other clients’ times accordingly. Keeping your regularly scheduled appointment times is important to ensure quality therapy and progress. You are strongly discouraged from missing your scheduled therapy as this undermines the therapy process, and you are encouraged to reschedule within the same week if a schedule conflict arises. If you need to cancel or reschedule an appointment, you must provide me with a minimum of 24 hours prior notice, excluding holidays and weekends. For missed appointments or cancellations with less than 24 hours’ notice, you will be billed a flat cancellation fee of $50.00. Insurance companies do not pay for missed appointments. Therefore, you will be responsible for the full amount charged. If you arrive more than 15 minutes late to your session, this will be considered a no show and subject to the cancellation fee.
Fees Not Covered By Insurance: Services that are not covered by insurance that you request (an example being the completion of disability or other forms), or I am otherwise required to provide (e.g., respond to a subpoena or provide testimony) will be charged an hourly rate of $150.00 for services performed in my office and otherwise at $300.00 per hour; prorated in 15-minute increments. These fees are due at the time of service. Additional examples include but are not limited to the preparation of requested records, treatment summaries, reports, and forms, letters written on your behalf, and third-party consultations; where the requested service is not in direct furtherance of your treatment, and for the preparation of documentation/travel/ waiting/testifying for subpoenaed records production, depositions or court appearances. I do not provide forensic psychological services and refrain from appearing as an “expert witness” in court.
Account Balance Maximum: Whenever a client’s account reaches an outstanding balance of $500 and no payments have been made or received toward the account, additional counseling services will be suspended. Services will remain suspended until you begin making payments to reduce your account balance. If no payments are made, services will remain suspended and/or you may be referred to alternate providers for services.
Collections: If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I may refer your account for collection. This can involve hiring a collection agency or going through small claims court. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. You will be responsible for all our collection costs, including our reasonable pre and post-judgment costs and attorney’s fees.
Social Media Policy: I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. This is not for lack of interest or care. I do keep a professional Instagram page that contains general therapeutic content that you are welcome to follow if desired.
I, the undersigned, have read the foregoing “Consent for Treatment,” acknowledge that I have been provided an adequate opportunity to clarify any questions I had regarding its provisions, understand and agree to these provisions, and, by my electronic signature, recognize that this “Consent for Treatment,” while becoming a legally enforceable Agreement, remains subject to future amendments and revisions that will become effective when they are communicated to me.
Consent for Transmission of Protected Health Information
I authorize Charis Chase, LCSW to transmit the following protected health information related to my therapy treatment via email:
Therapy homework assignments
Worksheets and exercises
Follow-up questions related to homework
Scheduling/rescheduling
I understand that while Charis Chase, LCSW uses a HIPAA-compliant Google Workspace account for email communication, there are still potential risks associated with email transmission of protected health information, including:
Emails can be accidentally sent to the wrong address
Backup copies of emails may exist even after deletion
Employers and online services may have a right to inspect emails sent through their systems
Emails can be used as evidence in court
I accept these risks and understand that Charis Chase, LCSW has implemented appropriate safeguards to protect my information, including the use of a HIPAA-compliant email service. I further understand that:
I can withdraw my consent to email communication at any time by notifying Charis Chase, LCSW in writing.
My decision to allow email communication does not affect my ability to receive treatment.
I am responsible for informing Charis Chase, LCSW of any types of information I do not want sent by email.
All emails concerning my treatment will become part of my medical record.
By signing below, I indicate that I have read, understand, and agree to the above conditions regarding email communication of my protected health information.
Health Insurance Portability Accountability Act (HIPAA)
Client Rights & Therapist Duties
Please read this document carefully, as it contains important information regarding your privacy protections and patient rights under the Health Insurance Portability and Accountability Act (HIPAA). HIPPA requires that I provide you with a Notice of Privacy Practices (this Notice) to inform you about how your Protected Health Information (PHI) will be used and disclosed in connection with my Practice’s healthcare Services (including Treatment, Payment, and healthcare operations).
OVERVIEW
I am required by law to: make sure that health information that identifies you is kept private; give you this Notice of our legal duties and privacy practices; notify you following a breach of your unsecured protected health information; and follow the terms of the Notice that are currently in effect. If you have any questions, it is your right and obligation to ask so we can have a further discussion before you sign this document. When you sign, this document will become a binding agreement between us. You may, at any time, in writing, revoke this Agreement. However, your revocation will not apply to any actions that may have already been taken in reliance on the provisions of our Agreement. I reserve the right to change our privacy practices and the terms of this Notice at any time. This Notice is being provided to you electronically and may be electronically signed. You additionally have the right to request a paper copy.
HOW YOUR INFORMATION IS USED
The law protects the privacy of all communication between a patient and a therapist. However, the law allows my Practice to collect, store, use, and disclose your health information for the purposes of providing my Services, including providing treatment, collecting Payment, and for my Practice’s related operations. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets specific legal requirements imposed by HIPAA. However, there are situations when your Protected Health Information may be disclosed without your consent or authorization, including the following:
1. Emergencies. Sufficient information may be shared to address an immediate emergency you are facing. Note that my Practice does not provide emergency Services.
2. Criminal Activity or Danger to Others. I may disclose health information if a crime is committed on our premises, or against our personnel, or if I believe someone, including you, is in immediate danger.
3. Judicial and Administrative Proceedings. If you are involved in a court proceeding, and a request is made for information concerning your diagnosis and treatment, the psychologist-patient privilege law generally protects this information. I cannot provide any information without your (or your legal representative’s) written authorization. However, I must comply with any court order or subpoena of which you have been properly notified should you fail to file a timely objection with the court. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
4. Worker’s Compensation. When a patient files a worker’s compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier, or an authorized qualified rehabilitation provider.
5. Public Health Activities. If a government agency requests information for health oversight activities within its appropriate legal authority, I may be required to provide it for them. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances.
6. Patient Disputes. If a patient files a complaint or lawsuit against me, I may disclose relevant patient information to defend myself.
7. Business Associates. My Practice may disclose appropriate health information to those business associates that perform functions or provide services for or on behalf of my Practice, provided these business associates sign agreements to protect the privacy of your information that prohibits their use or disclosure of any information other than as specified in our contract.
8. Administrative. You may receive emails, calls, or texts to schedule or remind you of appointments.
MANDATORY DISCLOSURE
1. Children. If I know or have reason to suspect that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the New Jersey Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
2. Vulnerable Adults. If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the New Jersey Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
3. Risk of Harm. If I believe that there is a clear and immediate risk of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member(s), and/or the police or to seek hospitalization of the patient.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:
1. For treatment – I will use and disclose your health information within my Practice during your treatment. If I wish to provide information outside of our Practice to another healthcare provider, I will have you sign an authorization for the release of your protected information. Furthermore, an authorization is required for most uses and disclosures of my Treatment notes.
2. For Payment – I may use and disclose your health information to obtain Payment for the services the Practice has provided.
3. For Operations – I may use and disclose your health information as part of my Practices operations. For example, this could mean utilizing records to ensure quality, comply with legal and regulatory requirements, and otherwise, as previously indicated. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.
4. Health Insurance: You should know that most insurance companies require you to authorize us to provide them with a clinical diagnosis for benefits to pay for services. Sometimes I am required to provide additional clinical information such as treatment plans or summaries or, in rare cases, copies of your entire record. This information will become part of the insurance company files. It will probably be stored on a computer and may be shared by the insurance company with national medical information databanks. Although all insurance companies have a legal duty to keep your information confidential, I will have no control over what they do with it once it is in their hands.
YOUR RIGHTS:
1. Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
2. Right to Confidentiality – You have the right to have your health care information protected as required by law. Subject to the exceptions outlined above, if you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purposes of Payment or in connection with our normal operations with your health insurer.
3. Right to Request Restrictions – You have the right to request restrictions on specific uses and disclosures of your protected health information. However, I am not required to agree to the restriction.
4. Right to Direct Confidential Communications. – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
5. Right to Inspect and Copy Records. – You have the right to inspect and obtain one free copy of your PHI. Record requests must be in writing, correctly signed, and allow two weeks for completion. There will be a charge for additional copies. Note that my personal psychotherapy notes, research records, and the business, regulatory compliance, quality assessment, and other Practice related records may be exempted from your request.
6. Right to Amend. – If you believe any information in your records is missing or incorrect, you may ask us to make specific changes. Your amendment request must be in writing, correctly signed, and include why you want the change made. We will inform you if your amendment request is approved or denied. If denied, we will tell you why and inform you about certain additional rights you have.
7. Right to a Copy. – Any forms and documents, including this Notice, that were transmitted to you electronically can be found in your inbox. Additionally, an electronic or paper copy can be provided at your request.
8. Right to an Accounting – With certain exceptions, you have the right to request and receive an accounting of disclosures of your protected health information made by us, or our business associates. As requested, I will discuss with you the details of the accounting process.
9. Right to Choose Someone to Act for You – HIPAA recognizes that there may be times when individuals are legally or otherwise incapable of exercising their rights or choose to designate another to act on their behalf. You or your “Personal Representative” must provide me with appropriate documentation before I will accept their directions.
10. Right to Choose – You have the right to decide not to receive services from me. If you wish, I will provide you with the names of other qualified professionals.
11. Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone to let me know you are terminating services.
12. Right to Release Information with Written Consent – With your written consent, any part of your records can be released to any person or agency you designate. The positive or negative considerations associated with any proposed release of your PHI can be discussed in our sessions.
THERAPIST’S DUTIES:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to your PHI. I reserve the right to change the privacy policies and practices described in this Notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised copy of the Notice.
COMMUNICATION BY EMAIL, TEXT MESSAGE, AND OTHER NON-SECURE MEANS
It may become helpful during treatment to communicate by email, text message (e.g., “SMS”), or other electronic communication means. These methods of communication, in their typical form, may not be HIPAA-compliant or secure. For example, if you use these methods to communicate, there is a chance that a third party may be able to intercept and eavesdrop on your messages. The kinds of parties that may intercept these messages include, but are not limited to:
1. People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages;
2. Your employer, if you use your work email to communicate with me;
3. Third parties, such as server administrators and others with access to your Internet traffic.
If there are people in your life you don’t want accessing these communications, you may wish to explore the various ways (like encryption) you can use to keep your communications safe and confidential. Finally, remember that your emails, text messages, and other responses can be added to your Treatment file.
COMPLAINTS
If you are concerned that I have violated your privacy rights, or you disagree with any PHI related decision I made, please contact me. If your concerns are not resolved, you may contact the State of New Jersey Department of Health, or the U.S. Department of Health and Human Services.
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