Intake Form

PATIENT INFOMATION

INSURANCE AUTHORIZATION SIGNATURE ON FILE

You can eliminate the need for the patient to sign every claim form by printing the words “Signature on File” in the appropriate boxes. This authorization form, properly completed and kept on file in your office and puts you in compliance with regulations.

• I request that payment of authorized Medicare and/or any insurer benefits be made by either me or on my behalf to A Time for Peace for any services furnished me by that of A Time for Peace Inc.
• I authorize any holder of this clinic or medical information about me to release to the Health Care Financing Administration and its agents and/or to any insurer any information needed to determine the benefits payable for related services. I permit a copy of this authorization to be used in the place of the original.

Medical History

Emergency Contact Information

HIPPA Compliance

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

Consent to Use and Disclose Personal Health Information

I understand that when my therapist or practitioner at A Time for Peace Inc. examines, treats, or refers me, they will be collecting what the law calls Protected Health Information (PHI).

• This information is needed to keep a file about me and/or others involved in my treatment, and that it may be necessary to share my PHI with other people or organizations necessary to provide treatment for me, arrange for payment of services, or for administrative purposes.
• I have the right to ask my therapist or other representative of A Time for Peace Inc. , not to share some of this information for treatment, payment, or administrative purposes. I realize that A Time for Peace Inc. and its representatives will try to respect my wishes, but that they are not required to agree to these limitations. However, if A Time for Peace Inc. or its appropriate representative does agree, A Time for Peace Inc. promises to comply with my wishes.

Signing this form gives permission to A Time for Peace Inc. to give me or my child mental health and/or medical treatment.

I understand that:

• A Time for Peace will have to send my medical record information to my insurance company.
• I may be held responsible for charges that exceed insurance reimbursement.
• Copay and/or deductibles will be due at the time service is rendered unless prior payment arrangements are made.
• I have the right to refuse any procedure or treatment.
• I have the right to discuss all medical treatments with my provider.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We am committed to protecting health information about you. We have created a record of the care and services you receive from me. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. This also describes your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information ("PHI") that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• We can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client's personal health information without the patient's written authorization, to carry out the health care provider's own treatment, payment, or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative subpoena in the follow ways:

• For my use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
• Required by law and the use or disclosure is limited to the requirements of such law
• Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
• Required by a coroner who is performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.
• Marketing Purposes. As a mental health and medical provider, we will not use or disclose your PHI for marketing purposes.
• Sale of PHI. As a mental health and medical provider, we will not sell your PHI in the regular course of this business.
  
  CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORI-ZATION. Subject to certain limitations in the law, We can use and disclose your PHI without your Authorization for the following reasons:
• When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.
• For health oversight activities, including audits and investigations.
• For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• To coroners or medical examiners, when such individuals are performing duties authorized by law.
• For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
• Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter­intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
• For workers' compensation purposes. Although my preference is to obtain an Authorization from you, A Time for Peace may provide your PHI in order to comply with workers' compensation laws.
• Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with the clinic. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that are offered.

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

• Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say "no" if we believe it would affect your health care.
• The Right to Request Restrictions for Out-of-pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
• The Right to Choose How to Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
• The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.
• The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, We will charge you a reasonable cost-based fee for each additional request.
• The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say "no" to your request, but will tell you why in writing within 60 days of receiving your request.
• The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e­mail. And, even if you have agreed to receive this Notice via e­mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 10/30/2019 Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this form, you are acknowledging that you have a copy of HIPAA Notice of Privacy Practices available to you.

PRACTICE POLICIES

APPOINTMENTS AND CANCELLATIONS

Fee Schedule

Hourly rates for therapy services are $150.00

The standard meeting time for psychotherapy is 1 hour. It is up to you, however, to determine the length of time of your sessions. Requests to change the times session needs to be discussed with the therapist in order for time to be scheduled in advance.

Group sessions are $35.00

Medical services are $150 for intake and $75 for follow ups.

Please note that A Time for Peace Inc. does not do custody evaluations, home studies and/or legal mediation. In certain special circumstances we may respond to a request to write a report or appear in court. In such cases, you will be required to pay a full fee rate ($100 per hour). Reports will only be released when full payment is received.

Only forms of payment accepted are cash, credit cards, HSA cards and money orders. ***Checks are not accepted.

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

Cancellations and no shows will be subject to a no-show fee of $25.00 if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

• You are responsible for keeping track of my appointment times and dates.
• You are responsible for contacting A Time for Peace Inc. if I need to cancel or change an appointment time for any reason.
• Although A Time for Peace Inc. does provide a “Courtesy Reminder Text” the day before the client is scheduled to be seen; ultimately it is the clients’ responsibility to know when they are scheduled.
• When the office is closed there is a voicemail set up for you to leave a message.
• If an emergency happens that is outside of your control that prevents you from appearing at your appointment at the scheduled time you can request the fee to be waived through your counselor.

---- NO SHOW/CANCELLATION FEES ARE NON-REFUNDABLE----

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message on my voice mail; we will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to tele-health sessions. However, if you are out of town, sick or need additional support, tele-health sessions are available but only if you are physically located in the state of Arkansas. If a true emergency arises, please call 911, 988, or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, We do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). We 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. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss personal or medical content and/or request assistance for emergencies.

MINORS

If you are a minor, your parents may be legally entitled to some information about your therapeutic or medical care. We will discuss with you and your parents’ what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you and a termination process if determined that the psychotherapy or medical treatment is not being effectively used or if you are in default on payment. We will not terminate the therapeutic or medical relationship without first discussing and exploring the reasons and purpose of terminating. If therapy or medical treatment is terminated for any reason or you request another provider, We will provide you with a list of qualified psychotherapists or prescribers to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive months, unless other arrangements have been made in advance, for legal and ethical reasons, We must consider the professional relationship discontinued.

CONSENT FOR TELEHEALTH TREATMENT

• I understand that my health care provider may wish me to engage in telehealth treatment.
• I accept that teletherapy does not provide emergency services. During our first session, my provider and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I can call 911, 988 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800-.273-TALK (8255) for free 24 hour hotline support.
• My provider may deem telehealth services not appropriate for me if presenting with risk of harm to self.
• My health care provider will explain to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
• I understand that telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
• I understand that I am responsible for: providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, along with the information security on my computer, and arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
• I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of A Time for PEACE that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
• In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services. I also understand that if my provider believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases may even get worse. I understand that I may benefit from teletherapy, but those results cannot be guaranteed or assured.

CONSENT TO USE THE TELEHEALTH BY DOXY.ME or REMOTEMDR SERVICE

Telehealth by Doxy.me or RemotEMDR is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

Telehealth by Doxy.me or RemotEMDR is NOT an Emergency Service and in the event of an emergency, I will use my phone to call 911 or 988.

• Though my provider and I may be in direct, virtual contact through the telehealth services, neither Doxy.me, RemotEMDR nor the telehealth services provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
• Doxy.me and RemotEMDR are not responsible for the delivery of any healthcare. Medical advice, or care.
• I do not assume that my provider has access to any or all the technical information in the Doxy.me or RemotEMDR service – or that such information is current, accurate or UpToDate. I will not rely on my healthcare provider to have any of this information in the telehealth by Doxy.me.
• To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

CONSENT TO USE TEXT COMMUNICATION THROUGH SIDELINES or RINGRX

Sideline and RingRx are professional communication apps used to communicate with patients. Each provider on site has access to these messages. By signing this document, I acknowledge:

• All communication between me and the sidelines/RingRx number is accessible to all providers affiliated with A Time for Peace inc.
• To maintain privacy, all communication will be centered around reminders, or requesting for provider assistance.
• To maintain confidentiality, I will not share the Sidelines/RingRx phone numbers to anyone unauthorized to make appointments.
• I understand that this numbers is not the personal phone number of my providers.
• I consent to allow A Time for Peace to send text reminders via Sideline or RingRx communication.
  

INFORMED CONSENT FOR PSYCHOTHERAPY & MEDICAL SERVICES

GENERAL INFORMATION

The therapeutic and medical relationships are unique in that they are highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationships will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with us.

THE THERAPEUTIC AND MEDICAL TREATMENT PROCESS

You have taken a very positive step by deciding to seek therapy and/or medical treatment. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

CONFIDENTIALITY

The session content and all relevant materials to the client's treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

• If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
• If a client threatens grave bodily harm or death to another person.
• If the therapist or medical provider has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
• Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
• Suspected neglect of the parties named in items #3 and# 4.
• If a court of law issues a legitimate subpoena for information stated on the subpoena.
• If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or other PHI.

If we see each other accidentally outside of the therapy office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the clinic.

OUR STAFF

A Time for Peace Inc. specializes in individual, family and group counseling along with primary medical care for children, adolescent and adults.

All of our therapists have a master’s degree and/or Ph.D. in a counseling or social work field.

Occasionally, we host a student intern that is currently attending graduate school to become a therapist. Feel free to ask your provider about their qualifications including their licensure status.

In addition to therapy we also offer collaborative care with a primary care practitioner, a consulting psychiatrist and behavioral care manager.

Goals and Outcomes:

In your first sessions, your provider will discuss what your goals for treatment are. Generally, treatment is most beneficial when individuals are willing to examine their own thoughts, feelings, and behaviors, and willing to change how they interact with others or the choices they make. You will determine the nature and amount of change you wish to make. At any time in treatment that you do not feel you are accomplishing your goals, please speak with your provider immediately.

Benefits and Risks:

Most people experience improvement or resolution to the concerns that brought them to counseling, but of course there are no guarantees; and there are some risks. For example, counseling could open up new levels of awareness that may cause some pain and anxiety.

After Hour Emergencies/Phone Calls:

Our telephone is answered during posted business hours by the front office staff to ensure that you are helped promptly. Our providers work varied schedules therefore your provider may not be available every day of the week to assist you. However, arrangements can be made for you to speak to a supervisor and/or a different clinician if needed. This provider will make every effort to be helpful to you. A Time for Peace hours of business are 8:00 AM until 4:00 PM, Monday through Friday. We are closed all major holidays. Our office number is (870) 237­1329, but if you need assistance after hours the afterhours number is (870) 230­ 0596. If you have an emergency after hours and we do not answer immediately, call the crisis line at (765) 742-­0244, call 911, 988, or go to an emergency room.