Starting November 21st our Savannah office will no longer be located on Congress Street . We're moving to 3025 Bull Street, Savannah, GA 31405 Unit 219.
While you consider these risks, you should also know that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. Your therapist does not take on clients they do not think they can help. Therefore, your therapist will enter your relationship with optimism about your progress.
There are two situations in which I might talk about part of your case with another therapist. I ask now for your understanding and agreement to let me do so in these two situations. First, when I am away from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be available to you in emergencies. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality. Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private.
Your name will never be given to them, and they will be told only as much as they need to know to understand your situation. If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access. There is an exception to confidentiality because of the family nature of the therapy I provide. I do not keep family secrets from family members as I think that secrets are often at the root of family problems. I also will not go behind your back. Instead, if you reveal something to me that I feel would be something important to share with your family members I will talk to you about it and encourage you to disclose that information yourself, or even help you in that disclosure.
If for some reason treatment is not going well, I might suggest you see another therapist or another professional in addition to me. As a responsible person and ethical therapist, I cannot continue to treat you if my treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, I will help you find a qualified person and will provide him or her with the information needed.
Video Monitoring and Recording: There may come a point in treatment when your therapist may request to video record/film sessions. Prior to filming, your therapist will discuss the terms and agreements as well as having a separate consent form signed. The client always has the option to not give consent.
Cell Phones: It is important for you to know that cell phones may not be completely secure and confidential. However, we realize that most people have and utilize a cell phone. Your therapist may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with her. Out of respect for yourself and the therapeutic process, your therapist does ask that all clients silence their phones and do their best not to respond to messages or take calls during therapy.
Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text and/or email because it is a quick way to convey information. Please note that your therapist does not accept or send texts as a way of communication with the exception to remind of appointments. Appointment reminders via text and email are sent from an automated system that you will not be able to respond to. Email will not be used for crisis situations or as a substitute for therapy. We ask that email only be used for brief matters of communications that can allow for a 24-48 hour response time. You also need to know that we are required to keep a copy of all emails and other electronic communications as part of your clinical record. If you find the need to communicate frequently with your therapist between sessions, it may be that you need to schedule more frequent visits. You are encouraged to protect your own confidentiality by controlling access to your communications with your therapist such as by using passwords only known by you, controlling access to your computer, etc. Please discuss with your therapist the preferred way for communicating outside of session.
Facebook, LinkedIn, Instagram, Pinterest Etc: It is your therapist's policy not to accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. You may “like” the Building Blocks Family Counseling Facebook page as this is a community page where upcoming events and helpful information are shared. We also encourage all clients to sign up to receive the Building Blocks weekly newsletter which is filled with blog posts, helpful tips, and upcoming events.
I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other patients. Therefore, I am rarely able to fill a cancelled session unless I have several days’ notice.
I accept debit and credit cards, health savings account, cash, or check. Those with insurance coverage are expected to pay the co-payment or co-insurance at the time of service. If your insurance coverage is rejected, then you will be responsible for the full fee. You should call your insurance company to verify benefits, determine co-pay amounts, and get information on deductibles, prior authorization or the need for a doctor’s referral.
Payment should be made when services are rendered. If you think you may have trouble paying your bills on time, please discuss this with me. If you get behind more than the cost of two sessions, I will notify you in writing. If it then remains unpaid, I must stop therapy with you. Fees that continue unpaid after this will be turned over to small-claims court or a collection service.
If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention. I will do the same with you. Such problems can interfere greatly with our work. They must be worked out openly and quickly.
If you have a behavioral or emotional crisis and cannot reach me, you or your family members should call the Georgia Crisis and Access Line at (800) 715-4225, or go to the nearest hospital emergency room (or dial 911).
In my practice as a therapist, I do not discriminate against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately.
I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this handout, I can talk with you about them, and you will do your best to answer them.
I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.
I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.
I have read, or have had read to me, the issues and points in this handout. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here. My signature below also indicates that I have been given a copy of the HIPAA Notice of Privacy Practices. My signature authorizes the release of information necessary to process health insurance claims and authorizes the payment of health benefits directly to the provider (if applicable).
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that my therapist will be billing me for therapy, evaluation services and or any other covered services. I further understand that I am responsible for all my fees as well as late cancellations or no-show charges.
I also understand that some services are not covered under insurance or that I have the option to not use my insurance. In either of these cases I agree to pay the full session fee as determined by my provider. I understand that fees are due at the time services are rendered and must be paid in full unless a payment plan has been agreed to by my provider.
I hereby acknowledge that I understand and give my therapist permission to charge my credit card for any services that have not been paid by myself. I understand that this form is valid for three years unless I cancel the authorization in writing. If I cannot provide a credit card to place on file then I agree to allow my therapist to release my demographic information to a collection agency for reimbursement if payment or balance has been outstanding for a minimum of 120 days.
If parents are divorced, our office needs a copy of the most recent court order showing primary custody or tiebreaker, or the consent of both parents.
Divorce, Separation, and Custody Agreements
Building Blocks Family Counseling will not be party to custodial, separation, or financial disputes relating to individuals with regard to minor children to whom services are provided. The individual who requests the counseling services and signs the financial agreement is responsible for any balance due. All co-pays, co-insurance, and deductible, if applicable, will be collected at the time services are rendered from the individual requesting the counseling services for the minor child/children. We expect consent from both parents for therapy services. The therapist will discuss the minor’s therapeutic information with the accompanied parent with the time of the visit. Building Blocks Family Counseling will provide a copy of any records requested, all though we reserve the right to charge a fee. Both parents have access to the minor child’s records, unless there is a court order that specifically mandates only one of the parents has the right to authorize treatment and release of the minor’s records.
