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*CLIENT RIGHTS*

To inform the clients of Green Apple Counseling, LLC of their legal and ethical rights in connection with therapeutic services.

Client Shall:

• Be treated with respect and dignity.

• Be treated without regard to physical or mental disability unless such disability makes treatment afforded by the facility nonbeneficial or hazardous.

• Have all clinical and personal information treated confidentially in communications with individuals not directly associated with their personal treatment program.

• Have the right to participate in the development of an individual treatment plan and any ongoing planning of your behavioral health services.

  • You have the right to a reasonable explanation, in terms you can understand, of your general condition; treatment objectives; the nature and significant possible adverse effects of recommended treatment; reasons this treatment is considered appropriate; and what, if any, alternative treatment services and types of behavioral health providers are appropriate and available.

• Have the right to be free from excessive or unnecessary medication. You have the right to give informed consent to take or not take antipsychotic or other medications if they are prescribed to you, unless the court has ordered differently, or an emergency situation exists where your life or the lives of others are in danger.

• Have the right to confidential records and access to said records. Although you must give written approval to allow your records to be released in most cases, there are some exceptions to this rule under state and federal law.

• Be provided reasonable opportunity to practice the religion of his or her choice, alone and in private, insofar as such religious practice does not infringe on the rights and treatment of others, or the treatment program. The client also has the right to be excused from any religious practice.

• Not be denied communication with family in emergency situations.

• Not be subjected by program staff to physical, psychological or sexual abuse, corporal punishment, or other forms of abuse.

• Have services for men and women which reflect an awareness of the special needs of each gender.

• Have access to an established client grievance procedure.

• Have access to Client Rights at any time by requesting a copy or by visiting www.greenapplecounseling.com

  • A copy of Client Rights will be given at first visit.

  • Clients will sign acceptance of client rights during intake purpose

 

*CLIENT CONDUCT*

We value the clients that we serve as well as the providers time and need cooperation with keeping appointments.

Missed Appointments:

• Missing or late canceling an appointment means we are unable to fill this appointment time with other patients who are in need of care.

• It also is inconsiderate of the provider’s time.

Cancellations:

• If you need to cancel your appointment, you must give us at least 24 hours’ notice.

• Cancellations made with less than 24 hours’ notice may be considered a missed appointment.

  • Appointment reminders that are sent out the day before your appointment does give you the option to cancel at that time.

Late Arrivals:

• If you are more than 15 minutes late to your appointment, you may be rescheduled, and your appointment given to another client.

  • This may be considered a missed appointment

Compliance with attendance:

• You must keep 75% (6 out of 8) of scheduled appointments.

  • If you miss 25% of your scheduled appointments, you may be discharged or put on suspension.

  • If you have three (3) consecutive No Shows, you may be put on suspension or discharged.

Client Behaviors and Expectations:

• Clients who exhibit treatment-interfering/progress-interfering behavior shall be treated in a firm but dignified manner consistent with therapeutic objectives.

• Clients may express their opinions, make recommendations or resolve grievances directly to their clinician/therapist/ physician or in writing to the director of the treatment program they are involved in.

• Green Apple Counseling does not allow smoking, alcohol, illegal substances, or paraphernalia on or around 2nd floor of leased building.

• Weapons are not to be brought to any Green Apple facility.

• The client is responsible for being considerate of the rights of other clients and Green Apple personnel and for assisting in the control of noise, smoking and distractions. The client is responsible for being respectful of the property of other persons and that of Green Apple Counseling.

Misconducts:

• All misconducts will be treated as an incident report and follow incident procedure.

• Any inappropriate behaviors will be addressed immediately by chain of command.

• For any possible emergencies, Green Apple is allowed to call 911 for medical or safety concerns.

• Any violation of these rules may result in a suspension of services if misconduct is minimal

  • To be determined by counselor and office manager.

• Any serious violation may result immediate termination of services depending on severity of misconduct and safety risk to Green Apple employees or clients.

Distribution of Information:

• Clients will be asked to sign an agreement indicating that they are willing to abide by these standards during the first visit.

 

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• Please present your insurance card so we can make a copy.

• We at Green Apple will do our best to rectify any issues that we can help with pertaining to billing and claims.

• It is ultimately the client’s responsibility to know benefits, copays and deductibles on their policy. 

• Green Apple cannot waive deductibles or co pays.

• Clients authorize payment directly to Green Apple Counseling, LLC from their insurance company. All charges incurred by clients are their financial responsibility and all court fees, attorney fees or other fees necessary to collect this amount are payable by client.

• Client agrees that, in the event Green Apple places any unpaid balance for collection with any third-party collection agency, client will be responsible to pay a reasonable collection agency fee of up to 50% of the unpaid balance due.

• Green Apple Does provide a sliding scale fee schedule

 

 

*Informed Consent for Psychotherapy*

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: 1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

1. If a client threatens grave bodily harm or death to another person.

2. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

3. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

4. Suspected neglect of the parties named in items #3 and # 4.

5. If a court of law issues a legitimate subpoena for information stated on the subpoena.

6. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

* Notice of Privacy Practices*

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to: Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a

subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you.

1. For my use in training or supervising mental health practitioners to help them improve their skills ingroup, joint, family, or individual counseling or therapy.

2. For my use in defending myself in legal proceedings instituted by you.

3. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

4. Required by law and the use or disclosure is limited to the requirements of such law.

5. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

6. Required by a coroner who is performing duties authorized by law.

7. Required to help avert a serious threat to the health and safety of others.

1. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

2. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believed it would affect your health care. 2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

1. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

2. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so. 5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

1. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that apiece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

2. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. When you sign intake forms, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

*CFR 42 Part 2*

SUBCHAPTER A—GENERAL PROVISIONS
PART 1 [RESERVED]
PART 2—CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS
(c) Prohibition against use of record in making criminal charges or investigation of patient
Except as authorized by a court order granted under subsection (b)(2)(C) of this section, no record referred to in subsection (a)
of this section may be used to initiate or substantiate any criminal charges against a patient or to conduct any investigation of a
patient.

Subpart B- General Provisions

 (2) If necessary, will resist in judicial proceedings any efforts to obtain access to patient records except as permitted by these regulations.
Records means any information,
whether recorded or not, relating to a
patient received or acquired by a federally assisted alcohol or drug program.

2.12 Applicability

(2) Restriction on use. The restriction on use of information to initiate or
substantiate any criminal charges against a patient or to conduct any criminal investigation of a patient (42 U.S.C. 290ee–3(c), 42 U.S.C. 290dd–3(c)) applies to any information, whether or not recorded which is drug abuse information obtained by a federally assisted drug abuse program after March 20, 1972, or is alcohol abuse information obtained by a federally assisted alcohol abuse program after May 13, 1974 (or if obtained before the pertinent date, is maintained by a federally assisted alcohol or drug abuse program after that date as part of an ongoing treatment episode which extends past that date), for the purpose of treating alcohol or
drug abuse, making a diagnosis for the treatment, or making a  referral for the treatment.

*COMPLAINTS AND GRIEVANCES*

To provide clients, visitors and employees a means to voice their concerns with the expectations that it will be rectified to their satisfaction.

Definitions:

• Complaint: defined as a verbal expression of dissatisfaction by the client/ family regarding care or services provided at Green Apple Counseling, LLC which can be resolved at the point at which it occurs by the staff present. Most complaints will have simple solutions that can be promptly addressed and are considered resolved when the client/family is satisfied with the action taken on their behalf.

• Grievance: defined as a formal written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family’s satisfaction at the point of service. All written complaints of abuse, neglect, patient harm or the risk of patient harm, a violation of the Patient Rights and Responsibilities are examples of grievances. A written complaint will be sent to the Administrator, HR Director, and medical director to be discussed and rectified by a formal meeting with client/family or written notice of decision.

Procedure for Complaints:

1. Any employee who receives a complaint from a client, employee, visitor or family member shall immediately attempt to resolve the complaint within that employee’s role and authority.

2. If the complaint cannot be immediately resolved, the employee shall escalate the complaint through the appropriate chain of command.

3. The supervisor or manager shall resolve the complaint or take steps to continue the resolution process with the knowledge and agreement of the patient/family making the complaint.

4. If it cannot be resolved, then it becomes a formal grievance.

Procedure for Grievances:

1. The client, employee, visitor, or family member will need to fill out a grievance form within 24 hours of complaint

2. The form will be reviewed by Administrator, director of HR, Office Manager, Medical Director

3. All measures will be taken to rectify the issue within 2 weeks.

4. All grievances will be filed in the client’s file, employee’s file, administration file and with the client/family.

5. Clients will be asked to come to office and sign a receipt of a copy of the filing.

   1. If Client does not come in, case will be considered automatically satisfied.

6. If no resolution can be found, then it may be referred to an advocacy organization or the Montana Board of Behavioral Health.

   1. Advocacy groups include:

      1. Casca-Can 406.454.6738

      2. Aware 406.453.0614

      3. YWCA 406.452.1315

      4. United Way 406.727.3400

      5. Cascade County health Dept 406.454.6953

      6. Public Health and Human Services 406.453.8902

APPEALS:

• Clients will sign a copy of the filing indicating that they are either satisfied or unsatisfied.

• If a client is unsatisfied with a decision or no resolution can be made, the client has a right to appeal.

  • Appeals will start with 2 other Green Apple Employees and another person on the managing board. And follow same procedure.

• Green Apple will contact the third party and request review of complaint and follow their recommendation.

INFORMING OF CLIENTS:

• Clients will acknowledge receipt of this policy during the first session and by looking at the policy manual on the Green Apple Website.

 

 

Grievance Report

 

Name of Grievant:________________          Date of Grievance:_________________

Client of Green Apple:_____________          Phone Number:___________________

Statement of Grievance:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Relief Sought: _______________________________________________________________________________________________________________________________________________________________________________________________________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­________________________________

Request Meeting:       Yes                  No                    Meeting Date:____________________        

 

Grievant Signatures:_______________________     Date:______________________

Received by:_____________________________      Date:______________________

 

Rectified:       

___Yes: Action Taken: ________________________________________________ ___________________________________________________________________

___No: Action Needed: _______________________________________________

___________________________________________________________________

 

Grievant Signature:_______________________       Date:______________________

Green Apple Director: _____________________   Date:______________________