Office Policies and General Information Agreement for Counseling Services

There are 3 parts to this form. Please read each carefully. Your agreement and name are required after each part.

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  Welcome to Scottsdale Bible Church Counseling Ministry (SBC Counseling Ministry). This is a church-based ministry that provides Lay Counseling, Professional Counseling, Stephen Ministry, Life Coaching, and Lay-lead support groups. SBC Counseling Ministry is a no-fee, short-term (8-10 sessions), biblical counseling facility. Counselees seen here will be considered “counselees of the agency.” We offer counseling to individuals seeking a biblical perspective on the issues of life. We require anyone receiving counseling from SBC Counseling Ministry to read and sign this informed consent, and you have a right to obtain a copy of this form.
  
  One of our staff members will contact you by phone once the initial paperwork is received, and will, as appropriate, assign you to a Lay Counselor, Professional Counselor, Stephen Minister, Life Coach, Support Group or resource in the community. Throughout this document, all care providers will be referred to as “counselors.
  
  Confidentiality.
  All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the notice of privacy practices that you received with this form.
  
  When Disclosure is Required by Law.
  Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of: (1) child, dependent, or elder abuse or neglect; (2) and where a Counselee presents a danger to self, to others, to property; (3) or is gravely disabled (for more details see also notice of privacy practices form).
  
  When Disclosure May Be Required.
  Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the Counseling records and/or testimony by your counselor. In couple and family counseling, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your counselor will use clinical judgment when revealing such information. Your counselor will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.
  
  Emergencies.
  If there is an emergency during our work together, or in the future after termination, where your counselor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the police, hospital, or the person whose name you have provided on the biographical sheet.
  
  Confidentiality of E-mail, Cell Phone, Fax, and Social Media Communication.
  It is important to be aware that e-mail and any cell phone or cordless phone communication, including text messaging, can be rather easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. E-mails, in particular, are vulnerable to such unauthorized access because servers have unlimited and direct access to all e-mails passing through them. Faxes can be sent erroneously to the wrong address. Please notify your counselor at the beginning of counseling if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. While reasonable backup, security, and other safeguards are in place, there is always some risk of inadvertent disclosure of information that comes with using these tools. By signing this informed consent, you agree to accept the risk of disclosure that comes with the use of these tools. Please do not use e-mail or fax in emergency situations.
  
  The various forms of Social Media (including but not limited to: Facebook, Twitter, LinkedIn, etc) could compromise your confidentiality. Please do not use any of these or like forms of Social Media as a form of communication with the SBC Counseling Ministry or your counselor. Our policy is to not accept friend or contact requests from former or current counselees. Please feel free to discuss this policy with your counselor or one of the SBC Counseling Staff members.
  
  Litigation Limitation.
  Due to the nature of the Counseling process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you, your attorney, nor anyone else acting on your behalf will call on your counselor to testify in court or at any other proceeding, nor will a disclosure of the Counseling records be requested. We do not offer custody, psychiatric, or psychological evaluations. In addition, you, the counselee sought biblical counseling as such adhered to by Scottsdale Bible Church, a non-profit religious organization. You, as the Counselee hereby acknowledge your understanding of the following condition and further releases from liability Scottsdale Bible Church, its agents or employees, from any claim arising from the undersigned participation in the above mentioned biblical counseling program, the same being identified as follows:
  This is a church-based ministry providing pastoral counseling. The counseling center is part of a non-profit ministry. In accordance with I Corinthians 6 and other passages, we require anyone receiving counseling from SBC to agree to release SBC, its pastors, agents, employees, and counselors from liability. Your signature at the end of this form is your agreement to these conditions.
  
  Consultation.
  Your Counselor consults regularly with other professionals regarding his/her Counselees; however, the Counselee’s name or other identifying information is never mentioned. The Counselee’s identity remains completely anonymous, and confidentiality is fully maintained. Considering all of the above exclusions, if it is still appropriate, upon your request, your Counselor will release information to any agency/person you specify unless he/she concludes that releasing such information might be harmful in any way.
  
  Telephone and Emergency Procedures.
  If you need to contact your Counselor between sessions, please call our Counseling Coordinator at 480-824-7239. You may need to leave a message via voice mail. Your call will be returned as soon as possible. SBC Counseling Ministry is not a crisis center. If an emergency situation arises, please hang up and call the Police (911). If you need to talk to someone right away, you can call one of the following 24-hour crisis lines:
  Empact at 480-784-1500
  Magellan Health Services Crisis Line at 1-800-564-5465
  
  The Process of Counseling/Evaluation.
  We believe that a strong relationship with Jesus Christ facilitates a person leading a healthy, productive life. Our own belief in Jesus Christ is the overriding influence of our counseling ministry. It is not essential that you share your counselor’s Christian beliefs, but you have the right to know that their value assumptions are rooted in their faith in Christ and influenced by their experiences. In addition, the Scriptures will be your counselor’s source of truth and s/he will help you seek Biblical solutions. You are free to discuss this with them at any time. Furthermore, goal-oriented brief counseling is provided by lay counselors. Stephen Ministers provide process-oriented care giving.
  
  Your emotional, physical, and spiritual wellbeing are of utmost importance to the SBC Counseling Ministry. Participation in Counseling can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek Counseling. Working toward these benefits, however, requires effort on your part. Counseling requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. During evaluation or Counseling, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong negative feelings. This is uncomfortable, but a natural part of the Counseling process and often provides the basis for positive change and personal decisions. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that Counseling will yield positive or intended results. A variety of Counseling approaches may be helpful for you. However, you have a right to participate in treatment decisions and in the development and periodic review and revision of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw informed consent to treatment. You and your Counselor need to discuss the potential consequences of such refusal or withdrawal. Feel free to discuss at any time the treatment goals, procedures, or your impressions of the services that are being provided.
  
  Cancellation.
  Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or canceling an appointment. There is no child or pet care available during your scheduled appointment times.
  
  I have read the above agreement and office policies and general information carefully. I understand them and agree to comply with them:
  
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• Notice of Privacy Policy
  
  THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO IT.
  PLEASE REVIEW IT CAREFULLY.
  
  Effective Date: April 14, 2003
  
  This Notice of Privacy Practices describes how Scottsdale Bible Church Counseling Ministry (SBC Counseling Ministry) may use and disclose your Protected Health Information (PHI). The PHI constitutes information created or noted by SBC Counseling Ministry that can be used to identify you. This Policy also describes your rights to access and control of your PHI. Please note: Counselees seen here will be considered “counselees of the agency.”
  
  We choose to follow federal and state law to provide you with this Notice about your rights and our duties and privacy practices with respect to your PHI. We will follow the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. Finally, you have a right to obtain a copy of this form.
  
  HOW WE MAY USE AND DISCLOSE YOUR PHI
  
  We may use and disclose your PHI for different purposes. We will not use your confidential information (PHI) or disclose it to others without your authorization, except where required by law. The following specifies the ways we may use your PHI, both with your authorization or without.
  
  Treatment. We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. We may also disclose your PHI to other ministry volunteers, such as a Stephen Minister, Lay Counselor, Professional Counselor, Life Coach, Counseling staff member, or Pastor. Example: If a psychiatrist is treating you, we may disclose your PHI to her/him in order to coordinate your care. This requires your prior written authorization.
  Healthcare Operations. We may disclose your PHI, with your authorization, to facilitate the efficient and correct operation of our office. These activities include, but are not limited to, quality assessment activities, employee review activities, conducting or arranging for other business activities. SBC Counseling Ministry may also provide your PHI to attorneys, accountants, consultants, administrative staff, or other volunteers and other office personnel to make sure that we are in compliance with applicable laws.
  Required by Federal, State, or Local Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, or any such uses or disclosures.
  To Avoid Harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public. For instance, we may need to disclose your PHI if you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim/victims. We also may disclose your PHI if it is determined that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others. Disclosure may be compelled or permitted if it is determined that you are gravely disabled, a condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs. In this case, we may determine that disclosure is necessary to prevent the threatened danger. Note: this may include the disclosure of information contained in our counseling notes.
  Arizona Child Abuse and Neglect Reporting law. For example, if we have a reasonable suspicion of child abuse or neglect. Note: this may include the disclosure of information contained in our counseling notes.
  Arizona Elder/Dependent Adult Abuse Reporting law. For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse. Note: this may include the disclosure of information contained in our counseling notes.
  Public Health Activities. We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the public health authority to a foreign government agency that is collaborating with the public health authority.
  Communicable Diseases. We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
  Legal Proceedings. We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). We may be required to disclose PHI when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. You will be contacted if such a request for records is requested, and you will be required to sign an Authorization for Release of Information. You have the right to refuse to comply with a subpoena. Your records are confidential, and they contain information that was received by reason of the confidential nature of the relationship. Be it known, a court may order you to comply and records would be released at that time.
  Law Enforcement. We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of SBC Counseling Ministry, and (6) medical emergency (not on SBC Counseling Ministry’s premises) and it is likely that a crime has occurred.
  Workers' Compensation. Your PHI may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
  
  YOUR INDIVIDUAL RIGHTS
  
  Right to Inspect and Copy Your PHI. You may ask to inspect or obtain a copy of your PHI that is included in certain records we maintain. You will receive a response within 30 days of receiving your written request. Under certain circumstances, we may feel it necessary to deny your request, and will provide in writing, the reasons for the denial. We will also explain your right to have the denial reviewed. Under federal law you may not inspect or copy the following records: psychotherapy notes, psychological test data and reports, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.
  Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or permitted to make.
  Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of any part of your PHI for the purposes of treatment or healthcare operations. You may also request that any of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. While we consider all restrictions carefully, we are not required to agree to a requested restriction.
  Right to Receive an Accounting of Disclosures. Be it known that no information will be released from this office in any form without your signed consent or an Authorization for Release of Information form from our office (SBC Counseling Ministry). This right applies to disclosures for purposes other than treatment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. We will respond to your request for an accounting of disclosures within 60 days of receiving your written request. The list we give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one request in the same year, in which case will charge you a reasonable sum based on a set fee for each additional request.
  Right to Amend Your PHI. You have the right to request us to amend your PHI that is contained in SBC Counseling Ministry’s records. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than your counselor. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.
  
  FOR MORE INFORMATION OR COMPLAINTS
  
  You may complain to SBC Counseling Ministry or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. You may file a complaint with us by notifying our Privacy Officer, David C. Walther at (480) 824-7239 for further information about the complaint process.
  
  We may change the terms of this Notice at any time. If we change this Notice, we may make the new Notice terms effective for all of your confidential information (PHI) that we maintain, including any information we created or received before we issued the new Notice. If we change the Notice, you may obtain a copy on your next visit or call and request a copy be mailed to you.
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• Consent for Non-Secure Electronic Communications
  
  
  
  
  COMMUNICATION BY EMAIL, TEXT MESSAGE, AND OTHER NON-SECURE MEANS.
  
  It may become useful during the course of treatment to communicate by email, text message or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with a Scottsdale Bible Church Counseling Ministry (SBC Counseling Ministry) staff or volunteers, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:
  
  • People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
  • Your employer, if you use your work email to communicate with SBC Counseling Ministry staff or volunteers.
  • Third parties on the Internet such as server administrators and others who monitor Internet traffic
  
  If there are people in your life that you don’t want accessing these communications, please talk with your SBC Counseling Ministry staff or volunteer about ways to keep your communications safe and confidential.
  
  
  CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
  
  I consent to allow the SBC Counseling Ministry staff and volunteers to use phone calls, voicemail, email, and/or text messaging to transmit to me the following protected health information:
  • Information related to the scheduling of meetings or other appointments
  • Information about referrals
  
  I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time.
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