TREATMENT GUIDELINES

param2
param3
param4
param5
param6
Patient Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
TREATMENT GUIDELINES
People enter into treatment seeking relief from distress or discomfort in their emotional state, behavior and/or relationships. The mission of Center for Family Guidance mission is to provide each individual or family in treatment with us with care that is effective, compassionate and efficiently delivered. The following guidelines are being provided to you to help you understand how our services are provided and to prepare you to participate in our clinical practice. Your sessions may be conducted in person in one of our offices, or by videoconference technology, or by telephone.

Prior to your initial session with a CFG clinician, you will be asked to complete a New Patient Background Questionnaire. This information will give your clinician a good overview of your goals and treatment needs to help your clinician and you decide together on the best treatment plan.

Initial Evaluation
This initial session gives you the opportunity to share with your clinician important information about you, your treatment goals and needs in order to determine which treatment could be most helpful for you. This clinical interview serves as an important initial phase of your care, and helps form the basis of your clinician's understanding and diagnosing of the problems and/or situation that motivated you to seek treatment. During this session and the sessions that follow, you and your clinician can develop a treatment plan together.

Therapy sessions

These sessions address the concerns that may have brought you to seek treatment. During these sessions you may discuss complex issues which go beyond and compliment the part of your care which may be treated through medication.
The sessions, which are longer in session length than medication management sessions, may be individual or involve members of your family or wider support system depending on your needs and preferences. If therapy is being provided along with medication management sessions, communication between your therapist and the clinician prescribing medication for you is an important component of your treatment.

Medication Management Sessions
These sessions involve discussion of your current mood, thoughts, relationships, and daily functioning in relation to the effects of any medications prescribed as part of your treatment. Also incorporated in these visits, when relevant to your emotional and behavioral care and progress, are discussions of any general health conditions, laboratory studies, and pertinent communication with and/or referral to, other behavioral health and general medical clinicians.

These sessions are typically shorter in terms of time compared to therapy sessions, so it is important that you come to them prepared to discuss issues related to your response to medication treatment. Other matters which may be important parts of your recovery plan are to be more completely addressed in sessions with your therapist. Relatives and other support system members, when appropriate and permitted, may be asked to or may wish to provide information to enable the clinician to get the most complete understanding of your progress and ongoing care needs.

Scheduling of Sessions
Your clinicians will advise you on the recommended optimum frequency of all treatment sessions to achieve your goals. It is important to maintain the recommended frequency of sessions as part of your treatment plan to receive full benefit of care. This includes appropriate intervals of medication treatment visits to achieve maximum response to, and safe use of, medications.

Usually after initiation of medication prescribed for you, there will be a follow-up visit within 2 weeks. Timing of subsequent visits will depend on the nature of and response to treatment. The maximum interval between medication management sessions is usually 12 weeks, including followup visits to maintain progress once treatment goals have been reached. When medications which are categorized as controlled substances, or other medications which require close ongoing supervision, are part of treatment, shorter intervals between sessions may be needed.

Communication Outside of Office Hours
On occasion, you may find it necessary to communicate with your clinician by telephone between scheduled visits to address a crisis or urgent issues about medication that cannot wait until your next scheduled session. Such telephone calls are not substitutes for scheduled appointments. In such instances of crisis or medically urgent problems, you can contact your clinician through the CFG Access Center answering service at (856) 552-4327.

Most telephone contacts with your clinician should be at most 5 to 10 minutes long with a follow-up plan made, including any recommendations for evaluation at an emergency department or crisis screening center. If the issue involves an acute safety concern that cannot wait for a timely return call from your clinician, please call 911 or go to the nearest emergency room or crisis center, informing your clinician through the Access Center that you have done so.

Prescriptions Renewals
Prescription renewals should occur during medication management sessions. Due to occasional, unforeseen circumstances, there may be times when you need to request a renewal in between scheduled visits. For those occasions, call the CFG Outpatient Prescription line at (856) 552-4350. Please understand that due to the need for your prescribing clinician to review your chart it may take up to 5 business days for the prescription renewal to be completed.

If you have not had a visit with your prescribing clinician at an appropriately safe interval to provide a renewal, or if there are other clinical issues, your prescribing clinician may inform you that a medication management visit must be scheduled and kept before any renewal or new prescription is provided.

Consent for Treatment of a Minor
If minor consent is not needed, please type N/A in the required fields, mark a line in the signature box, and mark today's date.

I/we do hereby give permission to have my/our minor child,First Name* Last Name*participate in mental health treatment provided by Center for Family Guidance. When sessions occur, my/our child may talk, draw pictures, play games, or do other things to help his or her clinician(s) get to know my/our child better and understand his/her problems.

I/we understand that as parents we have a right to know about how our child is doing in treatment. Sessions or brief consultations by phone with us may be arranged so that we can talk about concerns I/we may have about my/our child. Sometimes communications will be arranged without my/our child and at other times the family may meet together.

The things my/our child discusses in sessions with his or her clinician(s) are private. The clinician(s) providing care will not tell others about the specific things told to him or her. The clinician(s) will not repeat these things to parents, teachers, the police, probation officers, or agency employees. There are exceptions to that confidentiality. First, as required by law, your child’s clinician(s) will tell others what has been said if my/our child talks about seriously hurting him or herself or someone else. The clinician(s) have an obligation to tell someone who can protect my/our child or the person that my/our child has spoken of hurting. Second, if your child’s clinician(s) have reasonable suspicion that my/our child is being seriously hurt or abused by anyone, the clinician(s) have a legal obligation to tell someone for my/our child’s protection. I/we can also request information obtained in treatment be provided to others by completing a Release of Information form.

I/we are aware that we may stop treatment with Center for Family Guidance at any time. The only thing I/we will still be responsible for is paying for the services that have already been provided, as well as any other fees associated with treatment at Center for Family Guidance. I/we understand that we may lose other services or may have to deal with other problems if we stop treatment. (For example, if treatment has been court-ordered, I/we will have to answer to the court.)

I/we are aware that an agent of our insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments we receive. We understand that if payment for the services we receive here is not made, Center for Family Guidance may stop providing treatment.

Our signatures below show that we understand and agree with all of these statements.
Signature of parent (or legal guardian)*

Clear
Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Relationship to client*
Signature of parent (or legal guardian)

Clear
Date

MonthDayYear
Date
Printed Name

First NameLast Name
Relationship to client
Signature of patient*

Clear
Date*

MonthDayYear
Date
Printed Name of Patient*

First NameLast Name

INFORMED CONSENT FOR TREATMENT
I,First Name* Last Name* , agree and consent to participate in behavioral health care services offered and provided by Center for Family Guidance a behavioral health care provider. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I will inform any other individuals with whom I share custody arrangements for the patient of the initiation of treatment.
Signature (patients age 14 and above should sign this) *

Clear
Date*

MonthDayYear
Date
Signature of legal guardian (if applicable)

Clear
Date*

MonthDayYear
Date
Relationship to Patient (if patient is not providing signature)

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR LEGAL DUTY:

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices that are described in this Notice while it is in effect. This notice has been updated and takes effect September 4, 2018 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the term of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment and healthcare operations. For Example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. We will obtain your written consent for this disclosure if necessary.

Payment: We may use and disclose your health information to obtain payment for services we provided to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your authorization: In addition to our use of your health information treatment, payment or healthcare operations, you may give us written authorization to use your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law. The New Jersey Duty to Warn Law (9P.L.1991, Chapter 270, passed in 1991) was amended on June 13, 2018. Mental health practitioners have duty to warn responsibilities when a potential threat of serious physical violence against a readily identifiable individual or against him or herself has been communicated or assessed to be present by the practitioner. The amended law requires mental health practitioners to notify the chief law enforcement officer or the Superintendent of State Police if the patient resides in a municipality that does not have a full time police department, that a duty to warn and protect has been incurred.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you, or someone you specifically identify, are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal offical health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement official having lawful custody of protected health information or inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, text messages, and emails).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We may charge you 25 cents for each page copied. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information at this end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have a right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web Site or by electronic transmision, you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U. S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U. S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U. S. Department of Health and Human Services.

Contact Officer: Moira Roberts, Office Manager (856) 797-4707

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, First Name* Last Name* have received a copy of Center for Family Guidance’s Notice of Privacy Practices. Grievance Procedure and Patient Rights.
Please type patient's name*

First NameLast Name
If patient is a minor name of person signing*

First NameLast Name
Relationship to patient *
Signature*

Clear
Date*

MonthDayYear
Date

Cancellation Policy

Center for Family Guidance, PC
Patient's Name*

First NameLast Name

All appointments are scheduled in advance. This time is set aside specifically for you, we do not schedule any other patients with your clinician during the time of your appointment. We require no less than 48 hours advance notice (circumstances permitting) for the cancellation of an appointment. If you do not cancel your appointment within the above time frame, you will be charged the scheduled fee for the session. We cannot submit a charge to your insurance company for a session if the session was not actually held.

Examples of current scheduled session fees are as follows:

Type of Provider	Initial Evaluation	Therapy Session (45 minutes)	Time Reserved (60 minutes)	Medication Management
Psychiatrist	$275	$170	$215	$110
APN	$185	$140	$175	$80
Psychologist	$225	$140	$175	N/A
LCSW/LPC	$175	$115	$165	N/A

It is your responsibility to notify the office if you plan on cancelling your appointment. Appointment confirmation calls or texts are provided as a courtesy. A response to an appointment confirmation call or text is not an opportunity to cancel with less than 48 hours notice without being charged a missed appointment
fee.

Thank you for your cooperation in this matter.

Signature of patient or guardian (if patient is a minor) *

Clear
Date*

MonthDayYear
Date

Financial Responsibility Policy
Thank you for choosing us as your Behavioral Healthcare provider. We are committed to providing you with high quality health care. In order to make sure our patients are well informed about our financial responsibility policy, we require each patient or guarantor to read this policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance We participate in many insurance plans, including Medicare. If you are not insured by a plan with which we have a provider agreement contract, payment in full is expected at each visit. If you are insured by a plan with which we have provider agreement contract, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company.

3. Non-covered services Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4. Proof of insurance All patients must complete our patient information form before services can be provided. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of one or all insurance claims submitted to your insurance provider for payment.

5. Claims submission We will submit your claims and assist you in any way we reasonably can to help get claims for services provided to you paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

6. Coverage changes If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim, the balance will be billed to you.

7. Nonpayment If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise arranged. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

8. Missed appointments Our policy is to charge for missed appointments not canceled with more than 48 hours advance notice. These charges will be your responsibility and billed directly to you, and cannot be billed to your insurance provider. Please help us to serve you better by keeping your regularly scheduled appointment.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines:
Signature of patient or responsible party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

TREATMENT GUIDELINES

Consent for Treatment of a Minor

INFORMED CONSENT FOR TREATMENT

Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Cancellation Policy

Financial Responsibility Policy