Parent Coaching Intake Form

What can I expect from initial visit? The first 2 sessions are devoted to a comprehensive assessment of your concerns and the development of a treatment plan. After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light On Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. What will treatment entail? Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. What is expected of me? We expect you to come prepared to work hard and play an active role in treatment. We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life. But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life. How frequently will we meet? A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. When will treatment be completed? Light On Anxiety strives to make treatment as effective and efficient as possible. Therefore, progress towards your defined therapeutic goals will be measured frequently. As you move past the challenges that led you to initiate therapy, your therapist will discuss with you the process of terminating treatment as you become your own anxiety coach. If you are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645). If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. Do you accept Medicare/Medicaid? Light On Anxiety Treatment Centers are not a covered provider for Medicare or Medicaid. Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light On Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so. You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare. Are there any limits to confidentiality? The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law. If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program. If you disclose information related to suspected child or elder abuse, Light On Anxiety is obligated to report it. If Light On Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it. Light On Anxiety Litigation Policy I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose. I understand that my Light On Anxiety therapist will not serve as a witness in any type of litigation. I agree to advise my attorney that Light On Anxiety will not become involved in any litigation. I agree that should I seek the Light On Anxiety’s involvement in such litigation I will be responsible for Light On Anxiety’s attorney fees in consulting an attorney to avoid involvement. If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply: 1. Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 2. The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours. Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour. Fees must be paid at least one week in advance of the testimony being given. If not paid in advance, LOA will not appear to give testimony. 3. If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of another 3 hour minimum fee. Light On Anxiety In Person Treatment Policy Completion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. In order for LOA to provide you with in-person services, the following protocols must be followed by clients and providers: ease let us know. By consenting to in-person treatment you acknowledge that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID-19 (or any other infectious disease) symptoms and have been symptom free for the appropriate time frame, per CDC guidelines. Light On Anxiety Telehealth Treatment Policy Benefits and Risks of Telehealth Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks. For example: Risks to Confidentiality Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Technology Issues There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Appropriateness of Telehealth Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work. From time to time, we may schedule in-person sessions to “check-in” with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Records We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies.