Counseling Registration Form

Please take your time in providing the following information. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. All information provided is confidential.

Your therapy is especially important, and Milestone Behavioral Health Services, LLC wants to provide the most effective services to all clients. We are committed to helping improve your overall development; however, your therapy will not progress if too many sessions are missed.

In the event the client will not be able to attend the scheduled appointment, the client agrees to notify the therapist via phone/email/text. Also, the therapist reserves the right to dismiss client from therapy if the client does not adhere to this cancellation policy. 24-HOUR CANCELLATION NOTICE would be appreciated due to illness or conflicts in schedule. If you need to CANCEL ON THE SAME DAY, please call 678-914-5750 as soon as possible. If you are unable to reach the therapist, please leave a message.

If you do not cancel your appointment and if you do not show up with 20 minutes before or after your scheduled time arrives for the session, it will be considered a “NO SHOW”.

Three “NO SHOWS” and/or CANCELED VISITS in 1 month will forfeit your therapy slot. After the third missed visit, we will pass your slot to another client on our waiting list. If you are seen 2 times weekly and have four missed visits, your therapy slot will be passed to another client on our waiting list. If your scheduled visit is inconvenient, please notify your therapist as soon as possible. If the therapist must cancel a visit for personal reasons or vacation purposes, every effort will be made to contact parent via phone, text or email. Every effort will be made to make up therapy session if schedule permits by both client& therapist. Please review Client Handbook for detailed information regarding “make-up sessions.”

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

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, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 27, 2012 and will remain in effect until we replace it.

We reserve the right to change to change our policy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in 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 the Notice and make the new Notice Available upon request.

You may request a copy of our Notice at any time.

1. Milestone Behavioral Health Services, LLC, hereinafter Milestone Behavioral Health Services, LLC is permitted to make use of and to disclose health care information for the purposes of treatment, payment and healthcare operations. The following are examples of use or disclosure for each of the listed purposes:

A. Example of use or disclosure for the purpose of treatment: Private health information may be disclosed to gain knowledge about our diagnosis or prognosis to help us treat the client’s condition appropriately.

B. Example of use or disclosure for purpose of payment Private health information may be disclosed so that we may collect payment from your insurance company or other healthcare coverage.

C. Example of use or disclosure for the purpose of health care operations: Milestone Behavioral Health Services, LLC may contact the individual to provide appointment reminders, information about your treatment alternatives or other health related benefit services that may be of interest to the individual.

2. Milestone Behavioral Health Services, LLC is permitted or required to use or disclose protected health information without the individual’s written authorization for the following purposes:

A. To maintain a directory of individuals.

B.To notify a family member, a personal representative of the individual’s health or safety, or another person identifiable by the individual to the extent disclosure is directly relevant the individual’s care or payment related to the individual’s care.

C. Where necessary, to assist a public or private entity authorized by law or by its charter, in disaster relief efforts.

D. To assist a public health authority or other appropriate government authority authorized by law if reasonable believe that you or your child are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may not disclose your health information to the extent necessary to avert a serious threat to your health and safety or the health or safety of others.

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

Milestone Behavioral Health Services, LLC will not use your health information for marketing communications without your written consent.

Milestone Behavioral Health Services, LLC may use or disclose your health information to provide you with appointment reminders (such as voice mail message, postcards, or letters

Access: You have the right to inspect and obtain a copy of your protected health information, with limited exceptions. If you request a copy of your information, we may charge you a fee for the cost of copying, mailing, or other cost incurred by us as a result of complying with your request. Request for access to your protected health information must be made in writing.

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 restrictions, but if we do, we will abide by our agreement except in emergency. You must make your request in writing.

Alternative Communication: 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.

Right to Express Complaints: You have the right to express complaints to us and to the Secretary of Department of Health and Human Services if you believe that your privacy right has been violated. If you wish to complain to us, you must do so in writing, and direct your complaint to the Privacy Leader.

If you are concerned that we may have violated your privacy rights or disagree with a decision we made accessing your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to Milestone Behavioral Health Services, LLC communication with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services.

We support your right to privacy of your health information.

For more information about HIPPA or to file a complaint:

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

877-696-6775

I hereby authorize Milestone Behavioral Health Services, LLC to bill my insurance company for direct reimbursement of therapy services rendered to my child. Unless otherwise noted, benefit payment will be assigned directly to Milestone Behavioral Health Services, LLC. I understand that patient’s family is responsible to pay all fees accrued, regardless of insurance verification or anticipated insurance coverage, if insurance company refuses to pay provider portion of the fees or in full. I agree to pay all fees within 30 days after bill has been mailed and understand that any fees not paid within 30 days will result in a $10 late fee each month that is unpaid. In the event of a returned payment or invalid payment, as well as an unpaid balance over 90 days, I agree to pay any and all additional associated banking, legal and/or collection fees. I understand that I am ultimately responsible for payment of all services received. I understand that I am advised to fully know and understand my insurance benefits prior to receiving therapy services.

1. TELEMENTAL HEALTH SERVICES

THERAPIST NAME: Akilah Sabir, LPC

Introduction: Telemental Health involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records; Medical images; Live two-way audio and video; Output data from medical devices, sound and video files; Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits: Improved access to medical care by enabling a patient to remain in his/her Psychotherapist’s office (or at a remote site) while the Psychotherapist obtains test results and consults from healthcare practitioners at distant/other sites; More efficient medical evaluation and management and; Obtaining expertise of a distant specialist. Possible Risks: As with any medical procedure, there are potential risks associated with the use of Telemental Health. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Psychotherapist; Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; In rare cases, a lack of access to complete medical records may result in adverse or other judgment errors. By signing this form, I understand the following: 1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telemental Health, and that no information obtained in the use of Telemental Health which identifies me will be disclosed to researchers or other entities without my consent. 2. I understand that I have the right to withhold or withdraw my consent to the use of Telemental Health in the course of my care at any time, without affecting my right to future care or treatment. 3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. 4. My Psychotherapist has explained the alternatives to my satisfaction. 5. I understand that Telemental Health may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state. 6. I understand that it is my duty to inform my Psychotherapist of electronic interactions regarding my care that I may have with other healthcare providers. 7. I understand that I may expect the anticipated benefits from the use of Telemental Health in my care, but that no results can be guaranteed or assured.

Patient Consent to The Use of Telemental Health: I have read and understand the information provided above regarding Telemental Health, that I have discussed it with my Psychotherapist as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telemental Health in my medical care. I hereby authorize Akilah Sabir, LPC (name of Psychotherapist) to use Telemental Health in the course of my diagnosis and treatment. I have been offered a copy of this consent form

2.INTERACTION WITH THE LEGAL SYSTEM

I understand that I will not involve or engage my therapist in any legal issues or litigation in which I am a party to at any time either during my counseling or after counseling terminates. This would include any interaction with the Court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug evaluators, or any other contact with the legal system. In the event that I wish to have a copy of my file, and I execute a proper release, my therapist will provide me with a copy of my record, and I will be responsible for charges in producing that record. If I believe it necessary to subpoena my therapist to testify at a deposition or a hearing, I would be responsible for his or her expert witness fees in the amount of $1,500.00 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time I spend over one-half (1/2) day would be billed at the rate of $375.00 per hour including travel time. I understand that if I subpoena my therapist, he or she may elect not to speak with my attorney, and a subpoena may result in my therapist withdrawing as my counselor.

Parent/Guardian’s signature (if applicable)

By signing below indicates receipt of Parent Handbook. Please be sure to obtain a Parent Handbook from your therapist or office staff to review pertinent information and policies & procedures as it relates to services provided by Milestone Behavioral Health Services, LLC.