I acknowledge that I am eligible to receive a range of services from my provider. The specific type and extent of services will be determined following an initial assessment and thorough discussion with me. The goal of the assessment is to tailor the best course of treatment for me, and the duration may vary based on the determined course of action.

I understand that throughout the treatment, I have the right to ask questions and may request an outside consultation. My provider may offer additional information about specific treatment issues and methods as needed, and I have the right to consent to or refuse such treatment. I am aware that regular reviews of treatment will occur to assess the progress of treatment goals. I commit to being actively involved in the treatment and review process. No guarantees or promises regarding the outcomes of treatment or any procedures within it have been made. I retain the right to stop treatment at any time, with the agreement to discuss this decision first with my provider.

I acknowledge that I must provide written authorization for my provider to release information about my treatment. Confidentiality can be broken under certain circumstances, details of this can be found in the Notice of Privacy Practices.

Client Responsibilities:
1.       Actively participate in all areas of your or your child's treatment (planning, evaluation, and goal completion).
2.       Please give 24 hours' notice if you are unable to attend a scheduled appointment or group session, according to the No Show Policy. (See below)
3.       Pay for each appointment at the time services are rendered, according to your payment arrangement.
4.       Notify your provider if you wish to stop receiving services or make a change in services received.
5.       Notify MHFS promptly about any changes in contact information including residence, phone contact, employment, insurance coverage, or income.

No Show Policy
A No Show appointment is determined by the following criteria:

1. The client misses his/her scheduled appointment.
2. No contact is made by the individual before the appointment to cancel.
3. The individual is more than 15 minutes late for the appointment.

Exceptions regarding No Shows may be made on a case-by-case basis by the provider. Clients may receive a message via client portal regarding a missed appointment. After the third No Show appointment in six months, the client may be considered for discharge.

By signing below, I voluntarily request and consent to mental health assessment, care, treatment, or services. By signing this Informed Consent for Treatment Form, I confirm that I have read and understood the terms and information provided.

Definition of Telehealth: Telehealth involves the use of electronic communications to enable clinicians to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have the rights with respect to Telehealth: 
1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. Copy of our Office Policies and Therapeutic Informed Consent can be provided. 
2. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth during my care at any time, without affecting my right to future care or treatment. 
3. I understand that there are risks and consequences from Telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.  Ancestral Roots Reiki, LLC utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via CounSol.
4. Clinicians follow the State of Maryland COMAR Regulations for Tele-health:10.32.05 as well as their respective board regulations (including but not limited to: BOPC/ACA or BSWE/NASW) and ethics. 
5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented health care facility in my immediate area. I also acknowledge that I have received the Crisis Hotlines handout for support. 

Payment for Telehealth Services: ARR will bill insurance for Telehealth services when these services have been determined to be covered by an individual's insurance plan. The standard copay and/or deductibles would apply. If insurance does not cover Telehealth, you may wish to pay out-of-pocket, or when there is no insurance coverage. We can provide you with a statement of service to submit to your insurance company. 

Patient Consent to the Use of Telehealth: I have read and understand the information provided above regarding Telehealth, have discussed it with my therapist and/or medication management provider, and all of my questions have been answered to my satisfaction. I have read this document carefully to understand the risks and benefits related to the use of Telehealth services and have had my questions regarding the procedure explained. 

I hereby give my informed consent to participate in the use of Telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document. 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review.

Your Rights
You have the right to:
 - Get a copy of your paper or electronic medical record: You can ask to see or get a copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request.
 - Correct your paper or electronic medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. We may say "no" to your request, but we'll tell you why in writing within 60 days.
 - Request confidential communication: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests.
 - Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
 - Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
 - Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
 - File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
 - Share information with your family, close friends, or others involved in your care
 - Share information in a disaster relief situation
 - Include your information in a hospital directory
 - Contact you for fundraising efforts

If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission:
 - Marketing purposes
 - Most sharing of psychotherapy notes

Our Uses and Disclosures
How do we typically use or share your health information?
 - Treat you: We can use your health information and share it with other professionals who are treating you.
 - Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. - Example: We use health information about you to manage your treatment and services.
 - Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities.
 - We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
 - Help with public health and safety issues: We can share health information about you for certain situations such as: - Preventing disease - Helping with product recalls - Reporting adverse reactions to medications - Reporting suspected abuse, neglect, or domestic violence - Preventing or reducing a serious threat to anyone's health or safety
 - Do research: We can use or share your information for health research.
 - Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
 - Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
 - Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
 - Address workers' compensation, law enforcement, and other government requests: We can use or share health information about you: - For workers' compensation claims - For law enforcement purposes or with a law enforcement official - With health oversight agencies for activities authorized by law - For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
 - We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office.

Contact Information
If you have any questions about this notice, please contact:

Ancestral Roots Reiki, LLC
ancestralrootsreiki@gmail.com
443-312-9803

Acknowledgment of Receipt of Notice of Privacy Practices:
I acknowledge that I have received a copy of Ancestral Roots Reiki, LLC's Notice of Privacy Practices.