Terms and Conditions
Before receiving services by NextStep I acknowledge that I have read and agreed to the Terms & Conditions listed below:
1. I have the right to refuse any or all treatment, and to leave treatment at any time.
2. I will be actively involved in the planning of my treatment and understand the potential consequences of treatment and/or be actively involved in the planning of my child's treatment.
3. I will be continually informed as the type of treatment I will be receiving. I will receive appropriate referrals if or when there are concerns about any medical, academic, genetic, or other conditions that may be present and need evaluation or services.
4. I understand that my treatment, or that of my child, is confidential and protected under state and federal law. There are three instances that confidentiality is mandated by law to be broken:
A) Where there is immediate concern that I am imminently in danger to harm myself or another person, and
emergency measures must be taken for protection.
B) When there is significant reasonable suspicion that child or elder abuse or neglect is occurring.
C) When there is a direct order requiring a release of information through a Judicial subpoena.
5. If I am participating in couples or family counseling sessions, I understand that all information shared in a joint session is open to all participants. Any information shared in an individual session is kept Confidential and separate from joint sessions. This separate information is not open to any other member of the couple/family through the counselor or case documentation in the chart.
6. I understand the in accordance with the standard policies of Next Step; all cases are staffed under clinical and administrative supervision with qualified supervisors for the purpose of ensuring the best client care possible. The content of staffing is held confidential.
7. With the exception of emergency situations, I agree to notify my provider of a cancellation 24-hour prior to a scheduled session. I understand that there may be a fee charged for a cancellation or a no-show to a scheduled session.
Telehealth Services
I hereby consent to engage in telehealth with PROVIDER as part of my treatment.
I understand that telehealth includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, telephonic or data communications.
I understand that I have the following rights with respect to telehealth:
• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
• The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential.
• However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
• I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my written consent.
• I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
• These risks are offset by my provider’s use of a HIPAA-compliant service that is encrypted for video telehealth communications.
• I understand that if my provider believes I would be better served by another form of therapeutic services (e.g. face to-face services, group therapy), I will be referred to a provider who can provide such services in my area.
• I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured.
• The Zoom platform is the HIPAA compliant technology service used to conduct telehealth videoconferencing appointments. It is simple to use. You will either access it simply on your laptop, home computer and/or smartphone by logging into your email and opening the invitation sent from provider, through Zoom.
Considerations:
It is important to note that there are limitations of telehealth that can affect the quality of the session(s). These limitations include but are not limited to the following:
Provider cannot always see client, client’s body language, or client’s non-verbal reactions to what is being discussed.
Due to technology limitations, I may not hear all of what my provider is saying and may need to ask to have things repeated.
Technology might fail before or during the treatment session.
Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
To reduce the effect of these limitations, provider may ask client to describe how client is feeling, thinking, and/or acting in more detail than would occur during a face-to-face session.
I have read and understood the information provided above. I have discussed it with my provider, and all of my questions have been answered to my satisfaction.