Informed Consent

Behavioral Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in these services, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. SEKYBHLLC and/or your therapist, has corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Behavioral Therapy/psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life.  However, psychotherapy has been shown to have benefits for individuals who undertake it.  Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  But, there are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you some initial impressions of what our work might include. At that point, your treatment goals will be discussed, and an initial treatment plan will be developed. You should evaluate this information and make your own assessment about whether you feel comfortable working with your therapist toward the goals within the treatment plan.  If you have questions about the procedures, feel free to discuss them with your therapist whenever they arise. If your doubts persist, SEKYBHLLC will be happy to help you set up a meeting with another mental health professional for a second opinion.

Appointments will ordinarily be approximately 1 hour in duration, at a frequency that you and your therapist may determine based on your needs.  Keep in mind, some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, you must provide our office at least 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your co-payment unless there is an agreement that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, your therapist will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

The standard fee for the initial intake and subsequent sessions is equivalent to the current KY Medicaid Fee-for-Service Behavioral Health & Substance Abuse Services Outpatient (Non-Facility) Fee Schedule (which can be provided upon request.  You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash or major debit/credit cards.  Credit or debit transactions less than $10.00 will incur an additional $3.00 transaction fee.  Any checks returned to the office are subject to an additional fee of up to $36.00 to cover the bank fee that SEKYBHLLC incurs. If you refuse to pay your debt, SEKYBHLLC reserves the right to use an attorney or collection agency to secure payment.

In addition to scheduled appointments, SEKYBHLLC may practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of your clinician. If you anticipate becoming involved in a court case, it is recommended that discussion be held with your therapist in full before you waive your right to confidentiality. If your case requires your therapist’s participation, you will be expected to pay for the professional time required even if another party compels your therapist to testify.  The amount of time in which your therapist attends court proceedings (including time in which testimony is not provided).  This could and may be a minimum of eight (8) hour time span per day as previously scheduled appointments will have to be cancelled to accommodate the clinicians attendance in court.  This is considered a non-covered service per your insurance agreement. 

In order for SEKYBHLLC to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, SEKYBHLLC billing service and your therapist will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting the office know if/when your coverage changes.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow SEKYBHLLC to provide services to you once your benefits end. If this is the case, SEKYBHLLC will attempt to find another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require you to authorize SEKYBHLLC or your therapist to provide them with a clinical diagnosis. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems.  All diagnoses come from a book entitled the Diagnostic and Statistical Manual. There is a copy of this manual within our office and I will be glad to let you see it to learn more about your diagnosis, if applicable. Sometimes SEKYBHLLC or your therapist may have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, SEKYBHLLC has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. SEKYBHLLC will provide you with a copy of any report that is submitted, if you request it. By signing this Agreement, you agree that SEKYBHLLC and your assigned therapist can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for the services rendered by SEKYBHLLC and/or your therapist yourself to avoid the issues described above, unless prohibited by SEKYBHLLC provider contract.

If SEKYBHLLC or your therapist is not a participating provider for your insurance plan, SEKYBHLLC will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers.  If you prefer to use a participating provider, SEKYBHLLC will refer you to an in-network provider.

Southeast Kentucky Behavioral Health does not complete “custody evaluations.”  If you are seeking a professional opinion related to custody of your child or a minor in your care, you are here advised that this organization is unable to provide this service at this time.  At any time during treatment, your clinician or member of management of Southeast Kentucky Behavioral Health feels as though treatment has or is becoming custody related, your clinician and/or member of management of Southeast Kentucky Behavioral Health reserves the right to end treatment immediately at his/her discretion without explanation.  In the event of such termination of services is made, Southeast Kentucky Behavioral Health will assist in locating an organization or individual provider that may assist and support you in such evaluations and/or treatment. 

SEKYBHLLC is required to keep appropriate records of the services that provided. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress set for treatment, your diagnosis, topics discussed, your medical, social, and treatment history, records received from other providers, copies of records that SEKYBHLLC send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers.  For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If SEKYBHLLC or your therapist refuse your request for access to your records, you have a right to have the decision reviewed by another mental health professional, which will be discussed with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

SEKYBHLLC policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled “Notice of Privacy Practices”.  You have been provided with a copy of that document. Please remember that you may reopen the conversation at any time during our work together.

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is SEKYBHLLC’s policy not to provide treatment to a child under age 13 unless he or she agrees that the therapist can share whatever information that could be considered necessary with a parent. For children 14 and older, SEKYBHLLC requests an agreement between the client and the parents allowing SEKYBHLLC or the therapist to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy, if requested. All other communication will require the child’s agreement, unless SEKYBHLLC/therapist  feels there is a safety concern (see also above section on Confidentiality for exceptions), in which case every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. 

n with clients or otherwise unavailable. At these times, you may leave a message on SEKYBHLLC confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from SEKYBHLLC or your therapist is unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe:

• Contact the National Suicide Hotline at 1-800-273-8255
• go to your Local Hospital Emergency Room, or
• Call 911 and ask to speak to the mental health worker on call.

The office or your therapist will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering our practice.

TEXTING COMMUNICATION WITH YOUR PROVIDER
It is Southeast Kentucky’s policy that the organization may use text messaging as a means of communication between staff and Individuals, Services providers, and/or their guardian(s) to facilitate scheduling, reminders, and other non-emergency administrative matters. Text messaging is intended to enhance accessibility and convenience for our Individuals, Services providers, and/or their guardian(s) while maintaining the highest standards of privacy and confidentiality.
Text messaging is not a secure form of communication and should not be used to discuss sensitive, confidential, or clinical information. Text messaging should never be used in emergency or crisis situations. Individuals, Services providers, and/or their guardian(s) in immediate need should call 911 or utilize crisis hotline services.
Individuals, Services providers, and/or their guardian(s) must provide explicit written consent to receive text messages from our organization. By providing consent, Individuals, Services providers, and/or their guardian(s) acknowledge the potential risks associated with text messaging, including but not limited to interception, loss, or unauthorized access to information.
Text messages will only address administrative matters such as appointment confirmations, cancellations, or general inquiries related to services. No therapeutic advice, clinical discussions, or protected health information (PHI) will be included in text communications.
Staff are required to use organization-approved devices and secure platforms when texting clients. Personal identifying information (e.g., full name, diagnoses, or financial details) will not be included in text messages. Our organization monitors compliance with confidentiality policies to mitigate risks associated with text communication.
Individuals, and/or their guardian(s) are responsible for notifying the organization of any changes to their phone number. Individuals, and/or their guardian(s) should delete sensitive text messages after reading them to minimize potential exposure. Individuals, and/or their guardian(s) may opt out of receiving text messages at any time by notifying the organization in writing or by other designated means. Once opted out, all future communication will be conducted through alternative approved methods.
Acknowledgment of Risk
While we strive to protect the confidentiality of all client information, Individuals, and/or their guardian(s) should understand that no communication method is entirely risk-free. By consenting to text messaging, Individuals, and/or their guardian(s) acknowledge and accept these risks.

If you are unhappy with what is happening in therapy, please discuss the concerns with your therapist in an attempt to address your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that SEKYBHLLC or your therapist refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about your therapist’s training and experience. You have the right to expect that your therapists will not have social or sexual relationships with clients or with former clients.