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By signing this form, you agree to receive mental health services provided by Kentucky Mental Health Care, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KMHC policy, State and Federal Laws, and your rights about counseling. All KMHC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy and plan limitations and risks will be discussed with you today
TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process
If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KMHC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.
CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KMHC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KMHC you are in danger of harming yourself or others
5. Information shared with
6. When required by law.
If you need to contact me between counseling sessions, please call my office. E-mail, text messages and social networking sites are not confidential and I may not be able to respond. If an emergency situation would happen, you can call my office to have a counselor call you. If no call is received within 15 minutes or you can’t wait call 911.
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