WHAT THIS SERVICE IS NOT

This is NOT an Emergency Service and in the event of an emergency, use a phone to call 911. Some mental health agencies provide “crisis intervention services”. The service outlined in this Informed Consent is also NOT a crisis intervention service. Crisis intervention is defined as services provided to patients for acute mental or emotional problems that have a potential for physical injury to self or others, including suicidal behavior, or violent behavior. If you are in need of this level of support, call 911 or 988 (988 is a lifeline that specializing in support for suicidal ideation). Crisis intervention services are available 24 hours, 7 days per week.

Crisis intervention is not psychotherapy, counseling or a psychological assessment. Crisis intervention is as different from psychotherapy as emergency room medicine is from family medical practice.


WHO IS ELIGIBLE FOR THIS SERVICE

This service is intended to provide therapeutic support to an individual in moderate emotional distress. It is available to those who are reasonable safe and resourceful, and looking for someone who can dedicate 90 minutes to them, actively listen, and offer insight, guidance, support.

This service is only available to those physically located in New York State at the time of the appointment.


RISKS AND BENEFITS OF MENTAL HEALTH SERVICES
Counseling can have risks and benefits. Because counseling often involves discussing unpleasant parts of your life, risks include the likelihood of experiencing uncomfortable feelings like sadness, anger, or anxiety. Counseling also has benefits like uncovering solutions to specific problems, better relationships, feeling less distressed, and improved functioning. There are no miracle cures. No one can promise that your behavior or circumstance will change. Your provider promises to support you and do her very best to understand you, and help you clarify what it is that you want for yourself.



RISKS AND BENEFITS SPECIFIC TO TELEHEALTH SERVICES

Telehealth refers to sessions that occur via videoconferencing. Telehealth services have potential benefits including easier access to care and the convenience of meeting from a location of the patient/client’s choosing. It has been found to be effective in treating a wide range of disorders. However, there is no guarantee that all treatment of all patients will be effective.

Potential risks of telehealth technology include interruptions, unauthorized access, and technical difficulties. Some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption. Either you or the provider can choose to discontinue the telehealth visit if it is felt that the videoconferencing connections or protections are not adequate for the situation.

Your provider is not responsible for any technological problems of which she has no control over. Your provider cannot guarantee that technology will be available or work as expected.

The patient/client is solely responsible for information security on their device, including but not limited to computer, tablet, or phone. Do not share your telehealth appointment link with anyone unauthorized to attend the appointment.

Your provider may need to notify emergency personnel in any events including, but not limited to, active concern for your physical safety, and/or learning of a medical issue requiring immediate medical attention. Although you are in direct, virtual contact with your provider through the telehealth service - she, nor the telehealth service can provide any medical or healthcare services or advice. If medical services be required, contact your physician. If emergency services are needed, call 911.



CONFIDENTIALITY
Professional codes of ethics, federal law, and New York State law consider the personal information you discuss in mental health treatment to be confidential. The session content and all relevant materials will remain confidential indefinitely unless the client requests in writing to have all or portions of such content released to a specifically named person/persons/entity.

There are limitations to a client’s right to confidentiality. A more complete description of how your privacy is managed can be found in the separate Notice of Privacy Policies sent to you.

The situations in which the law authorizes or compels Clinicians to share your information with other people are listed here:

1. As may be needed to protect the safety of yourself and others, as allowed under New York State law

2. Information shared discloses any abuse or neglect of a child (under 18 years) or a vulnerable adult (over age of 60 or has a developmental delay). Clinicians are required to report such incidents to authorities.

3. If a court of law issues a legitimate subpoena for information stated on the subpoena.

If you see your provider accidentally outside of the therapy office, she will NOT acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to her, and she does not wish to jeopardize your privacy. However, if you acknowledge her first, she will be more than happy to speak briefly with you, but feels it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.


PAYMENT FOR SERVICES RENDERED

Mental Health Counseling is a service now covered by most health insurance plans. In order to expedite the delivery of this urgent request for an appointment, payment covering the cost of the appointment will be the full responsibility of the patient/client, referred to as “private pay.” The patient/client has the option to submit the invoice to their health insurance company after the appointment, requesting reimbursement of they paid to the provider. Every health insurance plan has different policies and procedures. Your provider does not have guidance to offer on this process.

Future appointments, if your provider accepts your insurance, can be covered by insurance, leaving the patient/client responsible only for paying the co-pay or deductible.


CANCELLATION POLICY

If you decide to cancel this appointment, or do not show up at the scheduled time, your credit card will be charged in accordance with the Credit Card Authorization document you were asked to sign. If you need to reschedule this appointment, and both you and your provider are available to still meet within the next 7 days, the cancellation fee will be waived. If the rescheduled appointment is not held, the cancellation fee will then be charged.


CLIENT RIGHTS AND RESPONSIBILITIES

You can and should ask questions if you don't fully understand what the clinician is doing or plans to do. Clients in mental health treatment have certain rights in addition to confidentiality. You may:

• Ask questions about the qualifications and experience of the clinician.

• Ask questions about anything related to your treatment and expect honest discussion of your concerns.

• Stop treatment at any time.

• Request a copy of your file at any time, request correction of any errors, and request a copy of your file be sent to any other health care providers.



ABOUT YOUR PROVIDER

NAME: KRYSTLE HEARLEY
TITLE: LICENSED MENTAL HEALTH COUNSELOR (LMHC)
COMPANY: KRYSTLE HEARLEY MENTAL HEALTH COUNSELING PLLC
LICENSE NUMBER: 007223
STATE THAT ISSUED LICENSE: NEW YORK