Consent Forms

INFORMATION, AUTHORIZATION, & CONSENT TO TREATMENT

Welcome to Renewed Journey. We are very pleased that you selected our practice for your treatment. This document is designed to inform you on what to expect from your psychiatrist, therapist, coach and/or group leader, policies regarding confidentiality, emergencies, and other details regarding your treatment here at Renewed Journey. Our goal is to facilitate your healing, growth and restoration. We are committed to helping you in whatever way seems to produce maximum benefit. For treatment to be most successful, it is important for you to take an active role. This means working on the things you and your provider talk about both during and between sessions. This also means avoiding any mind-altering substances like alcohol or non- prescription drugs for at least eight hours prior to your scheduled session. Ultimately, the more of yourselfyou are willing to invest, the greater the return. Furthermore, it is our policy to only see clients who we believe have the capacity to resolve their own problems with our assistance. It is our intention to empower you in your growth process to thedegree that you can face life's challenges in the future without the practitioners here at Renewed Journey.

Confidentiality & Records

Your communications with your provider will become part of a clinical record of treatment, and it is referred as Protected Health Information (PHI). Your PHI will be kept in our encrypted HIPAA compliant electronic health record system or stored in a locked cabinet in our business office. It is filed under your first initial and last name to protect your confidentiality.

Limits of Confidentiality

Your provider will always keep everything you say to him or her completely confidential, with thefollowing exceptions: (1) you direct your provider by signing a "Release of Information" form or"Coordination of Care" form; (2) your provider determines that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual; or (4) vour provider is ordered by a judge to disclose information. In the latter case, your provider's license does provide him/her with the ability to uphold what is legally termed "privileged communication." Privilegedcommunication is your right as a client to have a confidential relationship with a behavioral professional. The state of Georgia has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. We cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what vou've said confidential. Please make note that in couples and family counseling, your provider does not agree to keep secrets. Therefore, information revealed in any context may be discussed with eitherpartner. Your confidential information may also be used in many ways within Renewed Journey Counseling Services without vour written permission for coordinating services and delivering quality care. These may include: 1. consultations and case conference with other providers in office. 2. for insurance billing and insurance reimbursement purposes. 3. Electronic communication: this includes but is not limited to the follow methods of correspondence: email, video technology, text, cordless phones, cell phones, unsecuredWiFi, or fax. If you choose to utilize these forms of communication, please limit the contents to pragmatic issues such as cancellation or change in contact information. If you choose to include personal and/or clinical concerns please know that your PHI information is at risk, does not guarantee privacy, and is not deemed as confidential. Please know Renewed lourney will maintain vour confidentiality to the best of our ability; however, we cannot guarantee this with any electronic communication.

Tele-Mental Health Services

Tele-mental health services are used when our mental health providers are not physically present with you to evaluate your mental health needs and if appropriate the prescription of medications. You and your mental health provider will utilize HIPAA compliant virtual face to face apparatus on a computer, tablet, or cell phone. Tele-mental health services use a video camera and computer to send both voice and visual images between you and your mental health practitioner. Tele-mental health services can be just as beneficial as in person sessions. Since face to face treatment is relegated only in the state of Georgia so are virtual tele-mental sessions. Your provider will treat and document your session. Should any prescriptionsthat are prescribed with be sent to the pharmacy or ready for pick up.

In Case of An Emergency

Renewed Journey is an outpatient practice and we are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers nor are we available at all times. If at any time this does not feel like sufficient support, please inform your provider, and he or she can discuss additional resources or transfer your case to a provider or clinic with 24-hour availability. Generally, your provider will return phone calls within 24-48 hours. If you have a mental health emergency, do not to wait for a call back, but do one or more of the following:

• GCAL 800.715.4225
• Call Ridgeview Institute at 770.434.4567 or Peachford Hospital at 770.454.5589.
• Call 911.
• 24 hours a day walk into a psychiatric hospital or emergency room for an assessment

Professional Relationship

Mental health treatment is a professional service we will provide to you. Because of the nature of treatment, your relationship with your provider is different from most relationships. It differs in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of provider and patient. If you and your provider were to interact in any other ways, you would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health professions. Dual relationships can set up conflicts between the provider and the patient'sclinical needs. Therefore, your relationship with your therapist must remain professional in nature. Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. A provider's responses to your situation arebased on tested theories and methods of change.You should also know that medical providers are required to keep the identity of their patients' secrets. For your confidentiality he or she will not address you in public unless you speak to him or her first. Your provider also must decline any invitation to attend gatherings with your family or friends or accept requests on social networking sites Instagram, Facebook, Twitter, LinkedIn, etc). Lastly, when your treatment is completed, your provider will not be able to be a friend. In sum, it is the duty of your medical provider is to always maintain a professional role. Please note that these guidelines are not meant to be discourteousin any way, but strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare & Safety

Renewed Journey CS assures you that our services will be rendered in a professional manner consistent with the ethical standards of the American Psychiatric Association and/or the American Counseling Association and/or the National Association of Social Workers. If at any time you feel that your therapist is not performing in an ethical or professional manner, we ask that you please let him or her knowimmediately. If the two of you are unable to resolve your concern by emailing admin@renewedjourney.org ATTN: practice manager.

Disability & Time Off Documentation

As of January 1, 2018, we are permitted to complete release from work and disability documentation for our established patients only. Policy dictates that established patients are those that have been in continuous care (weekly individual or monthly medication management) for a minimum of four (4) months. Should this be your need, notify the front office immediately to ensure proper assessment iscomplete during your session with the clinician.

Health Insurance Portabilitv and Accountability Act (HIPAA) Rights

I acknowledge Renewed Journey Counseling Services, LLC adheres to the federal mandates of the HIPAA laws. My signature below acknowledges receipt of this notice. I am able to receive the full disclosein print, email, or by fax, upon request.

Authorized Billing

I authorize the Release of any medical or other information necessary to process my health care claims understanding that all information shared is protected health information and will fall in compliance to HIPAA laws. I also request payment of government benefits either to myself or to Renewed Journey. I authorize payment of medical benefits to the assigned clinician or contracted billing agent for healthcare services rendered. We are sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask our administrative office.

Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with your provider, and you are authorizing your clinician to begin treatment with you. By signing this you also agree to undergo mental health treatment and understand that you can end treatment at any time. It should be discussed with your clinician, but you always reserve the right to stop treatment.

Check each to indicate that you understand and agree to all information contained in this consent :

Financial Agreement

Renewed Journey seeks to keep medical costs down by ensuring we can get reimbursed for our services on a timely basis. To help our office provide the most efficient and reasonable health care services, it is necessary for us to have a financial policy indicating our requirements for payment of services provided to our clients. Structure and Cost of Sessions: Unless negotiated by your insurance carrier when applicable, your provider agrees to provide treatment and medication management at the following fee schedule:

Psychiatrist-

$400- Initial Psychiatric Assessment

$225 Follow Up Psychiatric Visit

Psychiatric Nurse Practitioner-

$400- Initial Psychiatric Assessment

$225 Follow Up Psychiatric Visit

Licensed Clinicians-

$100-$200 Initial Therapy Assessment

$100-$200 Follow Up Therapy Assessment

Master Level Interns-

$45-$65 Initial Therapy Assessment

$45-$65 Follow Up Therapy Assessment

The fee for each session will be due prior to the start of the session. The receipt of payment may also be used as a statement for insurance if applicable. Please note that insurances audit and will retract payment, making you fully liable, if they find the client ineligible at time of services, i.e. your employer indicates a termination date, but services were paid to the provider after that date.

Telephone Calls: Phone contact to set or rearrange appointment times or brief phone contact to obtain relevant treatment information will not be billed. Doing treatment by telephone is an option, however it requires advance scheduling and may not be covered by your insurance. If you need to talk to your practitioner between sessions as an emergency, you may be billed for that extra support. Telephone calls that exceed 10 minutes in duration will be billed at $1.00 per minute. If this is the case, vou and vour clinician will need to explore adding tele-mental sessions or develop other resources to help vou in-between sessions

Ancillary Services: Time spent performing services that support your treatment, such as writing reports, paperwork, contact with outside parties by phone or letter, and supportive phone contact to the cent outside of regular sessions, are not covered by insurance and will be billed directly to the client. Ancillary services such as these will be charged at $90.00 per need and due at time of request. Copy of records must be made in writing and emailed to info@renewedjourney.org ATTN: Records Request and will be charged Search, Retrieve. and Admin Costs $25.88 plus $0.97 per page.

Cancellation Policy & Fees: In the event vou are unable to keep an appointment, notify the office at least 24-hours in advance. If a notice is not received vou will be financially responsible for the session vou've missed. Please note that insurance companies DO NOT reimburse for missed sessions. To avoid a missed appt fee. a same week reschedule can be made. if availability exists. Same day appointment cancellations at a $45.00 per occurrence. Cancellations in the pre-hour of scheduled appointments and no-show appointments are charged at a $60.00 per occurrence. Pavment arrangements are mandatory prior to getting back on the schedule.

Legal/Court Policy & Fees: You are financially responsible for any fees related to legal/cout matters. For instances requiring court attendance, Renewed Journey will be paid a retainer at $300.00 per hour at a 3-hour minimum. Time spent addressing legal requests like subpoenas/court orders. notarized letters, phone conversations with lawyers will be charged at $100.00 per instance. Court related fees cover your clinician's time, we do provide expert testimony. As a client with Renewed Journey, legal fees that are incurred (regardless of who is making the request) the patient/patient guardian must make payment at least 14 davs in advance prior to court attendance or on the day the subpoena has been received.

Consent For Medication: Renewed Journey offers psychiatric and psychotherapy treatment from practitioners licensed to prescribe medication in the state of Georgia. When meeting with your psychiatric practitioner the appointment will include the assessment of your mental health condition and treatment options.

During the visit, you and your physician will discuss:

1. The nature of your mental condition.
2. Your physician’s reasons for prescribing the medication, including the likelihood of your condition improving or not improving without the medicine.
3. The importance of medication compliance and the option to discuss with your prescribing physician any desire to adjust or stop taking any prescribed medication.
4. Reasonable alternative treatments that are available for your condition.
5. There may be a need for initial or periodic medical or laboratory consultations with the use of these medication(s).
6. That certain antipsychotic medications may cause additional side effects for some persons, including tardive dyskinesia. Tardive dyskinesia is defined as persistent involuntary movements of the face, mouth, torso, hands, or feet. These symptoms are potentially irreversible and may continue after the antipsychotic medication has been stopped.

Psychiatry Follow-Up Visits:

Prescribing physicians provide prescriptions for medications during appointments. They will rarely approve refill requests from patients or pharmacies outside of an appointment. This practice results in the:

• reduction of prescription errors;
• improvement with patient safety;
• importance of appropriate follow-up;
• compliance with state and federal laws governing controlled substances

Patients receive enough medication or refills to last until the next recommended follow-up. It is therefore important to make and comply with follow-up appointments.

Please be proactive in your care and track how much medication you have and how many refills remain on your prescription and ensure you have an appointment to see the doctor before you run out of medication. In instances of emergencies, a psychiatric med check applies when a patient needs a between-visit refill.

Your Rights:

• I understand that I may refuse medication(s) unless the refusal would be unsafe to me/my child or others.
• Many psychiatric medications can cause sensitivity to sunlight or decrease the body’s ability to handle heat when being used. Using sunscreen when outdoors and drinking fluids when sweating or in hot settings is good practice on or off medications.
• If there are questions about other potential side effects, I know I can contact the prescribing physician.
• I understand the potential benefits, side effects, and alternatives and I agree to the medication treatment recommended.

I was given information about the recommended medication. I understand that the information does not cover everything, but it includes items of clinical significance to me. I should discuss all my medical problems and any medication that I take with my physician(s). For more information, I may refer to a pharmacist or to a standard text such as the Physician’s Desk Reference (PDR).

Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with your provider, and you are authorizing your clinician to begin treatment with you. By signing this you also agree to undergo mental health treatment and understand that you can end treatment at any time. It should be discussed with your physician, but you always reserve the right to stop treatment.

By typing your name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Additionally, the above-named parties, therapist & person (s) or entity (entities) designated under (1) or (2), agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these parties is considered a breach of confidentiality. Your agreement below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that a cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by Renewed Journey Integrative Psych Services at 1862 Independence Square Suite F Dunwoody, GA 30338 to be effective.

CREDIT CARD "ON FILE" AUTHORIZATION FORM

Renewed Journey Integrative Psych Services is authorized to maintain credit card payment information in my confidential file. This form is being provided for you to supply Renewed Journey Integrative Psych Services with this information for upcoming therapy sessions and missed appointments. Your signature authorizes RJIPS to review this information and deduct fees from the credit card below for upcoming appointments and missed appointments. Should the credit card decline, we will assess an additional fee to the outstanding balance of $15.00. It is the patient's responsibility to provide Renewed Journey with new payment information within 24 hours of card declination for the full amount due to avoid future appointment requests being denied. No appointment requests will be approved without a valid payment method on file. This is to ensure our providers are available for paying clients.

By typing your name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.ed text