College Station Christian Counseling (CSCC) is concerned about confidentiality. We believe a sense of safety and security is necessary to the process of healing in which our clients are engaged. It is the goal of CSCC to provide an environment in which our clients believe they can place their confidence and trust.

Under both federal and state law, confidentiality means communication with your CSCC counselor and any records pertaining to your identity, evaluation, and treatment will be kept secure and private. Where federal and state laws differ, we comply with the stricter standard to ensure that your right to confidentiality is respected at all times.

Examples of disclosure allowances under federal and state law for treatment, payment, and healthcare operations are as follows:

- The counselor will disclose necessary information and notify authorities or other third parties when there is reasonable suspicion a minor child (under 17 yrs), an elder person (65 yrs and older), or otherwise dependent adult (any age) has been harmed.

- The counselor will disclose necessary information and notify authorities or other appropriate parties when the client has directly admitted serious and imminent suicidal threats.

- The counselor will disclose necessary information and notify authorities or other appropriate parties when the client has directly admitted harmful acts or threatened action that is serious, imminent, and attainable against a clearly identified third person or persons.

- Counselors may be required to make disclosures to insurance and third-party payers, employee assistance programs and managed care groups concerning client's diagnosis, session dates, and, where required, client symptoms and treatment objectives.

- Client communication and records must be disclosed when ordered by the court.

- Exceptions to confidentiality are made in specified civil law cases such as disclosures relevant to a parent-child relationship, e.g., in a divorce action.

- If a client files a malpractice suit or formal complaint with their licensing board against a counselor, confidentiality is waived.

Other issues relative to confidentiality that may be applicable in specific instances follow:

- Practicum students or graduate interns receive supervision from CSCC counselors to facilitate their development and to ensure excellent care for our clients. In these instances, written or other legal authorization has been obtained from the client and client identities are protected.

- Written records of client communications are stored in a way to protect confidentiality and privacy rights. Electronically stored records are protected by password restrictions, backup systems, virus security software, and firewall protection.

A federal program called Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives you the right to put into writing any request you believe necessary to restrict possible misuse of your protected health information. All requests will be honored except as the law specifically outlines the use of your personal health information for treatment, payment, and healthcare operations.

HIPAA states once you give consent for the use of your personal information for treatment, payment, and healthcare operations by signing the professional services agreement, you may revoke the consent in writing at any time, except to the extent that CSCC has taken action relying on your prior consent. If we believe we cannot honor your written request for restriction of healthcare information, we will discuss our reasons with you and, if necessary, terminate our professional agreement formally in writing.

Under HIPAA, you have the right to request in writing, receive, and inspect copies of confidential protected health information held in this office. HIPAA has guidelines regarding what information must be included in response to a request from a client. If the information you request is outside those guidelines, we have the right to deny your request. Requests within the guidelines will be honored; however, there is a reasonable charge for labor and copying, and reasonable time for preparation must be allowed.

Under HIPAA, you have the right to amend any of your protected health information by a written request. If your written request is outside the laws' guidelines, we have the right to deny your request to amend records.

If you believe we do not follow the stated intentions laid out in this document and/or you believe your right to confidentiality has been violated, please talk with your counselor or CSCC's office manager or director. If you wish, you may file a written complaint with our office. Address your concerns to :

College Station Christian Counseling, PLLC
Attn: Executive Director
543 William D. Fitch Pkwy., Suite 111
College Station, TX 77845

If there is no resolution, you may file a complaint with the Department of Health and Human Services, Office of Civil Rights. For more information about HIPAA or to file a complaint:

US Department of Health and Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington D.C. 20201
Telephone: (202) 619-0257
Toll Free: (877) 696-6775

We are pleased that you have chosen College Station Christian Counseling (CSCC). This form gives you some information about our professional relationship. You are encouraged to ask your counselor any questions regarding his/her background, credentials, professional experience or philosophy.

CONFIDENTIALITY INFORMATION

CSCC is concerned about confidentiality. As Christian counselors, we believe God expects us to be trustworthy, and we believe that it is God's will for His people to know safety and security. It is the goal of CSCC to provide an environment in which our clients may place their trust and confidence. Under both federal and state law, confidentiality means communication with your counselor and any records pertaining to your identity, evaluation, or treatment will be held in confidence. Where federal and state laws differ, we comply with the stricter standard to ensure that your right to confidentiality is respected at all times. Also, beyond the law, we know that a sense of safety and security are necessary to a process of healing in which our clients are engaged. Holding to God's law as stated in His Word and by complying with federal and state laws, CSCC will maintain confidentiality to the fullest extent personally and professionally. You have a right to confidentiality.

Our Confidentiality Policy and Privacy Practices Brochure is a document you have received with this agreement. It is your copy to keep. It states more fully our policies and practices and your rights therein.

PLEASE READ THE DOCUMENT BEFORE SIGNING THIS AGREEMENT

If you believe the Confidentiality Policy and Privacy Practices document does not answer all your questions regarding confidentiality, talk with your counselor about any concerns you may still have.

Your signature at the end of this document indicates consent to use your personal health information for routine practices according to the law for treatment, payment, and health care operations. You may revoke this consent in writing at any time, except to the extent that CSCC has taken action relying on this consent.

RIGHTS & RESPONSIBILITIES

Rights
You have a right to be provided with professional and respectful care. You have a right to know your counselor's assessment of the problem, the recommended treatment, and resources available to help deal with your situation.

You also have the right to refuse our suggestions.

Responsibilities
1. To be honest, open, and willing to share your concerns
2. To ask questions when you don't understand or need clarification
3. To discuss any reservations you have about your treatment plan
4. To follow the agreed upon treatment plan
5. To report changes or unexpected events related to your problem
6. To keep appointments whenever possible or to call and cancel within 24 hours prior to your appointment. (See payment information - you will be charged the entire session fee for appointments not cancelled with 24-hour notification)

Remember, you are responsible for your thoughts, feelings, actions, and growth. We are here to help facilitate that growth to the best of our ability.

PAYMENT INFORMATION

The following information is provided to avoid any misunderstanding or disagreement concerning your payment for professional services.

- All professional services are rendered on a private pay, fee-for-service basis.
- Cash, check, or credit card is accepted.
- A $35.00 service charge will be assessed for returned insufficient fund checks. Insufficient fund checks are deposited twice. If the second deposit is also insufficient, a second $35.00 charge will be assessed. After the second insufficient funds deposit, we will only accept cash for payments for services rendered until the insufficient funds check and service charges are paid in full.
- The fee for the initial 50-minute counseling session is $235.00 (PhD); $185.00 (Master's, Fully Licensed); $135 (Master's, Associate); $65 (Practicum Student Counselor).
- The fee for all follow up sessions is $225.00 (PhD, Fully Licensed); $175.00 (Master's, Fully Licensed); $125 (Master's, Associate); $55 (Practicum Student Counselor).
- Fee is the same for individual, couple, or family counseling.
- Payment is expected at the beginning of the day of service.

Appointment Cancellation Policy
Twenty-four (24) hour notification is an expected courtesy to the counselor who is reserving time for you and to other clients who are waiting to schedule appointments. You must give 24-hour advanced notification for cancelled appointments. The advanced notice is standard in our profession.

If you miss an appointment without 24-hour notification, you will be charged the entire session fee on the day of your scheduled appointment. If you do not notify us 24 hours in advance when cancelling an appointment, you will be charged the entire session fee on the day of your scheduled appointment.

CSCC provides access through the secure portal that is available 24 hours/day to assist you in cancelling appointments in a timely manner.

You must pay for the missed/late cancellation appointment charge in full by your next scheduled appointment. Payment must be timely or we cannot continue to schedule appointments.

COURT PROCEEDINGS

Subpoenas: If a counselor is to receive a subpoena, then the attorney or office staff is required to call the office and set up a time for the subpoena to be served during office hours. A minimum of 72 hours notice of any court appearance is necessary so that schedule changes for clients can be made within a reasonable time frame. Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 hour notice there will be an additional $250 express charge. 

Requests for Records: If a client or legal counsel requests treatment summaries or session attendance documentation, you agree to pay according to the fee schedule detailed below. This includes information for legal, disability or insurance purposes. All payments must be processed before the documents are presented. 

The Fee Structure for court appearances/documentation requests is as follows: 

1. Preparation Time (including records submission): $200/hr (billable in 15-minute increments) 2. Phone calls: $200/hr (billable in 15-minute increments) 

3. Depositions: $600/day prepaid for first two hours; $200 for every hour thereafter

4. Time spent on Court premises (with or without testifying): $600/day prepaid for first two hours; $200 for every hour thereafter

5. Compensation for travel to and from court: Counselor's regular session fee per hour

6. All attorney fees and costs that are incurred by the counselor as a result of the legal action 

7. Filing document with the court: $100 

8. The minimum charge for a court appearance: $1000 

A retainer of $1500 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If the counselor is subpoenaed and the case is reset with less than 72 business hours notice prior to the beginning of the day of the scheduled subpoena, trial, then the client will be charged $500 (in addition to original retainer of $1500 for having to appear in court).

MINOR CLIENTS

If the minor child is named in any custody agreement or court order, we will need a copy (digital or paper) of the most recent decree documenting your right to seek counseling for the child(ren) before we can proceed with the child's first session. 

In conflictual situations, our ethical commitment is to seek and promote the well-being and emotional health of the minor client. Any communication and feedback with adults involved are for the benefit of the minor child client. Please feel free to discuss any concerns you have about your specific situation with the counselor at your initial session.

SIGNATURE FOR PROFESSIONAL SERVICES AGREEMENT

I do voluntarily agree to participate in the assessment and counseling as offered by College Station Christian Counseling. I am aware that treatment often involves family therapy or education, which will be recommended, if the counselor deems it important to the healing process. I acknowledge that no guarantees have been made to me regarding the outcome of my counseling process. I understand my rights and responsibilities as stated in this document.

I consent to the use of my personal health information for routine practices for treatment, payment, and health care operations according to the laws of the State of Texas and the Federal Government as outlined in the Confidentiality Section of this document and discussed in detail in the Confidentiality Policy and Privacy Practices Brochure.

I have received a copy of this Brochure.

I have read and agreed to the payment information as stated in this document.

I understand I will be charged the full session fee for appointments that are not cancelled within 24 hours or for appointments I miss altogether.

By my signature below, I accept all the terms and conditions as herein stated.

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