Consent Form
This document provides important information that your psychotherapist will discuss at your initial appointment. By completing the initial appointment agree to these policies.
Therapy Process
Your psychotherapist intends to help you achieve the goals established in the initial evaluation. Your psychotherapist will provide you with treatment recommendations specific to your situation. The therapy process will be a collaborative process and you have the right to agree or disagree with such recommendations. A treatment plan will be made which will be re-evaluated periodically to identify the progress in therapy. Due to the complexity of situations that involve emotional health, the length of the therapy process and specific outcomes cannot be predicted. you achieve the goals established in the initial evaluation. Your psychotherapist will provide you with treatment recommendations specific to your situation. The therapy process will be a collaborative process and you have the right to agree or disagree with such recommendations. A treatment plan will be made which will be re-evaluated periodically to identify the progress in therapy. Due to the complexity of situations that involve emotional health, the length of the therapy process and specific outcomes cannot be predicted.
Termination of therapy may be determined by either party (you as the client or your psychotherapist). The reasons can vary between:
Confidentiality
The communication between you and your therapist will be confidential. However, there are exceptions to confidentiality:
Treatment of Minors
In the state of Connecticut minors (under the age of 18) who demonstrate cognitive and emotional maturity and voluntarily request mental health services may obtain up to 6 sessions of therapy without parental notification or authorization if the treatment is clinically indicated and their health would be seriously impacted if he did not receive therapy. The treatment may exceed 6 sessions if it is clinically indicated and if the participation of the parents would negatively impact the treatment or cause the minor to leave the therapy process. Uninformed parents will not be forced to pay for any service that is not covered by the medical plan. However, if the minor has a medical plan, it can be used. Minors can also pay for services if they do not want to use the medical plan or can be referred to free or low-cost centers.
According to HIPAA regulations (confidentiality) parents generally have access to the records of minors. However, the psychotherapist has the ability to authorize or deny parental access to the records of the minor in treatment if the minor requested help without their consent and providing authorization would result in harm to the physical or emotional health of the minor.
Cases where minors under the age of 16 indicate sexual relations with someone 3 years older than the client's age (2 years older if the client is under 13 years old) will be considered “statutory abuse” and will have to be reported to the relevant agencies.
Availability of your Psychotherapist
Ideally, you should discuss any issues during your therapy sessions. However, you may call your psychotherapist between sessions if necessary. Important to leave a message if the call is not answered leaving your name, reason for your call and phone number. Your psychotherapist will call you back within 72 hours (excluding weekends). In the event of a medical or psychiatric emergency or a situation that involves a threat to your safety or the safety of others, you must call 911. Do not wait for your psychotherapist.
Cost of Therapy and Insurance
JSB Wellness LLC can only see clients who live in the state of Connecticut. Services will be offered through virtual appointments. For clients who want to pay privately (not using insurance) the cost of service will be $180 for the initial evaluation and $140 for subsequent sessions. Payments will be received in advance of session.
JSB Wellness LLC currently only accepts State Insurance known as “Husky” plan.
You will be responsible for any charges if insurance is not active at the time of service.
Additionally, you authorize JSB Wellness LLC to share the information necessary to request payment for services from your insurance. The information shared may include, but is not limited to, medical, mental health, or substance use, and other information may be shared with other agencies involved in your care.
Cancellation Policy
The usual frequency of sessions are weekly to bi-weekly. However, the frequency of therapy will be determined between you and your psychotherapist depending on the nature and severity of your case. Consistent engagement is proven to positively impact improvement of symptoms. To cancel an appointment you must notify 24 hours in advance by call, voice message or email. Failure to notify 24 hours in advance will result in a penalty of $50 (when applicable). If you as a client demonstrate a pattern of non-attendance, your case will be closed. A pattern can be described as 3 non-attendances or cancellations in a row without reasonable reason.
JSB Wellness LLC may request to keep credit card information on file to pay for the portion of services that are not covered by your insurance or in the event that you do not cancel 24 hours in advance (when applicable). Your card information will be kept secure and confidential. To request cancellation, you must do so in writing and your account must not have any outstanding balance.
Completion of Documents
In the event that you require psychiatric documentation to start or continue disability benefits or documentation for work, you must have at least 2 months minimum of treatment. These 2 months must be with frequent appointments without cancellations in order to offer a clinical description.
Therapy Process
Your psychotherapist intends to help you achieve the goals established in the initial evaluation. Your psychotherapist will provide you with treatment recommendations specific to your situation. The therapy process will be a collaborative process and you have the right to agree or disagree with such recommendations. A treatment plan will be made which will be re-evaluated periodically to identify the progress in therapy. Due to the complexity of situations that involve emotional health, the length of the therapy process and specific outcomes cannot be predicted. you achieve the goals established in the initial evaluation. Your psychotherapist will provide you with treatment recommendations specific to your situation. The therapy process will be a collaborative process and you have the right to agree or disagree with such recommendations. A treatment plan will be made which will be re-evaluated periodically to identify the progress in therapy. Due to the complexity of situations that involve emotional health, the length of the therapy process and specific outcomes cannot be predicted.
Termination of therapy may be determined by either party (you as the client or your psychotherapist). The reasons can vary between:
- The goals of your treatment plan were achieved.
- You require a high level of care in which appropriate referrals will be provided.
- You request for termination of services.
- The psychotherapist understands that the client is not benefiting from the treatment and other alternatives can be identified.
Confidentiality
The communication between you and your therapist will be confidential. However, there are exceptions to confidentiality:
- If you provide verbal or written authorization which will be documented in your file allowing your psychotherapist to discuss part of your treatment with the people identified by you.
- If you are in any legal proceedings and the judge requests information or documentation. This may include, and is not limited to, lawsuits, custody proceedings, DCF involvement, etc.
- Relevant information that is requested by your health plan needed for payments.
- In a medical emergency. If your life or that of another person is in danger.
- Your psychotherapist is required by law to report any situation where abuse of minors, the elderly, or people with disabilities is suspected.
Treatment of Minors
In the state of Connecticut minors (under the age of 18) who demonstrate cognitive and emotional maturity and voluntarily request mental health services may obtain up to 6 sessions of therapy without parental notification or authorization if the treatment is clinically indicated and their health would be seriously impacted if he did not receive therapy. The treatment may exceed 6 sessions if it is clinically indicated and if the participation of the parents would negatively impact the treatment or cause the minor to leave the therapy process. Uninformed parents will not be forced to pay for any service that is not covered by the medical plan. However, if the minor has a medical plan, it can be used. Minors can also pay for services if they do not want to use the medical plan or can be referred to free or low-cost centers.
According to HIPAA regulations (confidentiality) parents generally have access to the records of minors. However, the psychotherapist has the ability to authorize or deny parental access to the records of the minor in treatment if the minor requested help without their consent and providing authorization would result in harm to the physical or emotional health of the minor.
Cases where minors under the age of 16 indicate sexual relations with someone 3 years older than the client's age (2 years older if the client is under 13 years old) will be considered “statutory abuse” and will have to be reported to the relevant agencies.
Availability of your Psychotherapist
Ideally, you should discuss any issues during your therapy sessions. However, you may call your psychotherapist between sessions if necessary. Important to leave a message if the call is not answered leaving your name, reason for your call and phone number. Your psychotherapist will call you back within 72 hours (excluding weekends). In the event of a medical or psychiatric emergency or a situation that involves a threat to your safety or the safety of others, you must call 911. Do not wait for your psychotherapist.
Cost of Therapy and Insurance
JSB Wellness LLC can only see clients who live in the state of Connecticut. Services will be offered through virtual appointments. For clients who want to pay privately (not using insurance) the cost of service will be $180 for the initial evaluation and $140 for subsequent sessions. Payments will be received in advance of session.
JSB Wellness LLC currently only accepts State Insurance known as “Husky” plan.
You will be responsible for any charges if insurance is not active at the time of service.
Additionally, you authorize JSB Wellness LLC to share the information necessary to request payment for services from your insurance. The information shared may include, but is not limited to, medical, mental health, or substance use, and other information may be shared with other agencies involved in your care.
- Letters will be charged at $25 (if applicable). Payments must be made before the document is delivered.
- Court participation in the case of a legal proceeding. This payment will be made before going to court. This includes if your psychotherapist is called to testify for the other party. Additional details will be discussed at the time.
Cancellation Policy
The usual frequency of sessions are weekly to bi-weekly. However, the frequency of therapy will be determined between you and your psychotherapist depending on the nature and severity of your case. Consistent engagement is proven to positively impact improvement of symptoms. To cancel an appointment you must notify 24 hours in advance by call, voice message or email. Failure to notify 24 hours in advance will result in a penalty of $50 (when applicable). If you as a client demonstrate a pattern of non-attendance, your case will be closed. A pattern can be described as 3 non-attendances or cancellations in a row without reasonable reason.
JSB Wellness LLC may request to keep credit card information on file to pay for the portion of services that are not covered by your insurance or in the event that you do not cancel 24 hours in advance (when applicable). Your card information will be kept secure and confidential. To request cancellation, you must do so in writing and your account must not have any outstanding balance.
Completion of Documents
In the event that you require psychiatric documentation to start or continue disability benefits or documentation for work, you must have at least 2 months minimum of treatment. These 2 months must be with frequent appointments without cancellations in order to offer a clinical description.
Teletherapy
For the purposes of this document, the words virtual appointments, teletherapy, telecommunication, video calls, telemedicine and telehealth will mean the same thing.
JSB Wellness LLC will offer its therapy services through virtual appointments. The process is simple and does not require passwords to participate in video calls. The client only needs internet and a phone or a computer with a camera access to participate in the calls. Links will be sent via email or text message.
Benefits and Risks
One of the benefits of teletherapy is the ability to participate in therapy without having to be in the same physical location. In the case of JSB Wellness LLC, all appointments will be held virtually. However, some risks are:
If your insurance does not cover teletherapy sessions, it is your responsibility to pay for the sessions. Please confirm with your health plan company if teletherapy is included before starting your treatment (when applicable).
Video
Recording the video call sessions is not allowed. Your psychotherapist will keep a record of your sessions.
JSB Wellness LLC will offer its therapy services through virtual appointments. The process is simple and does not require passwords to participate in video calls. The client only needs internet and a phone or a computer with a camera access to participate in the calls. Links will be sent via email or text message.
Benefits and Risks
One of the benefits of teletherapy is the ability to participate in therapy without having to be in the same physical location. In the case of JSB Wellness LLC, all appointments will be held virtually. However, some risks are:
- Confidentiality risks: You the client must ensure that you are in a private place when beginning video calls.
- Connection problems: Like all technology, there can be problems with the internet connection or with the computer/phone system unexpectedly. In extreme cases there may be the possibility that unauthorized persons or companies have access to stored data. If this happens, you will be notified.
- Crisis management: The teletherapy system is not an emergency system nor does it substitute higher levels of care that may be required. If you have an emergency, you should contact 911. If your psychotherapist understands that your situation requires additional care, you or the psychotherapist can call 911, the police or any agency relevant to the situation.
- Communication: JSB Wellness LLC will only communicate by email and text for administrative matters with your authorization unless another agreement is established.
If your insurance does not cover teletherapy sessions, it is your responsibility to pay for the sessions. Please confirm with your health plan company if teletherapy is included before starting your treatment (when applicable).
Video
Recording the video call sessions is not allowed. Your psychotherapist will keep a record of your sessions.
HIPAA Privacy Rule
Your personally identifiable information is known as Protected Health Information (PHI) and is protected by the HIPAA Privacy Rule. JSB Wellness LLC will do its best to safeguard your information. JSB Wellness LLC may change the privacy practices at any time which will be notified to the client.
Your information may be disclosed/used without your permission on the following occasions:
You may revoke consent to the disclosure of identifiable health information, except as noted above, in writing. You release JSB Wellness LLC from liability for information disclosed prior to withdrawal of consent.
Your information may be disclosed/used without your permission on the following occasions:
- For treatment purposes such as planning, directing treatment, or following up with other medical or mental health providers who may be directly or indirectly involved in your care.
- To receive payments from health insurance
- In case of a medical emergency
- When required by law or if there is a need to report any situation were abuse of minors, elderly, or people with disabilities is suspected.
- To communicate with you
You may revoke consent to the disclosure of identifiable health information, except as noted above, in writing. You release JSB Wellness LLC from liability for information disclosed prior to withdrawal of consent.
Client's Rights
- Clients receiving services from JSB Wellness LLC have the right to receive humane and dignified treatment with respect.
- Clients receiving services from JSB Wellness LLC are entitled to receive individualized and specialized treatment.
- Any claims must be made in writing.
- JSB Wellness LLC will provide equal opportunity to access services for all persons without regard to race, color, sex, sexual orientation, age, national origin, or religion.
- You have the right to be explained any procedure, technique or treatment recommended by your psychotherapist before approving.
- You have the right to have your information corrected if it is incorrect.
- You have the right to know the name and title of your psychotherapist.
- Receive treatment in a language you understand.
- To be able to make a claim if I do not agree with any part of the treatment.
Client's Responsabilities
- Keep your appointments and cancel 24 hours in advance.
- Provide exchanges of information to your psychotherapist. Keep any personal and health plan information up to date.
- Treat your psychotherapist with respect.
- Follow these policies.
Claim Process
At JSB Wellness LLC we are committed to maintaining a high-quality service. You as a customer have the right to claim any wrong treatment. If you feel there is a problem, you must make a formal written complaint indicating the problem experienced. Staff have 7 business days to reach a resolution with you or offer you alternatives.
