INFORMED CONSENT FOR COUNSELING SERVICES
Member Assistance Program
Employee Assistance Program
Outpatient Therapy
Welcome to Christian Family Solutions (CFS). Thank you for choosing us to assist you. We pray that our gracious God works through our skilled counselors to resolve the matters that brought you to us for care.
Christian Family Solutions, founded in 1965, provides Christian counseling care and services in our clinics, in schools, and via secure video. We are committed to healing and helping people in need with the same excellence and unconditional love that Jesus Christ demonstrated in His ministry. It is our hope that you feel welcomed, safe, and supported within our family of care.
It is our prayer that your relationship with your Christian counselor will help you and/or your family members to gain better insight into your daily living and to grow toward a healthier, more satisfying Christian life. This requires mutual effort by both you and your counselor. Change does not happen by itself; we would fail without the strength of our gracious Lord. Living the Christian life is both a joy and a challenge for all of us.
Service Options
Member Assistance Program / Employee Assistance Program
Through this program, you are utilizing the counseling services available through your organization (church, school, employer). Counseling services are intended to be short-term and are available in person at one of our Christian Family Solutions clinics, or through a secure video connection. Your organization defines the session limit and services that are available to you at no cost. Should you and your counselor identify a longer-term need, you may continue meeting with your counselor through our outpatient services, or your counselor will help you find resources to meet your needs. If you are referred to an outside provider, it is your responsibility to pay for services received from that provider.
Outpatient Services
Christian Family Solutions provides professional Christian counseling services at one of more than 50 clinic locations in the U.S., or through a secure video connection (telehealth). These services are available to you if you are in need of longer-term counseling after you have reached your session limit through your Member Assistance Program or Employee Assistance Program. Services provided through our outpatient program are available only in states where our mental health professionals are licensed. If you choose to continue meeting with your counselor after your organization or employer’s session limit has been reached, you are responsible for the service fees.
Following is important information related to the counseling services you are agreeing to receive through Christian Family Solutions, including the process of counseling, our mission statement, and information on service fees. If you receive services through a secure video connection, please read the information related to telehealth. Please read it carefully and feel free to ask questions about anything that is not understandable. The purpose of this Informed Consent is to ensure that our relationship with you is founded on understanding and trust. You will be asked to sign a Client Acknowledgment Form, indicating that you understand and agree with the terms of this Informed Consent.
The Process of Counseling
There are multiple approaches to counseling, and the best solution depends on the personalities of the client and counselor as well as the particular problems that the client brings. The appropriate counseling approaches to help you with your specific situation will be discussed with you. Unlike most medical care, counseling requires an active effort on your part. Together with the counselor, you will choose how to approach your concerns. To be successful, you will have to work toward your goals both during sessions and at home.
Counseling has both benefits and risks.
- Counseling has been shown to reduce feelings of distress, create better relationships, and resolve specific problems. Counseling often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
- Risks include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, loneliness, and helplessness that may be part of the process of change. Relationships may also be affected. Side effects or risks of side effects from any psychotropic medications should be discussed with your physician.
Your experience may be similar to or vary from those described above.
There are two main steps in counseling.
- The first step is assessment. You and your counselor will spend time evaluating your needs and your goals and gathering pertinent information. A plan will be completed and will include an initial assessment, goals for change, and intervention techniques to accomplish these goals. Outpatient services may also include diagnosis and a formal treatment plan. You will then need to make a decision to continue the counseling process. If you choose not to work with your counselor, we will refer you to another mental health professional in your area. Counseling involves a commitment of time, energy, and often a financial commitment as well. Any questions you have about the process should be discussed whenever they arise. Should you choose to not pursue counseling or discontinue prematurely against your counselor’s advice, your symptoms may return and/or worsen.
- The second step is the actual counseling. While the first step usually takes 1 to 2 sessions, the actual number of sessions needed to accomplish goals for clients will vary. Some matters are quite complex and beyond the scope of the short-term counseling services available through your Member Assistance Program or Employee Assistance Program. Considerable time may be needed to accomplish some goals. However, other situations take less time to resolve. Your counselor will make every effort to be as time and cost efficient as possible to help you resolve your concerns through the Member Assistance Program, Employee Assistance Program, or professional outpatient services. If your assessment indicates that more intensive care is appropriate for your situation, you may receive a referral to a higher level of care, either within the CFS family of services or to the provider that best fits your needs.
Emergency Coverage
In cases of a mental health emergency or “after hours” coverage, please call 800.438.1772 and follow the prompt to be connected with a professional counselor immediately. For life-threatening situations, please call 911 or go to your nearest hospital.
Confidentiality
The counseling relationship is confidential. Your counselor cannot release any information about the counseling process without your written permission. This includes even the fact that you are a client at CFS. Confidentiality is governed by Federal and State law, and Christian Family Solutions will abide by the law. A copy of our Privacy Practice Notice is available on our website at ChristianFamilySolutions.org. You may also request a written copy of this notice.
Confidentiality does have legal and ethical limitations. A therapist may break confidentiality if, in his/her judgment, it is necessary to protect the safety or welfare of the client or another person. If you threaten to hurt yourself or someone else, or raise suspicion of child abuse, or if a minor under the age of 16 reports sexual activity, your therapist may be bound by law to report it to the proper authorities.
Your counselor may discuss your case with other Christian Family Solutions professional staff including contracted consultants for purposes of effectively coordinating treatment and/or to meet state-mandated requirements.
All state-certified mental health clinics are obligated to maintain clinical records in accordance with the respective administrative rule. Christian Family Solutions is a state-certified mental health agency. We maintain an electronic record that is confidential and kept within a secure software system developed specifically for the counseling industry. All records are not only secure; they also have a redundant backup system in the event of a system malfunction. Only authorized personnel have access to these electronic records.
Outcomes Measurement
For quality assurance and continuous improvement in our therapy practices, CFS administers a client feedback system called “Better Outcomes Now” (BON). Your therapist will ask you to contribute feedback to your own progress during your course of treatment. This data is used to create conversations with your therapist about your treatment goals, your progress, and your therapist’s responsiveness to your needs. This progress tracking is not included in your medical record, and conversations about your progress will remain between you and your therapist. The data on your progress may also be deidentified and compiled with data from other CFS clients for research purposes. This generalized, aggregate research helps our clinicians improve their work and improves services for many people over time. You may choose to opt out of the BON measurement process, and your therapist will still build rapport and discuss progress with you. BON simply provides the context and the framework for these discussions.
Consultations and Supervision
You or your counselor may request to consult with the agency’s supervising psychiatrist and/or psychologist regarding the course of your treatment. Also, as part of your counselor’s ongoing professional development, he/she may be receiving supervision. Your counselor will inform you at your first meeting if he/she is being supervised. Any outside-of-clinic assessments or evaluations will be handled according to the policies and procedures of the outside source.
Fees and Insurance for Outpatient Services
Your sessions provided to you through your organization’s Member Assistance Program or Employee Assistance Program are available to you at no cost. The number of sessions or hours of services depends on your organization’s program limits. If you choose to continue meeting with your counselor after your organizational counseling benefit has been reached, and you reside in a state where your counselor is licensed, you will be responsible for fees associated with outpatient services. Information on outpatient fees and payment information:
Insurance
- It is important for you to understand the benefits of your insurance policy. Your health insurance is a contract between you and your health insurance company or employer. Please contact your insurance company or employer with any questions you may have regarding your coverage. Please note that it is your responsibility to know (i) your insurance benefits, including covered benefits and any exclusions, coverage limits, co-payments, and other out-of-pocket costs, and if Christian Family Solutions is a contracted provider with your insurance company; and (ii) if your insurance company has specific rules or regulations such as the need for referrals, prior authorizations, and limits on coverage regardless of whether or not our clinicians participate in your benefit plan. As a courtesy, Christian Family Solutions will make reasonable efforts to verify your insurance benefits. We assume no responsibility for any incorrect information received from you or your insurance company or for any errors based on such incorrect information. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
- Please provide all referrals and authorizations in advance of your appointment. If an authorization is required and is not in place at the time of your appointment, you will be responsible to pay for the cost as a self-pay client at the time of service.
- You must present a current and valid insurance card upon request. Whether or not you have insurance coverage for services provided by Christian Family Solutions, you acknowledge and agree that you are responsible for payment for all services rendered.
- If you are covered under Medicare, you understand and agree that you will need to provide us with your Medicare ID card and your secondary ID card, if applicable. If you do not provide us with the proper information for any secondary insurance, the secondary insurance will not be billed, and you will be responsible to pay any balance owed after payment by Medicare.
- If you do not provide Christian Family Solutions with your current insurance information, or if you do not have insurance coverage, you will be responsible for payment in full at the time of your appointment.
- If your insurance carrier is not one with which Christian Family Solutions participates, you are responsible for payment in full at the time of service. Insurance plans and Medicare consider some services to be “non-covered,” in which case you are responsible for payment in full at the time of service.
Self-Pay Clients
- Self-pay clients will be expected to pay at the time of each visit.
Billing
- If your insurance company has not paid your claim within 60 days of service, you agree to pay any then-existing balance due. Christian Family Solutions will mail a statement to you, and payment of the balance due must be made within 10 days of the receipt of that statement. Subject to the “Refund” section of this Agreement, you will receive a refund from Christian Family Solutions if your insurance company pays a claim for services that you previously paid for. Any such refund will be up to the amount that the insurance company paid, limited to the amount you had previously paid for the same services.
- If any balance remains on your account after your insurance company has made a payment, you must pay any remaining balance due within 10 days of receipt of a statement showing such amount due.
- If you cannot pay the balance in full within 10 days, please contact a Client Accounts Specialist at 262.293.9746 to see if you qualify for special payment options or to arrange a payment plan.
Failure to Pay
- Past due accounts may affect scheduling of future appointments.
- If you have accrued an outstanding balance of $350 or more, Christian Family Solutions may reduce the frequency of your scheduled appointments or discontinue services until you have reduced your balance.
Fees
- Returned checks are subject to a $25 fee, and your account will be placed on a “cash only” status. Christian Family Solutions will accept payments only by cash or credit card until the balance is paid in full.
- If you must cancel an appointment, Christian Family Solutions requires a minimum of a 24-hour notice.
- Failure to give a 24-hour notice or keep your scheduled appointment may result in a charge of $75. Missed appointments represent a cost to Christian Family Solutions and to other clients who could have been seen in the time that was set aside for you.
- Clients who fail to pay will be responsible for Christian Family Solutions’ reasonable collection agency or attorney’s fees, and costs and expenses.
Guarantor
- Any client over the age of 18 or an emancipated minor will be held financially responsible for all charges incurred. If another party is responsible for the payment of your account, whether as a parent, guardian, or guarantor, you and that party will be jointly and severally liable for the full payment of your account and for all of the other obligations under this Agreement, including the obligations under the “Fees” section of this Agreement.
Minors and Dependents
- Parents and guardians are responsible for the payment of services provided to their dependents at the time services are rendered.
- The parent or adult accompanying a child is responsible for payment of services or out-of-pocket charges at the time services are rendered to the child. In all circumstances, it is the responsibility of the accompanying parent or adult to work out any payment arrangements for the child’s care, whether between the custodial and non-custodial parent or otherwise.
Refund
- A refund will be issued only if there are no outstanding balances on other accounts with the same guarantor or financially responsible party. If you feel that a refund is due, please contact our office.
Counseling Services Through Secure Video
Counseling services provided through a secure video connection is also called telehealth. You can utilize telehealth services both through Christian Family Solutions’ outpatient services as well as through your organization’s Member Assistance Program or Employee Assistance Program.
Telehealth involves the use of electronic communications to enable Christian Family Solution’s mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, and may include diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.
You have the following rights with respect to telehealth:
- The laws that protect the confidentiality of your personal information also apply to telehealth. As such, the information disclosed by you during the course of your sessions is confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where you choose to make your mental or emotional state an issue in a legal proceeding. The dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without your written consent.
- You can choose to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
- There are potential risks and consequences from receiving services through telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of your personal information could be disrupted or distorted by technical failures, the transmission of your personal information could be interrupted by unauthorized persons, and/or the electronic storage of your personal information could be unintentionally lost or accessed by unauthorized persons. Christian Family Solutions utilizes secure, encrypted audio/video transmission software to deliver telehealth.
- If your counselor believes you would be better served by another form of intervention (e.g., face-to-face services), alternatives to counseling through telehealth will be explained to you and you will be referred to a mental health professional that can provide such services in your area. Once referred to an outside provider, it is your responsibility to pay for services received from that provider.
- There are potential risks and benefits associated with any form of counseling, and that despite your efforts and the efforts of your counselor, your condition may not improve, and in some cases may even get worse.
- In choosing to participate in telehealth, you are agreeing to participate using video conferencing technology. However, at your request or at the direction of your counselor, you may be directed to “face-to-face” psychotherapy.
- You may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in your care, but that no results can be guaranteed or assured.
- Others may also be present during the counseling session other than your counselor in order to operate the video equipment. If others are present, they will be identified to you at the beginning of the session and will all maintain confidentiality of the information obtained. When others are present in the session, you have the right to request the following: (1) omit specific details of your medical history that are personally sensitive to you, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the session at any time.
- For your safety, you will be asked by your counselor to confirm your physical location during the session. Certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If you are in crisis or in an emergency during your session, your counselor will contact emergency services in your area, or ask you to immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in your immediate area.
- Information about your counselor, including a written and video biography with details on their credentials and training, is provided on our website ChristianFamilySolutions.org.
Mission Statement and Statement of Beliefs
Mission Statement
The mission of the counseling division of Christian Family Solutions is to provide Christ-centered, Scripture-based counseling services with the purpose of reflecting the healing and helping ministry of Jesus Christ to the people of a sinful and troubled world.
Statement of Beliefs
- We believe in the Triune God, one God eternally existent in three persons: Father, Son, and Holy Spirit (Matt. 28:19).
- We believe that the Bible is the inspired (2 Pet. 1:21), inerrant (1 Cor. 2:13), infallible (Jn. 10:35), and completely authoritative (2 Tim. 3:16) Word of God.
- We believe that all people are sinners by nature and activity (Ps. 51:5) and unable to reconcile themselves to God by any human efforts (Eph. 2:1, Rom. 3:9-18).
- We believe that salvation is by God’s grace and action alone (Eph. 2:8-9) accomplished through His Son, Jesus Christ (Jn. 3:16, Acts 4:12, Gal. 4:4-5).
- We believe that Jesus Christ is the eternal Son of God, who became man, lived the perfect life that God requires, died a substitutionary death, and rose again from the dead to atone for the sins of the whole world (Col. 2:9, Acts 2:23-24, 1 Pet. 3:18).
- We believe that it is by the working of the Holy Spirit through the Means of Grace that people receive faith in Jesus as their Lord and Savior (1 Cor. 12:3). The Holy Spirit gives believers the wisdom and strength to walk according to His will (Phil. 2:13, Gal. 5:16-25, Is. 41:10).
- We believe that Jesus shall return visibly and bodily to judge all people. Those who believe in Jesus will live with Him forever, while unbelievers will be condemned to an eternity in hell (Mk. 13:26, Jn. 5:27-29).
Client Rights and Satisfaction
IIf you consider that the services you received are unsatisfactory or think your rights have been violated, you have the right to use a grievance procedure. Please contact any Christian Family Solutions counseling office for an information packet on the procedures to follow. Or you may contact the Clients Rights Specialist to request the packet: Christian Family Solutions, Attn: Clients Rights Specialist, W175 N11120 Stonewood Drive, Germantown, WI 53022. Include your name, address, and phone number. Also, each state may establish a Patient Bill of Rights. These rights are posted in our waiting room or are available as a handout.
Client Acknowledgment
Your physical or electronic signature indicates the following:
- You have received this Informed Consent for Counseling Services document and acknowledge that you are receiving initial counseling services available at no cost through your organization’s Member Assistance Program or Employee Assistance Program;
- You have received this Informed Consent for Counseling Services document and you agree to abide by its stated terms regarding the cost/charges for outpatient care and treatment services provided after your organization’s services have been utilized;
- You are aware that the Privacy Practice Notice is available on ChristianFamilySolutions.org or in writing at your request;
- You have read and understand the information provided in this document regarding telehealth or video-assisted counseling services available to you;
- You consent to enable us to use and disclose your personal health information for purposes of outpatient treatment, payment, and health care operations;
- You are aware of your rights and the grievance procedure available to you on our website or in written form;
- You have received information describing the Mission Statement and Statement of Beliefs from Christian Family Solutions;
- By supplying your home phone number, mobile phone number, e-mail address, and any other personal contact information, you authorize Christian Family Solutions to employ a third-party automated outreach & messaging system to use your personal information, the name of your therapist, the time and place of your scheduled appointment(s), and other limited information, for the purpose of notifying you of a pending appointment, missed appointment, unpaid balances, or any other reasonable healthcare-related communication;
- You agree that, in order for Christian Family Solutions to service your account or to collect monies you may owe for outpatient services, designated agents may contact you by telephone at any telephone number associated with your account, including telephone numbers that could result in charges to you. They may contact you by sending text messages or e-mails, using any e-mail address you provide to them. Methods of contact may include using prerecorded/artificial voice messages and/or use of automatic dialing devices, as applicable.
The time period for this informed consent shall be one year. At the end of this time frame, this material will be shared with you again and your informed consent obtained. You have the right to withdraw informed consent at any time, in writing. This will, in effect, terminate counseling.