Communities In Schools of the Permian Basin Mental Health Support Program

A client’s mental health record contains personal health information referred to as “PHI”. PHI may identify the client and relates to past, present, or future physical or mental health condition(s) and related health care services. This Notice of Privacy Practices describes 1) how we, Communities In Schools of the Permian Basin, may use and disclose a client’s PHI in accordance with applicable law, 2) your rights, and 3) how you may gain access to and control your PHI. 

Communities in Schools of the Permian Basin (CISPB) is required by law to maintain the privacy of all clients’ PHI and to abide by the terms of this Notice of Privacy Practices (NOPP), which includes notice of the legal duties and privacy practices with respect to PHI. We reserve the right to change the terms of our NOPP at any time; any new NOPP will be effective for all PHI that we maintain at that time.  We will provide all clients with a copy of any revised NOPP by posting a copy on the CISPB website, sending a copy to all active clients in the mail or email upon request, or providing one at the next appointment.

 

HOW WE MAY USE/DISCLOSE PHI:

• With Initial Written Consent for Treatment
  • By consenting to treatment with Communities In Schools of The Permian Basin, a client’s PHI may be used/disclosed for the purpose of providing, coordinating, or managing health care treatment and related services, such as consultation with clinical supervisor(s) or other treatment team members, including school/district personnel (for student clients only).
  • PHI may be used/disclosed to third-party services (i.e. technological support services, electronic record keeping, data tracking and analysis, etc.) for the purposes of Health Care Operations. All third-parties have a written contract with Communities In Schools of The Permian Basin that requires the third-party to safeguard the privacy of all PHI.

 

• With Separate Authorization
• Many clients wish to involve other parties in their treatment, which requires coordination. We may only disclose a client’s PHI to professionals outside of CISPB with prior written authorization. This authorization, which includes the release of psychotherapy notes and treatment summaries, may be revoked at any time, will be reviewed/updated every year, and will expire on the date listed on the Authorization form.
• If you wish to involve other family members in your care, you may give prior verbal authorization. This will be noted in your file. You may revoke this authorization at any time.
• Communities In Schools of the Permian Basin supervises clinical interns and supervisees and utilizes these individuals as Mental Health Counselors in some circumstances. PHI is disclosed to clinical interns and supervisees only with your prior written authorization.

 

• Without Separate Authorization (Verbal or Written)

Under the law, we must make disclosures in certain circumstances. These circumstances include 

• The Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule
• The Texas Behavioral Health Executive Council, the Texas State Board of Social Work Examiners, and/or the Department of Health and Human Services for the purposes of audits or investigations, Department of Family Protective Services for the purpose of reporting abuse and/or neglect
• The courts for judicial and administrative proceedings, by court order
• Law Enforcement or others reasonably able to prevent or lessen threat of harm to you/your student/the public in case of an emergency, national security concerns, or concerns for public safety (Duty to Warn)

A CLIENT’S RIGHTS REGARDING HIS OR HER OWN PHI

All clients have the following rights regarding their own PHI maintained by our office. To exercise any of these rights, please submit a request in writing to the CISPB Program Manager of Mental Health Support, Eliseo Elizondo at PO Box 10532, Midland, Texas, 79702.

• Right of Access to Inspect and Copy 

All clients have the right to inspect and copy PHI that may be used to make decisions about a client’s care. The client’s right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm.

• Right to Amend

If a client feels that his or her PHI is incorrect or incomplete, the client may request an amendment to the information. Please note that an agreement to the requested amendment is not guaranteed.

• Right to an Accounting of Disclosures

All clients have the right to request an accounting of certain PHI disclosures. 

• Right to Request Restrictions

All clients have the right to request a restriction or limitation on the use or disclosure of PHI for treatment or health care operations. An agreement to the request is not guaranteed.

• Right to Request Confidential Communication

All clients have the right to request that we communicate about medical matters in a certain way or at a certain location.

• Right to Copy of this Notice

All clients have the right to a copy of this notice.

BREACH NOTIFICATION 

If there is a breach of a client’s unsecured PHI, we may be required to notify the client of this breach, including what happened and what the client can do to protect yourself. The client authorizes Communities In Schools of the Permian Basin to provide notice by telephone or verbally in the event of a breach of a client’s PHI.

COMPLAINTS

If any individual believes someone with Communities In Schools of the Permian Basin has violated privacy rights, the individual has the right to file a complaint. The individual may do so by using the Complaints Form found by visiting cispb.org or by contacting Eliseo Elizondo, the Program Manager of Mental Health Support, at PO Box 10532, Midland, Texas, 79702 or (432) 205-1364. An individual may also file a complaint with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257 (HIPAA concerns) or with the Texas Behavioral Health Executive Council at 333 Guadalupe St;, Ste. 3-900, Austin, Texas, 78701or by calling 1-800-821-3205.

The law prohibits any retaliation against any persons for filing a complaint. All complaint records are kept for 6 years of the creation or effective date.

The effective date of this Notice of Privacy Practices is January 31, 2021.

PAYMENT OF FEES AND INSURANCE
Payment is not required for services provided by Communities In Schools of The Permian Basin except as provided in other policies involving unusual circumstances.

APPOINTMENTS AND CANCELLATIONS
Appointments will be scheduled in conjunction with the school’s schedule to maximize student learning and performance. If your student is absent, we will work to reschedule the appointment with school personnel. The standard meeting time for counseling is between 45-50 minutes. It is up to you and the school’s schedule, however, to determine the length of time of your sessions. Requests to change the session time needs to be discussed with the Mental Health Counselor in order for time to be scheduled in advance.

COUNSELING SESSIONS
Communities In Schools of The Permian Basin will accept new child clients only if the parents/family are willing to provide the most current custody agreement and are willing to schedule time with the Mental Health Counselor for psychoeducation and progress updates as needed. Family sessions may be encouraged as a part of the child’s treatment in order to increase effectiveness for the child and family unit. If this may be a problem for your family, please discuss this with your Mental Health Counselor so a plan can be made to best meet your child’s and your family’s needs.

TELEPHONE ACCESSIBILITY
If you need to contact your Mental Health Counselor between sessions, please leave a message on Communities In Schools of The Permian Basin voicemail or call your student’s school. Your Mental Health Counselor is often not immediately available; however, your Mental Health Counselor will attempt to return your call within 24 hours. Although Communities In Schools of The Permian Basin can provide some appointments in crisis situations, Communities In Schools of The Permian Basin cannot guarantee that your Mental Health Counselor is reachable or available for 24-hour service. If you or your child is in immediate danger to yourself or anyone else, please go to the nearest emergency room, call 911, or call the MHMR 24-hour hotline at 1-800-866-2465. Please keep between-session phone calls to 10 minutes in length unless it is an emergency. I am available to schedule a phone consult or a crisis session within 24 hours if an urgent (not life threatening) matter arises. You may agree to have your Mental Health Counselor leave you a voicemail at the number you provide containing brief details of your or your child’s treatment, but you are not obligated to agree to this service. If you do not agree to this service, your Mental Health Counselor will call you in order to discuss various topics but will not leave a voicemail.

SOCIAL MEDIA AND TELECOMMUNICATION
The Mental Health Counselor at Communities In Schools of The Permian Basin may hold separate and isolated accounts to be used for the sole purpose of professional matters regarding Communities In Schools of The Permian Basin. These accounts are separate from any personal accounts held by Mental Health Counselor as an individual.

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Communities In Schools of The Permian Basin Mental Health Counselors do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. We will not follow any client on Facebook, Twitter, Instagram, or other apps/websites. If there is content you wish to share from your online life, please bring it into our sessions where we can explore it together. Please be aware that following our Mental Health Counselors on any of my social media sites may compromise your confidentiality. If you have questions about this, please bring them up during your session so you can talk more about it.

To protect your privacy, do not check-in at my office on Facebook, Foursquare, Google+, or any other location-based service. For your safety and privacy, PLEASE DISABLE LOCATION SERVICES (if you have that feature on your mobile phone or device) immediately upon coming to the office.  If you have enabled location services on your mobile phone, check-ins on such services could make it possible for others to surmise you are a counseling client at our office location.  Further, we cannot and will not be held responsible for others finding that you are attending counseling when you are using location services and/or check-in with any social media apps.

 

ELECTRONIC COMMUNICATION
The confidentiality of any form of communication through electronic media, including text messages and emails cannot be guaranteed, therefore, your Mental Health Counselor will not be permitted to give you his or her personal phone number nor his or her email address. If for some reason you come to obtain this personal number or email address, please do not send text messages or emails to your Mental Health Counselor. Any text message or email received from you becomes a part of your mental health record. Please remember that if you email or text content related to our counseling sessions, it is not completely secure or confidential. If you do email or text your Mental Health Counselor, they will not be permitted to respond and we cannot guarantee an immediate response (returned via phone call) to these forms of communication.

Communities In Schools of the Permian Basin will only communicate with you via e-mail through our HIPAA compliant database in order to ensure confidentiality and to protect your privacy.

MINORS
If you are a minor, your parents may be legally entitled to some information about your counseling. Your Mental Health Counselor will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

SCHOOL PERSONNEL
Communities In Schools of The Permian Basin works in conjunction with the school campus and/or district. Should information arise during your counseling session, such as a need to coordinate care or a threat to safety, your Mental Health Counselor will need to communicate this information with necessary school and/or district administration in addition to other authorities (such as Child Protective Services in the event that abuse and/or neglect is suspected). This collaboration with the school campus and/or district personnel is crucial to the continued success of students receiving counseling through Communities In Schools of The Permian Basin Mental Health Support and Counseling Services. However, this will be discussed with you prior to the information being shared and the least amount of information required will be communicated in these instances.

DATA COLLECTION

Communities In Schools of The Permian Basin Mental Health Counselors will need to access the district’s electronic record keeping system (i.e. Skyward, FOCUS, TxEIS, eSchool, etc.) as well as your student’s cumulative files in order to monitor various items, such as: grades, attendance, conduct, disciplinary reports, schedules, etc. Additionally, you and your student may be asked to fill out a questionnaire or assessment tool to gather information on life skills and mental health. This instrument will help the Mental Health Counselor gain more information on how interventions and treatment are affecting your student. The tool will be administered and scored at the beginning of treatment, at the end of treatment, and may be administered and scored at assigned intervals throughout treatment depending on your student’s progress. All data will be collected, stored, and protected in CIS electronic records, including but not limited to the CIS internal database, and will be used to demonstrate the value of the program to current and/or potential stakeholders, such as funders, community partners, research and evaluation personnel, and independent school district personnel. All student data and reports will be de-identified to protect the student’s confidentiality and PHI. 

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment, but breaks in treatment over assigned school district breaks, such as Winter and Summer break, are guaranteed. Your Mental Health Counselor may terminate treatment after appropriate discussion with you and a termination process if your Mental Health Counselor determine that the counseling is not being effective, if you have repeated no-shows or cancellations, or if the end of the school year arises and the district does not renew their contract to employ the Mental Health Supports Program for the following school year. Your Mental Health Counselor will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If counseling is terminated for any reason or you request another Mental Health Counselor, your Mental Health Counselor will provide you with a list of qualified Mental Health Counselors to treat you. You may also choose someone on your own or from another referral source. Should you fail to attend three straight scheduled session without properly canceling, unless other arrangements have been made in advance, for legal and ethical reasons, Communities In Schools of The Permian Basin must consider the professional relationship discontinued.

 

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

INFORMED CONSENT FOR COUNSELING SERVICES WITH 

COMMUNITIES IN SCHOOLS OF THE PERMIAN BASIN

MENTAL HEALTH SUPPORT PROGRAM

Please read and sign at the end stating you have fully read and understood the information below. 

Professionals Include: Kayla Carrasco, LMSW, License #109614; Cashmere Cates, LPC-Associate, License #95038; Lorena Castillo, LPC-Associate, License #98399; Amy Garcia, LPC-Associate, License #99590.

Client/Mental Health Counselor Relationship: You and your Mental Health Counselor have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional, confidential, and involves only the therapeutic aspect. The therapeutic relationship is unique in that it is a highly personal and, at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. 

Available Services: Communities In Schools of the Permian Basin Mental Health Support Program offers school-based individual and group counseling services. Effective counseling is founded on mutual understanding and good rapport between client and Mental Health Counselor. This consent will provide a clear framework for our work together. It is our intent to convey the policies and procedures used in this practice, and we will be pleased to discuss any questions or concerns you may have. 

Risk and Benefits: Counseling is beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are: improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling.

The Therapeutic Process: We provide out-patient counseling designed to address many of the issues our clients are dealing with. Your first visit will be an assessment session in which you and your Mental Health Counselor will determine your concerns and, if both agree that Communities In Schools of the Permian Basin Mental Health Support and Counseling Services can meet your therapeutic needs, develop a plan of treatment. Should you choose not to follow the plan of treatment agreed to by both parties, services to you may be terminated. 

The goal of Communities In Schools of the Permian Basin Mental Health Support Program is to provide the most effective therapeutic experience available to you. If at any time you feel that you and your current Mental Health Counselor are not a good fit, please discuss this matter with your Mental Health Counselor to determine if a change in treatment plan should be made or if transferring to another Mental Health Counselor with another organization is right for you. If you and your Mental Health Counselor decide that other services would be more appropriate, we will assist you in finding a provider to meet your needs. It is important that you keep your Mental Health Counselor informed of any psychiatric hospitalizations or other mental health treatment you are receiving concurrently with your therapy. You are also responsible to communicate any change in psychiatric medications, side effects of medications, or thoughts of hurting yourself or others.

Appointments:  Appointments are typically scheduled on a weekly, every other week, or monthly basis and are approximately 50 minutes long. More frequent sessions or intensive outpatient services scheduled are available if determined appropriate by your Mental Health Counselor. Scheduled appointments are reserved especially for you. Please arrive on time. Because of the need to keep appointment times with other clients, late arrival may result in a need to reschedule your appointment and loss of valuable work toward meeting your counseling goals. If you do not attend counseling appointments or contact me over a 45 day period, you will be considered an inactive client and your case will be closed.
Please DO NOT COME to an appointment if you are under the influence of any substance including drugs or alcohol (if you arrive in an altered state your appointment will be canceled and we will contact school administration for the safety and wellbeing of all students and school staff) or if you or your child is running a fever or is contagious (vomiting, coughing, etc). 

 

Emergencies: You may encounter a personal emergency which will require prompt attention. In this event, please contact our office regarding the nature and urgency of the circumstances. We will make every attempt to schedule you as soon as possible or to offer other options.  Because clients may be scheduled back to back, it is not always possible to return a call immediately. However, we will make every effort to respond to your emergency in a timely manner.  If your emergency arises after hours or on a week-end, or if you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room for help. Please make sure to contact your Mental Health Counselor as soon as possible to notify her of your emergency. 

Confidentiality: Communities In Schools of The Permian Basin Mental Health Support Program follows ALL ethical standards prescribed by the state and federal law. We are required by practice guidelines and standards of care to keep records of your counseling sessions. 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. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you.

 

Discussions between a Mental Health Counselor and a client are confidential. To ensure your confidentiality, recording audio or video in your session without the written consent of your Mental Health Counselor is prohibited. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the Mental Health Counselor has a duty to disclose, situations where the Mental Health Counselor must inform the school administration, or where, in the Mental Health Counselor’s judgment, it is necessary to warn or disclose; fee disputes between the Mental Health Counselor and the client; a negligence suit brought by the client against the Mental Health Counselor; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the Mental Health Counselor when you and the Mental Health Counselor discuss this matter further. By signing this Information and Consent Form, you are giving consent to the undersigned Mental Health Counselor to share confidential information with all persons mandated by law and with the agency (including school/district administration and Mental Health Counselors, when necessary) that referred you and the insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding harmless the undersigned Mental Health Counselor from any departure from your right of confidentiality that may result.

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.

Please understand that you need to disable functions such as Siri, Alexa, Google Home, and other applications/personal device assistants/virtual assistants in order to ensure that confidentiality is maintained.  

Duty to Warn/Duty to Protect: If my Mental Health Counselor believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my Mental Health Counselor to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger. 

You and your Mental Health Counselor have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your Mental Health Counselor can best serve your needs by focusing solely on counseling and avoiding any type of social or business relationship. Gifts are not appropriate, nor is any sort of trade of service for service. If we see each other accidentally outside of the counseling 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 counseling office.

Incapacity or Death:  I understand that, in the event of the death or incapacitation of the undersigned Mental Health Counselor, it will be necessary to assign my case to another Mental Health Counselor and for that Mental Health Counselor to have possession of my treatment records. By my signature on this form, I hereby consent to another licensed mental health professional assigned by Communities In Schools of The Permian Basin, to take possession of my records and provide me copies at my request, and/or to deliver those records to another therapist of my choosing. Unless and until that occurs, Communities In Schools of The Permian Basin will continue to be the custodian of my records at all times. 

Consent to Treatment: BY SIGNING THIS CLIENT INFORMATION AND CONSENT FORM, AS THE CLIENT OR AS THE GUARDIAN OF SAID CLIENT, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS AND CONDITIONS CONTAINED IN THIS FORM. I have been given an appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time. NOTE: If you are consenting to treatment of a minor child, if a court order has been entered with respect to the conservatorship of said child, or impacting your rights with respect to consent to the child’s mental health care and treatment Communities In Schools of the Permian Basin will not render services to your child until the Mental Health Counselor has received and reviewed a copy of the most recent applicable court order. 

 

 

Notice of Privacy Practices: Acknowledgement of Notice

I hereby acknowledge that I have been given an opportunity to read a copy of Communities In Schools of the Permian Basin Privacy Practices. I understand that if I have any questions regarding the Notice of my privacy rights, I can contact the Program Manager of Mental Health Support at (432) 205-1364.

Group Services

I hereby acknowledge that I understand that both individual and group services may be utilized in my student’s treatment. I understand that I am not obligated to allow my student to engage in group services. If I do not agree, my Mental Health Counselor will only see my student for individual services.

Voicemails and Texting

I hereby acknowledge that I understand that I may choose for my Mental Health Counselor to leave voicemails and/or texting at the number I provide containing brief details of my or my child’s treatment. I understand that I am not obligated to agree to this service. If I do not agree, my Mental Health Counselor may call the number I have provided to discuss various topics but will not leave a voicemail or text.

It is the policy of Communities In Schools of the Permian Basin that the staff and interns of Communities In Schools of the Permian Basin may not participate in person, by phone, or in writing in any court related matter. At no time will any staff or intern of Communities In Schools of the Permian Basin offer an opinion or recommendation regarding a matter before the court. Texas State Law clearly prohibits our counselors, interns, trainees, and other staff from offering any opinion relating to possession, conservatorship, or parental rights or obligations for children involved in litigation. 

If a subpoena is served and is requesting an appearance or testimony from a counselor, intern, trainee, or staff member of Communities In Schools of the Permian Basin, a court order will be required. Further, a retainer must be deposited by the requesting party with Communities In Schools of the Permian Basin, before any appearance for testimony, whether in court or for deposition will be scheduled. The retainer deposited must be sufficient to pay for eight hours of the counselor, intern, trainee or staff member's usual and customary fee. By their signature, below, the parent requesting the appearance accepts the obligation to deposit the retainer with Communities In Schools of the Permian Basin at least 1 week before scheduling the appearance and for obtaining a proper order from the court with jurisdiction. 

By your signature, below, you agree that if an appearance of a counselor or intern from Communities In Schools of The Permian Basin, is subpoenaed or ordered, the fee to be paid is as follows: 

• $2,000 per day
• $1, 200 per half day
• $200 per hour for preparation and any preliminary discussions with the client, their lawyer, or any court personnel. 

Should a case be postponed, the counselor will be paid in full for each day of anticipated appearance, and an additional retainer deposit will be required. 

By your signature you agree to pay the required fees upon receipt of a statement from Communities In Schools of the Permian Basin showing the charges. Fees for appearances may be deducted at Communities In Schools of the Permian Basin’s sole discretion from the retainer deposited with Communities In Schools of the Permian Basin. The retainer becomes non-refundable if the appearance is not cancelled at least seven days in advance of the scheduled appearance. 

If records are requested, whether by subpoena or otherwise, the client's written consent will be required before releasing any client's record of treatment. If there is a request, the client will be told exactly what has been requested by the court and there is no guarantee that, after the release of the record, any information in the record will be kept confidential. This includes a client's mental health history, current status and inclusive records. Release may not be in the best interest of the client, and Communities In Schools of the Permian Basin assumes no responsibility for records after they have been released from Communities In Schools of the Permian Basin's custody. The counselor-client relationship does not render the counselor as an advocate. No Communities In Schools of the Permian Basin counselor will engage in a dual relationship with the client, children, or other party. Any requests for records must be in writing, signed by the responsible party, with signature verified to the satisfaction of Communities In Schools of the Permian Basin. Communities In Schools of the Permian Basin reserves the federally-mandated 14-day period between delivery to its office and the release of the record. It is the client or responsible party's obligation to see that any request for records is timely made. Communities In Schools of the Permian Basin charges a real-cost fee of ten dollars for the first ten pages of any record and fifty cents per page for each additional page. No record will be released until the reproduction cost has been paid. For security reasons, Communities In Schools of the Permian Basin does not release records in electronic format. 

Communities In Schools of the Permian Basin counselor, interns, trainees, and staff will NOT, at any time, discuss any clients by telephone with any client's lawyer. 

All court fees must be received by cash, cashier's check or credit card 14 days prior to the court date. Should the court calendar change the hearing for another date, the counselor or intern must be provided a court order or subpoena showing the new court hearing date. For appearance cancelled with less than 72-hour notice, NO refund will be issued. 

In the event there is a separation, divorce or other litigation involving Communities In Schools of the Permian Basin during a child's treatment, both parents are responsible for adhering to this notice. Further, if any legal action is begun after treatment has started, the parents are responsible to see that their counselor and Communities In Schools of The Permian Basin receive a copy of any court order regarding access, possession, rights, or obligations of any child client at Communities In Schools of The Permian Basin. 

Should the counselor or interns be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena. 

I have read, discussed with my counselor and I understood the information above. I accept full responsibility for any court fees described, above, should I or my attorney request my therapist to be present in court or for a deposition. Further, I understand and agree that Communities in Schools of The Permian Basin (CIS) is not responsible for the records maintained by the counselor or therapist and any opinion which they might share is their own professional opinion and CIS is not and cannot be responsible for those opinions, whether they are shared orally in testimony or in writing.

I understand that Communities In Schools of the Permian Basin is authorized by me to disclose/obtain Protected Health Information (PHI) related to the named Student for the purpose of treatment, payment or health care operations. I have read this authorization and understand what information will be used or disclosed or obtained, who may use and disclose the information, and the recipient(s) of that information. 

I specifically authorize Communities In Schools of the Permian Basin to disclose/obtain PHI as described on this form to the recipients listed below. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by state or federal privacy regulations. I further understand that I retain the right to revoke this authorization, if done so according to the steps set forth. On behalf of the client, I agree that a photocopy of this authorization may be considered valid. I fully understand and accept the terms of this authorization. I, further, certify that I have the right and power sign this Authorization as a parent/guardian of the student.

Parent/Guardian does not wish to include other outside entities (not including school district and campus personnel) in order to coordinate treatment and understands that outside entities may be added at the parent’s/guardian’s written request at any time during the course of treatment.

According to the law: Prior to commencement of counseling services to a minor client who is named in a custody agreement or court order, a licensee shall obtain and review a current copy of the custody agreement or court order, as well as any applicable part of the divorce decree. A licensee must maintain these documents in the client's record.

Therefore, Communities In Schools of the Permian Basin, policy requires when a child's parents are no longer together a copy of the child's custody papers MUST be provided to begin treatment if there are any. If no custody papers then agreement to begin treatment must be provided by the non-custodial parent. In the best interest of the child's treatment, both parents shall be contracted to begin treatment.
I, hereby understand that I am required to bring child custody documents, if any, for my child in order for treatment to begin and if I do not, I understand that the appointment will be cancelled until documents are provided.

If there are no custody papers, please fill out the information below:

It is important that you are fully informed about the services you will receive. By signing below you are saying:

 

1.I understand that Kayla Carrasco is licensed by the State of Texas as a Licensed Masters Social Worker, LMSW #109614.

 

2. I understand that Ms. Carrasco is bound by the Code of Ethics set forth by the National Association of Social Workers, and I can request a copy of these ethics at any time.

 

3. I have been informed that Kayla Carrasco, LMSW, is currently working to fulfill state requirements for additional licensure (working towards clinical licensure) and is working under the supervision of Kimberly Garcia Crowley, LCSW-S. Confidentiality will be respected within the limits of that supervision. I understand that my client file may be reviewed or discussed with Kimberly Garcia Crowley as the acting supervisor.

 

Any concerns or questions about my treatment can be brought to Ms.Garcia Crowley's attention by calling Kimberly Garcia Crowley at 432-242-1910. Concerns or questions can also be directed to Ms. Carrasco' supervisor, Eliseo Elizondo, at 432-205-1364.

 

4. I understand the confidentiality policies detailed in the “Notice of Privacy Practices”, including the circumstances in which Texas Law may permit or mandate limits to confidentiality.

 

5. I understand that there are risks and benefits associated with therapy and I have discussed those with Ms. Carrasco to my satisfaction. I also understand that no promises have been made to me as to the results of treatment or of any procedures provided by Ms. Carrasco.

 

6. I understand that I may leave therapy at any time and agree to discuss the termination of therapy at a regular therapy session, rather than by phone.

 

 

7. I have received the Notice of Privacy Practices form that informs me of my rights and other pertinent information, and the information has been explained to me and any questions answered by Ms. Carrasco.

 

My signature below indicates that I give my full and informed consent to receive therapy services with Kayla Carrasco, LMSW.

It is important that you are fully informed about the services you will receive. By signing below you are saying:

 

1. I understand that Cashmere Cates is licensed by the State of Texas as a Licensed Professional Counselor Associate (LPC-A), LPC-A License Number #95038.

 

2. I understand that Mrs. Cates is bound by the Code of Ethics set forth by the American Counseling Association, and I can request a copy of these ethics at any time.

 

3. I have been informed that Cashmere Cates, LPC-Associate, is currently working to fulfill state requirements for additional licensure (working towards full Licensed Professional Counselor (LPC) status) and is working under the supervision of Amber Chapman. Confidentiality will be respected within the limits of that supervision. I understand that my client file may be reviewed or discussed with Amber Chapman as the acting supervisor.

 

Any concerns or questions about my treatment can be brought to Ms. Chapman's attention by calling Ms. Chapman at (432) 300-6110. Concerns or questions can also be directed to Mrs. Cates supervisor, Eliseo Elizondo, at 432-205-1364.

 

4. I understand the confidentiality policies detailed in the “Notice of Privacy Practices”, including the circumstances in which Texas Law may permit or mandate limits to confidentiality.

 

5. I understand that there are risks and benefits associated with therapy and I have discussed those with Ms. Cates to my satisfaction. I also understand that no promises have been made to me as to the results of treatment or of any procedures provided by Mrs. Cates.

 

6. I understand that I may leave therapy at any time and agree to discuss the termination of therapy at a regular therapy session, rather than by phone.

 

7. I have received the Notice of Privacy Practices form that informs me of my rights and other pertinent information, and the information has been explained to me and any questions answered by Mrs. Cates.

 

My signature below indicates that I give my full and informed consent to receive therapy services with Cashmere Cates, LPC-Associate.

It is important that you are fully informed about the services you will receive. By signing below you are saying:

 

1. I understand that Lorena Castillo is licensed by the State of Texas as a Licensed Professional Counselor Associate (LPC-A), LPC-A License Number #98399.

 

2. I understand that Mrs. Castillo is bound by the Code of Ethics set forth by the American Counseling Association, and I can request a copy of these ethics at any time.

 

3. I have been informed that Lorena Castillo, LPC-Associate, is currently working to fulfill state requirements for additional licensure (working towards full Licensed Professional Counselor (LPC) status) and is working under the supervision of Jennifer Mason, LPC-S. Confidentiality will be respected within the limits of that supervision. I understand that my client file may be reviewed or discussed with Jennifer Mason as the acting supervisor.

 

Any concerns or questions about my treatment can be brought to Ms. Mason's attention by calling Ms. Mason at (806)544-2615. Concerns or questions can also be directed to Mrs. Castillo’s supervisor, Eliseo Elizondo, at 432-205-1364.

 

4. I understand the confidentiality policies detailed in the “Notice of Privacy Practices”, including the circumstances in which Texas Law may permit or mandate limits to confidentiality.

 

5. I understand that there are risks and benefits associated with therapy and I have discussed those with Mrs. Castiilo to my satisfaction. I also understand that no promises have been made to me as to the results of treatment or of any procedures provided by Mrs. Castillo.

 

6. I understand that I may leave therapy at any time and agree to discuss the termination of therapy at a regular therapy session, rather than by phone.

 

7. I have received the Notice of Privacy Practices form that informs me of my rights and other pertinent information, and the information has been explained to me and any questions answered by Mrs. Castillo.

 

My signature below indicates that I give my full and informed consent to receive therapy services with Lorena Castillo, LPC-Associate.

It is important that you are fully informed about the services you will receive. By signing below you are saying:

 

1. I understand that Amy Garcia is licensed by the State of Texas as a Licensed Professional Counselor Associate (LPC-A), LPC-A License Number #99590.

 

2. I understand that Mrs. Garcia is bound by the Code of Ethics set forth by the American Counseling Association, and I can request a copy of these ethics at any time.

 

3. I have been informed that Amy Garcia, LPC-Associate, is currently working to fulfill state requirements for additional licensure (working towards full Licensed Professional Counselor (LPC) status) and is working under the supervision of Nancy Vanley, LPC-S. Confidentiality will be respected within the limits of that supervision. I understand that my client file may be reviewed or discussed with Anita McNew as the acting supervisor.

 

Any concerns or questions about my treatment can be brought to Ms. McNew's attention by calling Ms. Vanley at (432) 530-3873 Concerns or questions can also be directed to Mrs. Maass’s supervisor, Eliseo Elizondo, at 432-205-1364.

 

4. I understand the confidentiality policies detailed in the “Notice of Privacy Practices”, including the circumstances in which Texas Law may permit or mandate limits to confidentiality.

 

5. I understand that there are risks and benefits associated with therapy and I have discussed those with Mrs. Garcia to my satisfaction. I also understand that no promises have been made to me as to the results of treatment or of any procedures provided by Mrs. Maass.

 

6. I understand that I may leave therapy at any time and agree to discuss the termination of therapy at a regular therapy session, rather than by phone.

 

7. I have received the Notice of Privacy Practices form that informs me of my rights and other pertinent information, and the information has been explained to me and any questions answered by Mrs. Maass.

 

My signature below indicates that I give my full and informed consent to receive therapy services with Garcia, LPC-Associate. 

Eye Movement Desensitization and Reprocessing (EMDR) therapy is a form of therapy that utilizes bilateral stimulation (BLS) usually in the form of eye movements, tapping, or auditory tones in order to accelerate the brain's capacity to process and heal troubling memories, thoughts, feelings, or phobias. BLS stimulates the same eye movements which occur during Rapid Eye Movement (REM) or dream sleep. BLS causes two parts of the brain to work in conjunction in order to reintegrate a memory.

Research has demonstrated that EMDR is effective for the treatment of Post Traumatic Stress Disorder (PTSD), panic attacks, anxiety disorders, depression, stress, sexual abuse, physical abuse, disturbing memories, complicated grief, chronic pain, dissociative disorders, and other traumatic experiences.

The possible benefits of EMDR treatment include, but are not limited to, the following:

The memory or event is remembered, but the painful emotions, physical sensations, disturbing images, and thoughts are no longer present. These memories can be reprocessed.
Symptoms of disturbance such as poor concentration, intrusive thoughts, irritability, hopelessness, sleep disturbance, physical aches, etc. may decrease.
The meaning of painful events is transformed on an emotional level.
EMDR helps the brain reintegrate the memory or event.
The possible risks of EMDR treatment include, but are not limited to, the following:

Distressing, unresolved memories might surface through the use of the EMDR therapy treatment. 
Reprocessing a memory or event may bring up associated memories. During EMDR, the client may experience physical sensations and retrieve emotions, images, sounds, and other factors associated with the memory or event.
Reprocessing the memory or event may continue after the end of the formal therapy session. Other memories, flashbacks, feelings, dreams, and sensations may occur. Frequently, the brain processes these additional memories without assistance, but arrangements for assistance will be made in a timely manner if the client is having trouble processing or coping with the additional memories.
As with any other therapeutic approach, reprocessing traumatic memories can be uncomfortable; meaning some clients will not like or tolerate EMDR therapy. 

Clients may need more preparation, offered by the therapist, before processing traumatic events using EMDR. 

There is no known adverse effect for interrupting EMDR therapy; you can discontinue treatment at any time. 

Alternative therapeutic approaches may include group therapy or different psychotherapy modalities on an individual basis.

 

The client must:

Have the ability to tolerate various levels of emotional disturbance, have the ability to reprocess associated memories resulting from EMDR therapy (as guided by the therapist), and to use self-control and relaxation techniques. 
Disclose to the therapist, and consult with your physician, before consenting to EMDR therapy if you have a history of eye problems, a diagnosed heart disease, elevated blood pressure, are pregnant, or at risk for or have a history of stroke, heart attack, seizure or other limiting medical conditions that may put you at medical risk. Due to the stress related to reprocessing some traumatic events, postponing may be appropriate in some cases.
Inform the therapist if you wear contact lenses. The therapist can substitute other forms of simulation (as appropriate) if the client reports eye pain, irritation, or dryness. 
Before participating in EMDR, discuss with the therapist all aspects of an upcoming legal case where testimony may be required in court. EMDR may not be an appropriate treatment prior to the client's involvement in the testimony, legal process, etc. because traumatic material processed during EMDR may fade, blur, become less intense, or disappear.
Consult with your medical doctor before utilizing medication. Some medications, such as benzodiazepines, may reduce effectiveness due to state-dependent processing and/or regression may occur after ceasing antidepressants.
EMDR is not appropriate for recent or long-term crack, cocaine, or amphetamine users.
Discuss with the therapist any dissociative disorders with little treatment progress. EMDR may trigger these symptoms but may also be helpful in attempting to resolve them.
Before commencing EMDR therapy, I have thoroughly considered all of the above information. I have obtained additional input, information, professional advice, and anything else I needed before consenting to treatment of EMDR therapy. 

I have read and understand the possible outcomes of EMDR listed above and understand that I may end EMDR therapy at any time. 

My signature on this acknowledgment and consent is free from pressure or intelligence from any person or entity and I agree to hold harmless my EMDR clinician and Communities In Schools of the Permian Basin, for any unpleasant or unexpected effects which may arise from my experience or my child's experience with EMDR therapy. 

I agree that I, or my minor child, agree to participate in EMDR therapy and I assume any risks involved in such participation.

Tele-therapy Services are provisions of mental health services with your Communities In Schools Mental Health Counselor (MHC) and you/your student being in separate locations, and the services being delivered over electronic media. Services delivered via tele-therapy rely on a number of electronic, often internet-based, technology tools. The tools that CIS will be utilizing to provide services are either phone call or video conferencing on any electronic device with a camera, microphone, and ability to connect to the internet. Communities In Schools Mental Health Supports Program uses a HIPAA compliant software program called Theranest to provide video conferencing and Phone.com to conduct audio- only phone sessions. All limitations to confidentiality exist in traditional and tele-therapy session formats and will be followed by your MHC. Prior to engaging in tele-therapy, the parent/guardian of the student will need to read and then electronically sign this consent document. If you have any questions, please reach out to your MHC. Any and all contact with students and/or parents/guardians (in person or electronically) becomes a part of your student's clinical record.

Benefits:

• Receive services at times or in places where the services may not otherwise be available.
• Receive services in a fashion that may be safer (during a pandemic), more convenient, and less prone to delays than in-person meetings.

Limitations (include but are not limited to):

• Technology services could cease working or become too unstable to use.
• You may be asked to be more detailed during sessions when your MHC cannot see you, your body language, or your non-verbal reactions to what we are discussing (during phone calls)
• Cloud-based services personnel, IT assistants, and malicious actors ("hackers") may have the ability to access your private information that is transmitted or stores in the process of tele-therapy delivery.
• Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
• You must remain in Texas to complete tele-therapy with your MHC.

Logistics and Important Information:

• You will be contacted via phone at our scheduled time or you will be sent a link for our secure and HIPAA compliant video session through Theranest. Your MHC will be calling you from a private location where the MHC is the only person in the room. You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a public place or where others can hear you, your MHC cannot be responsible for protecting your confidentiality.
• In the event of an emergency (i.e. your student is in a mental health related crisis, makes a threat of suicide or homicide, or states that there is abuse or neglect occurring), your MHC will need to break confidentiality and contact emergency services to intervene at your student's physical location. Therefore, you must give your current phone number and physical address at the start of every tele-therapy session to ensure your MHC can reach emergency services in these situations.
• Before entering this type of treatment, you must agree to utilize/take your student to appropriate emergency services if needed, (i.e. going to the nearest emergency room, calling 911, or contacting the National Suicide Hotline (1-800-784-2433)
• If the connection is lost during the session, your MHC will call you back immediately using the provided phone number. The number may show up as restricted or blocked. If your MHC cannot reach you after 3 phone calls, he/she will remain available for the entire session so that you may resume the session if you choose. Recording (audio or visual), screenshots, etc. of any kind of any session is not permitted and are grounds for termination of the student-MHC relationship.

Consent to Participate in Tele-Therapy Sessions:

I confirm that I have read and understood this entire document, agree to provide and abide by emergency protocols. And consent to attend scheduled tele-therapy sessions. I understand that my typed name will suffice as my electronic signature.

The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology.

Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint.

To file a complaint with the Texas Behavioral Health Executive Council, please contact the Council using the information below:

 

Texas Behavioral Health Executive Council

George H.W. Bush State Office Bldg
1801 Congress Ave Suite 7.300

Austin, Tx 78701
Tel. (512) 305-7700
1-800-821-3205 24-hour, toll-free complaint system

To file a complaint with Communities In Schools of the Permian Basin, please contact Crystal Ruiz, LCSW using the information below:

 

Communities In Schools of the Permian Basin
Attn: Crystal Ruiz, LCSW
PO Box 10532
Midland, Texas 79702
Tel. (432) 205-1364

To file a HIPAA Privacy and Security Complaint, please contact the Secretary of Health and Human Services using the information below:

Secretary of Health and Human Services

200 Independence Ave, S.W.

Washington, D.C., 20201
Tel. (202) 619-0257