New counseling/mental health client – adult

Service Agreement | Behavioral Healthcare

Welcome to Family Counseling Service of Aurora. It is our privilege to offer you quality behavioral healthcare services at our agency. This document is intended to act as an agreement between you and Family Counseling Service for the services we provide.

Risks & Benefits of Behavioral Healthcare Treatment

Before you begin services, it’s important to know that behavioral healthcare carries both benefits and risks. Treatment often leads to a significant reduction in feelings of distress, improved relationships and resolution of issues. Risks can include experiencing uncomfortable feelings such as sadness or anxiet during the course of treatment. If you are prescribed medication as part of your treatment, there are possible side effects to most medications. Your prescribing professional can discuss these side effects with you before you start taking new medications.

Staff Qualifications

Family Counseling Service maintains high standards for clinical excellence. Our counselors hold degrees and are fully licensed in their area of expertise, as their level of college degree allows. Staff who are not yet clinically licensed work under the direct supervision of a licensed supervisor. We also work with psychiatrists and/or Psychiatric Advance Practice Nurses (APN’s) to manage psychotropic medications.

Fees & Cancellations

In addition to billing private insurance (e.g. Blue Cross Blue Shield), Family Counseling is funded by United Way, INC Board NFP, and other public funding sources, including the Illinois Department of Human Services, Division of Mental Health (DMH) and Healthcare and Family Services (HFS). We offer a sliding fee scale to accommodate the income circumstances of our clients when necessary. If you are paying a sliding scale fee, the difference in costs will be made up by one of the funding sources listed above. If you are unable to attend a scheduled session, please notify us at least 24 hours in advance. If you miss your appointment, you may be charged a $20 cancellation/missed appointment fee. This is simply because we have many clients who are waiting for open appointments and would like to be able to offer them your appointment if you need to cancel for any reason. If you fail to attend 3 or more appointments and carry a balance of $60 or more, services may be suspended until the balance is paid in full or payment arrangements have been made. Questions about balances or payment arrangements can be directed to the billing department at 630-844-2662 x311.

Most contracted services (for example, if an insurance company or state agency is paying for your services here) do not reimburse us for missed or cancelled appointments, If your services are being paid for through an outside contract and you have a late cancellation or fail to keep an appointment, you may be responsible for payment for the missed session.

Confidentiality of Your Records

As a client, you will provide us with some important and sensitive information about yourself. This information is known as Protected Health Information. Family Counseling Service will not disclose your Protected Health Information UNLESS we have your written authorization to do so, except under the following special circumstances. State and federal laws require Family Counseling Service to disclose your private information without your consent in certain circumstances, including the following:

• Child Abuse: If your counselor has reasonable cause to believe a child known to him/her in his/her professional capacity may be an abused child or a neglected child, your counselor must report this belief in accordance with the Abused and Neglected Child Reporting Act.
• Adult and Domestic Abuse: If your counselor has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, he/she must report this belief in accordance with the Illinois Elder Abuse and Neglect Act.
• Serious Threat to Health or Safety: If your counselor believes that you present a clear, imminent risk of physical or mental injury being inflicted against yourself or another individual, he/she may make disclosures that he/she believes are necessary to protect that individual from harm in accordance with the Illinois Mental Health and Developmental Disabilities Confidentiality Act, or Public Act 098-0063 (Firearm Concealed Carry Act).

Federal law also permits us to use your protected health information for the following purposes:

• For Payment: We may use and disclose your Protected Health Information to be reimbursed for the medical services and supplies we provide to you. For example, your health plan or Health Insurance Company may ask to see parts of your medical record before they will pay us for your treatment.
• For Psychiatric Services: those services may be funded, partially or in full, by a grant FCS receives from the INC Mental Health Alliance, a local funder of mental health and substance abuse services. Your signature on this document gives us permission to provide certain billing and demographic information to INC Mental Health Alliance staff that is typically considered Protected Health Information (PHI). Staff from INC Mental Health Alliance will maintain your confidentiality for any information received from FCS. If you do NOT wish to allow FCS to provide this information to INC Mental Health Alliance, please let your assigned clinician know immediately.”
• For Health Care Operations: We may use and disclose your Protected Health Information for health care management, which include internal education, administration, planning, and other various activities that improve the quality of care we provide to clients. We may disclose Protected Health Information to outside companies to support administrative functions such as data analysis, accounting or legal services, but we will only do so after they have signed an agreement stating that they will abide by our privacy policy. This information is usually aggregated, so no individual can be identified.
• For Quality Improvement: At completion of treatment, we would like to send a satisfaction survey and feedback form via email to ensure we are providing the highest quality of care and aim to improve in any area when applicable. You will be asked to provide an email address to receive this
  survey via email but can refuse at time. Your contact information including your email is Protected Health Information and will not be distributed without written authorization.
• For Training Purposes: All masters level and doctoral level intern clinicians report to a supervisor as a trainee under supervision. Assessments and treatment is discussed under the provisions of the student/supervisory relationship and information from treatment sessions may be used for educational purposes. As part of their education and training, intern clinicians may discuss their clients in group supervision, case staffings, academic consultation and/or student review. All material is reported anonymously, and personal confidentiality is strictly maintained.
• For Training Purposes: A limited number of rooms at FCS have video cameras running constantly for the safety and protection of visitors in our building and the staff. These cameras are used by agency supervisors only to observe the work being done by staff and to help them improve the
  quality of care they provide.

Client Rights and Responsibilities

CLIENT RIGHTS
As a client of Family Counseling Service, you ate entitled to the rights outlined in the Mental Health and Developmental Disabilities Confidentiality Act and Chapter 2 of the Mental Health Code Developmental Disabilities Code. Client rights and FCS responsibilities include but are not limited to, the following:

• You have a right to be provided mental health services in the least restrictive setting.
• You have the right to a safe and therapeutic environment. Agency staff will provide the necessary supports and resources to keep you, other clients and staff safe and minimize the use of restrictive behavioral management interventions. Staff will use verbal and non-verbal de-escalation strategies to maintain a safe environment. If staff determine there is imminent risk of harm, they may deem the use of manual restraint necessary until law enforcement arrives to ensure the safety of the others. For minors, the parent/guardian will be notified if a minor is involved in harassment, violence or when a restrictive intervention is used.
• You are entitled to have your rights explained to you using a language or method of communication you understand upon commencement of services.
• You may have a guardian with whom we must cooperate or you may be restricted legally through court or by probation.
• You have the right to nondiscriminatory access to services as specified in the Americans with Disabilities Act of 1990 (42 USC 12101).
• You have the right to have disabilities accommodated according to section 504 of the Rehabilitation Act and the Human Rights Act.
• You have the right to be free from abuse and neglect.
• You do not have to provide information regarding HIV/AIDS status or testing. If information is provided, it will not appear in your clinical record, be discussed with personnel, or be released to any other agency.
• You and/or your guardian have the right to receive a copy of the agency’s grievance procedure and will not be denied service, suspended from services, or terminated from services because of filing a grievance. You have the right to present a grievance up to and including FCS’s Board of Directors. You will receive a response to your grievance within 5 business days. The Board of Director’s response to the grievance will constitute a final administrative decision. A record of grievances and responses will be maintained in your client file.
• If applicable, you have the right to contact the public payer or its designee and to be informed of the public payer’s process for reviewing grievances.
• You have the right to an individualized treatment plan that is based on your strengths, abilities, needs, preferences, and desired outcomes. You have a right to a copy of your plan.
• You have the right to services free from abuse, neglect, seclusion, retaliation, humiliation, corporal punishment, or exploitation, including financial exploitation.
• You have a right to privacy and no information will be disclosed about you to others without your informed written consent, except for the following: FCS has to follow state laws about special requests for information.
• We have a responsibility to warn others if you threaten to hurt them. We must report any suspected child or elder abuse or neglect. We may communicate information to others if you are at risk of harming yourself or others.
• Your confidentiality is governed by the Confidentiality Act and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). If your confidentiality rights are restricted for any reason, justification for the restriction shall be documented in your clinical record. For minors, the client and the guardian shall be notified of the restriction.
• You have the right to contact the Guardianship and Advocacy Commission or Equip for Equality if you believe your rights have been violated. Our staff will assist you in contacting these groups if you so desire.
• You have the right to be free from exploitation.
• You have the right not to be denied mental health services because of age, sex, race, religious belief, ethnic origin, marital status, sexual orientation, physical or mental disability, or criminal record that is unrelated to any possible present dangerous behavior, HIV/AIDS status, or ability to pay.
• You have the right not to have services denied, suspended, reduced or terminated for exercising your rights. You and/or your guardian have a right to present grievances up to and including FCS’s executive director. The executive director’s decision on the grievance shall constitute a final administrative decision. You will be informed by our staff how your grievance will be handled. ECS shall keep a written record of your grievance.
• You have the right to give informed consent to services and treatment. Except in emergencies no services will be provided to you without your or your guardian’s informed consent.
• You have the right to refuse any services that are offered to you, and to be informed of the consequences, if any, of such refusal.
• You have the right to purchase and use the services of other professionals, or private physicians, and other behavioral health services and providers, and to have FCS transmit your records to another provider at your legal request.
• You have the right to participate in any team meeting where your case is being discussed.
• The State of IL requires reporting of Tuberculosis. Individuals who have or are suspected of having TB will be reported to Public Health as required by statute.
• You have the right to inspect and copy your clinical records that are generated by FCS. You have the right to request corrections of errors or incomplete information.
• Any incidents of abuse or neglect will be reported to the Department of Public Health, IL Dept. of Human Services, or the IL State Police for investigation.

If your rights are restricted, staff must notify:

1. You and the person of your choice, if one is identified
2. Your parent or guardian if you are under 18, and your guardian if one has been appointed
3. FCS’s Executive Director
4. The Guardianship and Advocacy Commission if you say you want the Commission to be contacted and all persons and agencies that you choose to know about the restriction.
5. Staff must document justification for rights restriction in your client record. You have the right to contact any of the following if you have questions about your rights:

Client Responsibilities

Family Counseling Service believes that clients have responsibility for their own health and well-being as much as this is possible. A mutually acceptable partnership between clients and service providers can be ensured if clients are aware of their following responsibilities:

• To show consideration and respect and behave in a manner which does not cause undue disruption to staff and other clients at FCS.
• To be responsible for the safety, behavior, and supervision of their children at all times and children through age eleven (11) must be accompanied by a parent, guardian, or responsible caregiver age fourteen (14) or older.
• To maintain confidentiality regarding information about other clients in groups or programs conducted by FCS.
• To provide complete and accurate information to FCS in order to receive the best care. Clients are encouraged to ask questions, discuss treatment and if in doubt request a second opinion.
• To keep appointments or to cancel at least 24 hours in advance if unable to attend.
• To pay account balances in a timely manner or make payment arrangements.
• To follow action plans or treatment programs which have been chosen in consultation with the service provider.
• Give accurate information about their mental health, substance use, and domestic violence issues as well as other circumstances which might impact upon the care of their children;
• Inform staff immediately if they have any concerns or problems with the service they are receiving.