Youth Personal Data, Consent to Attend Program and Consent to Treat if Necessary
Client/Youth
Parent/Guardian How would you prefer to be contacted?
Necessary Medical Information Is your youth living with a mental illness or illnesses? (This helps us incase they have a melt-down during one of our programs)
Please list the best ways you have found to help your youth to come down when they start having a melt-down.
Any Activity Restrictions Can your child see a therapist during the program Photo Consent: I grant permission to Heart to Heart – WY for the use of the photograph(s) or electronic media images of the client/youth named above, as identified below in any presentation of any and all kind whatsoever. I understand that I may revoke this authorization at any time by notifying Heart to Heart – WY in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.
Image Description: Participation during any of Heart to Heart - WY programs, back of head images during talk therapy, photos working one on one with volunteers.
Insurance Information: Note: Heart to Heart – WY’s insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is on a Heart to Heart – WY related activity, or if the client’s therapist recommends the client attends one of these programs. Please initial next to each paragraph: By typing in your initials you agree to the following items.
Professional Records: Both law and ethical standards of the profession require that appropriate treatment records be kept. As a client, you have the right to review or receive a summary of your records at any time if a request is made in writing, except in limited legal or emergency circumstances or when releasing such information might be harmful in any way. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended records be reviewed with the clients therapist during a session.
HIPAA CONSENT FORM: I have read Heart to Heart – WY “Notice of Policies and Practices to Protect the Privacy of the client's Health Information” (also known as “HIPAA Consent” form either on the Heart to Heart – WY website or within the attached program packet. I understand that it describes how psychological and medical information about the client may be used or disclosed and how I can gain access to this information. In addition, I understand that I am welcome to a copy of this HIPAA Consent form if I request it from Heart to Heart – WY. You can find our Notice of Policies and Practices at www.hearttoheartwy.org/HIPAA
Confidentiality: Individuals seeking mental health services during our programs should be clearly informed about their confidentiality rights. Generally, information that the client discusses with the therapist at the time and the written records pertaining to those sessions is strictly confidential and will not be discussed with anyone without your expressed consent. This means that anything that is told in one of the programs, will not be reported to anyone, even other family members. However, there are some exceptions to confidentiality when disclosure is required by law:
If a court of law orders the client records in regards to a legal proceeding.
If the client threatens to harm themselves or anyone else or the client is suspected of being a risk to themselves or others.
If the client reports any abuse or neglect of a child, disabled person, or elderly person.
If the client is using mental health insurance policy to pay for their visits, we may be required to provide certain diagnostic and basic treatment information in order to process the clients’ claims to obtain payment for our services.
Program Fee Arrangements: All programs last between 1-3 hours, weekly for a total of 12 weeks. There is no fee for these programs, but we recommend a donation so we can keep the programs running. Each program averages out to be $40.00/client/program. If the clients’ therapist recommends attending one of the programs, insurance may be billed with parental consent. If you would like to donate to the program you may do so online or with a check. All donations are tax-deductible. www.hearttoheart.org/donate
Programs Provided (Mark which programs you are interested in so we can contact you when they are available)
Talk Therapy Fee Arrangements: Fees for talk therapy services are as follows. All Initial Evaluations are 60 minutes while therapy sessions are 30-45 minutes depending on the need that week. If your youth or your family would like to take advantage of our talk therapy services please let us know.
Therapy Services Provided:
Initial Evaluation of Child/Teen $ 75.00
Individual Talk Therapy with Child/Teen $ 50.00
Family Therapy Initial Evaluation $100.00
Family Therapy Session $ 75.00
Group Therapy Session $ 25.00
Parent Consultation/Coaching $100.00
School Consultation Package $600.00
Returned Check Fee $ 35.00
If Soar Counseling, is not in-network with your insurance company, we will work with your insurance company to find a therapist that is in-network. *If none of our therapists are in-network, you can apply for a scholarship through our hands-up program . You can sign up at www.hearttoheartwy.org/hands-up-scholarship .
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Confidentiality Regarding Mental Health Services with Minors: All of the above applies, although the legal guardian(s) of minors are permitted access to a minor’s therapy records. It is in the best interest of the therapeutic relationship to preserve confidentiality between the child, program director, and therapist. However, there are exceptions. The therapist during Heart to Heart – WY programs must inform the guardian, or appropriate authority, if the minor is in danger of hurting himself or someone else, if someone is harming the minor, or if the minor is engaging in risky behavior that could result in harming themselves or another.
Canceled/Missed Appointments: There is no charge for canceling an appointment or not attending a program that the client was registered for. However, if multiple appointments or programs are missed without proper notification, your spot may be given to another individual that could use Heart to Heart – WY services. As a courtesy reminder, our office will call or text the client to remind them of their appointment or program. It is the responsibility of the client or guardian(s) to keep Heart to Heart – WY informed of any changes in contact information.
Attendance: Regular attendance at talk therapy sessions or programs is essential for therapeutic progress. Missing sessions, while sometimes necessary, can disrupt the flow of healing and extend the length of treatment. It is important that utmost consideration be given to the process when cancellation may be made.
Court Testimony: We do not testify in court as an expert witness. If the client's family is undergoing custody determination, Heart to Heart – WY will not testify as to parental fitness or custodial rights.
Emergencies: If there is an emergency during a program or a talk therapy session, either during or outside a therapy session, Heart to Heart – WY and the therapist on staff will do whatever can be done, within limits of the law, to prevent the client from becoming injured and to ensure that proper medical care is received. This may include contacting the emergency contact person designated below. Additionally, consent is not required if emergency treatment is needed, as long as your consent is sought after treatment is rendered, or if attempt is made to obtain your consent and you are unable to communicate. If an emergency arises outside of the client's programs or talk therapy sessions, please call 911 or go to your nearest Emergency Room for a risk assessment to determine the clients need for hospitalization to ensure safety.
Emergency Contact I have carefully read, understand, and agree to comply with the above policies and consent for the youth to participate in the programs offered by Heart to Heart – WY.
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I have carefully read, understand, and agree to comply with the above policies and consent for the client to have talk therapy treatment for psychological services.
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I understand that the psychological services are voluntary and the client can discontinue at any time.
I consent to the electronic transmission of data (e.g., email, text) as means of communicating with the therapist, program director, or other individuals who are involved in my child/adolescent’s programs and treatments. And I understand that electronic transmission of data is not 100% confidential as email is retained in the logs of email service providers, may be stored on personal computers that send and receive the email, and can be vulnerable to third-party interference.
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I understand that to improve the likelihood that I receive positive outcomes from the programs and talk therapy, Heart to Heart – WY and the therapists involved might consult with other practitioners within the community. I understand that this will be confidential and names and sexes will NOT be used.
I accept terms & conditions