Consent for Counseling
Consent for Behavioral Health Counseling
Counseling is an opportunity to explore changes you want to make with a qualified health care professional. At Teri’s Health Services clinicians are licensed or license eligible. Teri’s Health Services also employs masters level interns who are under the direct supervision of an independently licensed professional. All clinicians whether licensed or interns are trained in several various trauma informed care approaches including CBT, EMDR, Sand Tray Therapy, SFT, Brain Spotting, Family Systems approaches, among other types of approaches. All or some of these approaches may be used with clients who seek therapy services from Teri’s Health Services. At intake, a qualified clinician will complete an initial assessment and treatment plan to identify those goals you want to meet and what approaches will be used to get you there.
Cost and Copay
Copays are required to be paid prior to the visit. You will be asked to pay through your online patient portal or at the front desk when checking in at the Kiosk. You may also provide a credit card to keep on file and your credit card will be processed for any balances.
Supervisor Billing
When your provider is an LMSW/LAC we will bill under their clinically licensed supervisor who reviews their clinical work and signs off. Incident to billing or supervisor billing scenarios are permitted by most major health plans except TriCare for Life and Magellan. For these plans we will ensure you are matched with an independently licensed provider who is credentialed under these plans directly.
Emergency
If an emergency, please call 911 or EMPACT-SPC crisis line at 480-784-1500. This crisis line is available 24-hours a day, 7 days a week. If you need to speak to me off hours please contact Teri Hourihan 602- 503-0710 directly.
Client Records
All of your information is stored within a HIPAA compliant electronic medical records forum. Teri’s Health Services will save your chart for up to 7 years following the closure of chart for services. At any time, you have a right to your records. If you are requesting your records, please allow up to 14 days from the medical records department. You may complete a record request by following this link and completing: https://terishealthservices.jotform.com/form/210261816831147, or if you have questions you may email medicalrecords@terishealthservices.org.
Records Sharing
Your record is only shared with those you provide a release of information for. In some cases, there are court orders that require sharing of records. If one or both of these scenarios are not present than your records are not shared with anyone outside of Teri’s Health Services practice. You are also authorizing the release of information about your care to your insurance company. The information often required by insurance companies may include, but is not limited to, diagnosis, prognosis, and treatment goals. It is important for you to understand that your insurance company has the right to your records for the purpose of verifying the billed services. As a treatment team, all of Teri’s Health Services employees have access to your record. We also will frequently speak specifically about the care of clients in a treatment team setting. You have a right to ask what if anything was shared about you in these settings. We only share that information that is pertinent to client care.
Guardian Expectation
For guardians completing this form with or for your minor child or adult dependent. You agree that you will allow treatment to take place for your dependent with some privacy. As guardian, you have full access to request records from Teri’s Health Services at any time by signing a release of information for how you choose to have them released to you. In counseling it is important even for dependents to feel they have privacy in the session to share. Sharing is very important to the outcome of treatment. For this reason, we ask that guardians allow privacy. Clinicians at Teri’s Health Services agrees that if a high-risk situation or emergency presents in session clinician will bring guardians into session to address with them. If clinician does not speak to guardians outside of the set timeframes, then it is to be realized that no crisis or high-risk situations have been shared. Further, it is expected that guardians will take an active role in the healing process their dependents are enrolled in for counseling. This means that engagement at intake and treatment plan updates at minimum is expected.
Confidentiality
By law, a clinician is considered and titled a "Mandated Reporter." In the state of Arizona mandated reporters include doctors, teachers, nurses, social workers, and counselors. What this means is that if you report to a clinician or healthcare worker at Teri’s Health Services anything that suggests serious and foreseeable harm to yourself or someone else we are required to break confidentiality and get you help and/or warn someone about your plans to harm them. If we are court ordered to release records, we are also required to break confidentiality. If you are court ordered to treatment the courts have a right to your record. If you are a minor (17 or younger) your parents or guardian have a right to your record and this consent will go to them to sign as well. Also, guardians will be provided treatment plans to sign as they are updated at minimum every 90 days.
Complaints
Complaints can go directly to a Clinical Supervisor listed below which you can email directly to leadership@terishealthservices.org. If you feel the complaint is not answered or attended to, you can also make complaints to AZBBHE, 1740 West Adams St. #3600 Phoenix, Az 85007, 602-542-1882. You can also make complaints to AZDHS medical licensing division. To find out who your clinician is being supervised by please see "Team" page at terishealthservices.org, your clinician’s picture, and next to their name will be listed their direct supervisor.
Teri’s Health Services takes all complaints, grievances and concerns very seriously. It is our goal to ensure your compliant, grievance, or concern is addressed and resolved as quickly as possible. If you have concerns regarding your care by you clinical team (this is where you enter the information you current have one the form).
If you have concerns regarding any other care, services, or treatment render by THS, please go to our website and complete the complaint form. You may also email our Chief Strategy and Compliance Officer, Trevor Cooke, at Trevor.cooke@terishealthservices.org. If you feel your complaint, grievance, or concern was not handled or addressed appropriately, you may file a complaint with the Arizona Department of Health Services. A written complaint can be mailed to them at:
Arizona Department of Health Services
Medical Licensing Department
150 N 18th Ave, Suite 450
Phoenix, Az 85007
Supervisors at Teri’s Health Services
Teri Hourihan PHD, LPC, NCC
Audre Medlock LPC (Zachary Arrington, Michaela Halwachs)
Toni Watson LCSW (Terra Barry, Ashley McCann, Anne Reynolds)
How to Contact Clinical Supervisors
When a counselor/social worker are associate licenesd (LMSW/LAC) or license eligible (MSW, MA, MS, Clinical intern) they are clinically supervised by one of the five above clinical supervisors. If your insurance plan is contracted with a supervisor, certain insurance plans do allow for supervisor or incident to billing per CMS guidelines. Counselors and social workers will go over with you in session who their clinical supervisor is and how to contact their supervisor if needed to. Supervisors can all be contacted by calling also our front desk line at 602-358-7073 or emailing frontdesk@terishealthservices.org. If you are not sure who supervises your counselor social worker and would like to have that information also feel free to call or email and we will follow up with you.
No Call No Show Policy
Please cancel within 48 hours of your appointment time/date. If you need to reschedule or cancel please call 602-358-7073. Please refer to our cancelation and no show policy.
Right to Treatment
At any time, you have the right to end counseling or to refuse any treatment modality that a clinician uses at Teri’s Health Services. No penalties regarding your care will be provided for refusing counseling.
Consent to Treatment
Your signature below indicates that you have had an opportunity to read and review this information and that pertinent questions regarding you have been satisfactorily answered. Furthermore, it indicates your willingness and agreement to participate in treatment.