Avance Behavioral Wellness Informed Consent

  • Avance Behavioral Wellness is required by federal law to provide you with this information in written form, and to obtain your signature indicating your understanding and acceptance of the contents. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections (PHI) for the purposes of treatment, payment, and health care operations. Signing this document creates an agreement between us. We can discuss any questions you may have prior to signing. If additional questions arise in the future, you are always welcome to bring them to the attention of the therapist with whom you are working.


    We take a systemic, whole-person, strength-based approach to psychotherapy, in order to maintain the integrity of our integrated patient care model. Therapy varies depending on the training background of the therapist, the personality and diagnosis of the patient, and each situation’s particular challenges. In working with the various aspects of your life, which may become relevant during the therapeutic work, you may experience a range of feelings and emotions, including potential triggering or intensification of unpleasant thoughts and feelings. However, therapy has also been shown to yield many benefits, including a significant reduction of clinical symptoms associated with psychiatric diagnoses, improved relationships, and solutions to specific problems. In spite of the generally robust evidence supporting the effectiveness of this mode of treatment, there are no guarantees regarding the outcome. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things outside of sessions, in addition to efforts made during formal psychotherapy appointments.

    The first two to four sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, the therapist will be able to offer some initial impressions of what your on-going treatment might include. Based on the information you provide on your comprehensive intake form and the discussions in the initial sessions, you and your therapist will develop your initial treatment goals and plan. While this plan is not “set in stone” and may evolve when the progression of treatment reveals new concerns, it generally facilitates the promotion of change for patients to be working toward tangible goals from early in the therapeutic process.


    Therapy sessions usually begin at a frequency of once per week, ordinarily lasting 45-55 minutes in length. Sessions may occur more or less frequently and vary in duration as individual needs dictate. The frequency of appointments can often be spread out over time, as progress is made and the treatment focus moves to a more supportive role for the purpose of maintaining the gains that have been made.

    Keeping your regularly scheduled appointments is very important to the continuity and success of therapy. If at all possible, you should attempt to avoid rescheduling appointments. When unavoidable circumstances do arise, please provide a 24 hour notice if a session needs to be rescheduled or canceled. This is an appropriate courtesy to respect the time of your therapist, as well as other patients who may be in need of an appointment and are waiting on a cancellation list.

    If you miss a session without notifying our office or if you cancel with less than 24 hours notice, our policy is to charge $35.00. Due to the increased demand for prime-time appointments, all behavioral wellness office visits scheduled between 4:00-7:00 pm and weekends will incur a $75.00 fee for a late cancellation or no-show. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus you will be responsible for these charges. In addition, you are responsible for coming to your session on time. If you are late, your session will still need to end on time.


    It is important to evaluate what resources you have available to pay for your treatment, in order to set realistic treatment goals and priorities. If you have health insurance, it will usually provide some coverage for mental or behavioral health treatment. As a professional courtesy and with your permission, our billing service will assist you in filing claims and verifying information about your coverage, to the greatest extent possible. You are ultimately responsible, however, for knowing your coverage and alerting us of any changes to your coverage.

    For Behavioral Wellness services, we are currently a participating provider for Blue Cross Blue Shield product lines. If you plan to use your insurance, authorization from your insurance company may be required before they will cover therapy fees. Our intake coordinator will assist you in contacting your insurance to confirm your coverage of psychotherapy fees prior to your first appointment. Your co- payment is expected to be paid at the time of the visit by cash, check, or credit or card.


    If we are not a participating provider for your insurance plan, we will provide you a receipt of payment for services, which you can submit to your insurance company in an attempt to obtain partial reimbursement for the expenses you incurred. Please note, however, that not all insurance companies reimburse for out-of-network providers. Again, our Behavioral Wellness Coordinator can assist you in verifying specific policies on this matter with your insurance carrier.

    Psychologists’ out-of-network fees are $175 for the initial intake, $165 for each subsequent hour-long session, and $110 per hour for psychological testing. Masters’ level therapists are $135 for the initial intake and $125 for each subsequent hour-long session.

    Avance Care offers medical discount cards for uninsured/self-pay patients ages 5 and up. For an annual fee of $50, you receive a 25% additional discount on top of our prompt-pay discounted fees for all medical services (excludes vaccinations) received at Avance Care.

    Self Pay Fees

    Initial Assessment:  $135

    Subsequent Visit: $125

    Purchase Subsequent Visit Bundle and Save: 4 Subsequent Visits for $320 (2 Installments of $160 Each to be Paid During First Two Visits)


    There may be sessions where we will work with multiple members of a family (e.g. partner, sibling, children, etc). In such relational cases, the therapist may need to share information learned in an individual session or via email/phone contact with the entire treatment unit (e.g., couple, family, etc.) in order to ensure effective and ethical treatment. This allows the therapist to continue treating the couple or family by preventing a possible conflict of interest, in which an individual’s interests may not be consistent with the interests of the unit being treated. The precise nature of how much information will need to be shared will vary individually with each case. Ongoing review of such matters should occur with your therapist prior to revealing any material, if there is ever concern over the sensitivity of the information being discussed.


    Avance Behavioral Wellness is not intended to be used as a vehicle to substantiate client testimony in a court of law. Forensic specialists should be sought if you desire or require depositions, interrogatories, courtroom testimony, et cetera. These are not services that Avance employees typically provide. If you anticipate becoming involved in a court case, it is recommended that this be discussed fully before you waive your right to confidentiality. It is important to understand that asking the clinician to testify in court, or obtaining a subpoena may harm the professional and therapeutic relationship between patient and clinician. In the unusual event your case requires participation of the clinician in legal process, you will be obligated to pay for the professional time required at standard forensic rates (i.e. which range from 150% to 200% of usual psychotherapy rates). This policy applies even if another party compels the clinician to testify, so it is imperative that you advise your therapist at the first sign of potential litigation, so that you might be assisted in risk management and other attempts to avoid having your behavioral health treatment brought into any legal process.


    We are required to keep appropriate records of the behavioral health services that are provided. Your records are maintained in our secure, password protected online system that is HIPAA compliant, which involves for example the utilization of encryption services. Records include: intake and assessment information such as medical, social, and treatment history; treatment goals and treatment plan; progress notes from individual sessions; records received from other providers; copies of records sent to others; billing records; et cetera.

    Except in unusual circumstances that involve potential danger to yourself, you have the right to a copy of your file. It is recommended that you initially review them with your treating therapist, as they are professional records and often involve jargon that can be misinterpreted and this may lead to emotional harm or other negative outcomes. If your request for access to your records is refused, you have a right to have that decision reviewed by another clinical professional. 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.


    Avance Behavioral Wellness has established strict protocols regarding confidentiality of electronic medical records (EMRs). Different levels of security have been put in place. Access to records is only available to the treating providers which, aside from your therapist, could for example include your primary care provider (i.e., physician or nurse practitioner). Our EMR security system prohibits any support staff from getting into these records, as well as preventing access for review by quality control personnel. This is a special measure of privacy afforded specifically to behavioral health records.


    Our 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 and we will have discussed those issues during the initial evaluation process. Please remember that you may reopen the conversation at any time, as questions or concerns arise.


    The law allows parents of patients under 18 years of age who are not emancipated to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with adolescents, we request that parents agree to give up direct access to the details of their child’s records. If you agree, you will only be provided with general information about the diagnosis, treatment plan, therapeutic progress of treatment, and their attendance. Any other communication will require the minor’s additional authorization. In spite of this general policy and intent to protect the integrity of the therapeutic setting for the minor; if the clinician feels the minor is in danger or is a danger to someone else, the clinician will notify the parents of his/her concern. If possible, the matter will be discussed with the minor first, and the clinician will do his/her best to handle any objections before speaking to others.


    If the therapist is not immediately available by telephone, please feel free to leave a message on his/her confidential voicemail and your call will be returned as soon as possible. Please note, as therapists are often occupied during some sessions up to a full 60 minutes out of each hour, it may take more than 24 hours to return calls for non-urgent matters. Your therapist may simply not have sufficient time to address concerns in between scheduled patients and active psychotherapy sessions are not to be interrupted, out of respect for the patient currently receiving treatment. If you have an emergency and cannot wait for a return call, please contact your primary care physician or the nearest emergency room and ask for the psychiatrist on call. Your therapist will make every attempt to inform you in advance of planned absences, as well as provide you with the name and phone number of the therapist covering in his/her absence.


    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 expect that the therapist will not have social or sexual relationships with patients or with former patients. The relationship will always remain entirely professional and will be focused on the clinical needs of the patients at all times.

    If you are unhappy with what is happening in therapy, please talk with the therapist so that he/she can respond to your concerns. Such comments will be taken seriously and handled with care and respect.

    Often your emotional reactions to the therapist are vital to helping you understand yourself and the way you interact with people. As such, addressing these openly is often significantly beneficial in unexpected ways and is therefore highly encouraged. If the patient/therapist match is not a good fit, however, you may also request to be referred to another therapist. Under all circumstances you are free to end therapy at any time. However, you are again encouraged to discuss your motivations for doing so with your therapist first, in order to ensure that you are not potentially avoiding a critical, but difficult point in your treatment.


    This Informed Consent will be valid and remain in effect as long as you are attending therapy sessions, unless revoked by you in writing, with written notice provided to Avance Behavioral Wellness.

    In addition, you understand that you certify to have legal authority to give consent for the treatment of all minor children that are included in therapy.

    Your signature below indicates that you have read this Informed Consent and the attached Notice of Privacy Practices and agree to their terms:

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