Registration Packet

Who We Are

Samaritan Counseling Center of SETX respects, values and affirms the sacred dignity of each individual by caring for the mind, body, spirit and the relationships they build. We provide an inclusive environment for all staff, clients, and community members regardless of culture, socio-economic status, race, gender, and belief system. We offer personalized integrated care, education, and advocacy in the areas of mental wellness and healing. We meet community and client needs with empathy to ensure they feel valued, heard and validated on their journey to holistic healing.

Getting Started

Your concerns may cause different feelings and reactions within you. Many of these feelings may be uncomfortable. Your therapist’s goal is to discover, in the early sessions, how you may benefit best from your counseling relationship.

Responding To The Whole Person

Since the relationship between the mind and body is close, your concerns may lead to physical distress as well. A basic part of your therapy will be to identify such stress factors and learn healthier methods of self-care.

Appointments

Therapy sessions are generally scheduled for 45 minutes. It is hoped that you can arrive within minutes of your scheduled appointment. If you are more than fifteen minutes late to an appointment, it will be treated as a no show, or late cancellation.

Emergencies

Samaritan Counseling Center of Southeast Texas is not an emergency crisis center. If you are unable to contact your therapist in an emergency, it is suggested that you call 911, your pastor, or the crisis hotline at Spindletop MHMR (1-800-937-8097).

Cancellations And No Shows

If client needs to cancel an appointment it is required that a 24-hour notice be given. The center has voicemail with a time-date stamp, so client can leave notice at any time. A $30.00 fee will be charged when less than 24-hour notice is given. Naturally, unforeseen emergency situations will be given consideration. A continuation of missed appointments will result in a requirement for client to pre-pay a $30.00 deposit to schedule a future appointment and any recurring appointments on the schedule will be removed. This deposit will be credited to the co-pay due upon arrival at client’s next appointment. FOR NEW CLIENTS, if client is unable to keep the first appointment, the $30.00 deposit also applies and will be required to re-schedule the missed appointment and will be credited to the co-pay due upon arrival to the appointment.

Fees And Payments

The center charges a standard fee for everyone. When the family’s income is limited, a partial subsidy of that fee may be provided using funds from charitable sources. The size of the subsidy is set using the household income and total number of members in the household. If this is a concern for you, mention it to your therapist. Payment is to be made at the time of each appointment. A receipt will be issued on request. No further appointments may be scheduled when payment is not received unless special arrangements are made. This policy is maintained so that we may remain fiscally sound, and therefore able to provide consistent quality service. Your therapist and the Executive Director must approve any exceptions.

NOTICE OF PATIENT’S RIGHTS AND RESPONSIBILITIES

This notice tells you how we utilize your health information at our center, how we might disclose this information to others, and how you can get access to the same information.

• We have a legal responsibility under the laws of the United States and state of Texas to keep your health information private.
• We reserve the right to change any of these privacy practices as permitted or required by law.
• Any changes in our privacy practices will affect how we protect the privacy of your health information. This includes health information received about you or that we create here at the center. These changes could also affect how we protect the privacy of your health information before these changes were made.

Privacy Practices – Examples of Use and Non-use of Information

1. We may use or disclose your health information.
   1. Your physician or other healthcare provider
   2. Governmental agencies if disclosure is required or authorized by law
   3. To receive payment from a third-party payer for services provided for you by the center
   4. Our own staff, in connection with our center’s operations. Examples of these include, but are not limited to, the following: evaluating the effectiveness of our staff, supervising our staff, improving the quality of our services, and meeting accreditation standards.
   5. To anyone you give written authorization to have your health information. You may revoke this authorization in writing at any time. If you revoke an authorization, it will only affect your health information from that point forward.
   6. A family member, a person responsible for your care or your personal representative in the event of an emergency. If you are present in such a case, you will be given opportunity to object. If you object, or are not present, or are incapable of responding, our professional judgment may be used, in light of the nature only your health information necessary in response to the emergency will be disclosed or used.
   7. If it is believed that a child, dependent, or elder has been or will be abused or neglected, the proper authorities will be notified.
   8. If a serious threat to harm yourself or another person is made, the law requires me to protect you or that other person. This usually means informing others about the threat.
   9. If you were court ordered for evaluation or treatment, a report is expected by that court. If this is your situation, please inform me before disclosing information you may not want the court to know. You have the right to inform me of only what you are comfortable disclosing.
   10. If you are being sued or are being charged with a crime and you inform the court of our therapeutic relationship, I may be ordered to disclose your records to the court.
   11. We will not use your health information in any of our center's marketing, development, public relations, or related activities without written authorization.
2. Your rights as a client of Samaritan Counseling Center of Southeast Texas.
   1. With limited exceptions, you can request, in writing, to inspect your health information that is maintained by us for our use.
   2. You can ask us for photocopies of the information in part "I" above. The center complies with Texas Health & Safety Code when charging clients for copies.
   3. You can make a written request to have us communicate with you about your health information by alternative means, at an alternative location. (An example would be if your primary language is not spoken at this center, and we are treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.
   4. You can make a written request that we place other restrictions on the use or disclosure of your health information. We may deny any or all of your requested restrictions. If we agree to these restrictions, we will abide by them in all situations except those which, in our professional judgment, constitute an emergency.
   5. You can make a written request that we amend the information in part "I” above.
   6. If we approve your written amendment, we will change our records accordingly. We will also notify anyone else who may have received this information, and anyone else of your choosing.
   7. If your requested amendment is denied, you may place a written statement in our records disagreeing with the denial of your request.
   8. You may request, in writing, that we provide you with a list of those occasions the center disclosed your health information for purposes other than treatment, payment, or our center's operations. This includes a period of six years, but not dating before April 14, 2003.
   9. If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights in this notice you may complain to the Compliance Officer listed below.
   10. You may also submit a written compliant to the United States Department of Health and Human Services. Office of Civil Rights: 200 Independence Ave, Washington, D.C. 20201

Statement of Agreement Between Counselor and Client

• It is agreed that the Samaritan Counseling Center of Southeast Texas will provide counseling dealing with individual, relational, and family problems, including matters of religious concerns. I recognize that an intellectual, emotional, and behavioral investment on my part is essential to reaching my personal goals through therapy.
• I understand that in order to provide quality professional counseling, the center must charge a fee for services. I also understand that the standard fee for each session is $150.00 for the initial visit and $125.00 for each session thereafter. The center offers fee assistance, which is determined by the client’s household income and number of people in that household.
• I understand that I am responsible for payment at the time of each session.
• It is agreed that appointments may be changed or cancelled without charge provided a 24 hour notice is given. If a 24-hour advance notice is not given, I will be charged for the session. As a courtesy, I may receive a reminder phone call of upcoming appointments.
• The center is not an emergency crisis center. It is suggested that I call 911 or go to the nearest emergency room.
• It is agreed that my relationship to my therapist and the center is confidential. The only exceptions to my right to confidentiality are those situations that are life threatening, involves child abuse or neglect, the abuse of a vulnerable adult or by court order. In such cases, counselors are required by law to report to the appropriate agencies.
• I agree that I will not cause harm to myself or anyone else in any way, accidentally or on purpose, no matter what I am feeling or thinking at that time.
• It is agreed that the center and my therapist will maintain records of these counseling sessions on file as necessary and that the staff of the center will use all information about the counseling relationship responsibly.
• It is agreed that as a courtesy to the referring person, an acknowledgement will be made. Unless noted below, some consultation may occur between the therapist and this referring professional.
• In the case of 3rd-party payment, I authorize the center to disclose necessary information to the disclosed entity.
• The center solicits donated funds for various expenses. I am aware that my client status is confidential and any fund solicitations I may receive are completely coincidental. Donations are never expected from current clients of the center.

Insurance Benefits

*** WE MUST RECEIVE A PICTURE OF YOUR ID AND INSURANCE CARD (FRONT AND BACK). PLEASE EMAIL TO: samaritancenter@sccset.org ***

Information provided to the client regarding eligibility and benefits is information which has been provided to Samaritan Counseling Center of Southeast Texas (SCCSET) by the client's insurance carrier. Since the insurance carrier does not guarantee payment until all Health Insurance Claim Forms are received by them, SCCSET cannot guarantee the payment for services rendered to be supplied by the insurance carrier. The amount determined by the insurance company will be the client's responsibility and will be billed to the client. Any amounts the client has overpaid on co-payments or deductibles will be reimbursed to the client upon notification from the insurance carrier. Eligibility and benefit quotes are based upon the health information provided. The information given regarding eligibility, benefits, and/or co-payments/deductibles is not a guarantee of benefits.

Insurance benefits are determined by the following:

• Review of health information or records
• The client's eligibility on the date service is rendered
• Other contractual provisions of the plan

Preauthorization is not a guarantee of payment. It means only that treatment is medically necessary. A company determines if a claim is payable after receiving all the necessary documents and reviewing the claim against the client's benefit plan.

(Please complete Application for Fee Adjustment at intake.sccset.org)

Agreement to Pay for Services Rendered

I agree to pay for the professional services that I receive at the agreed upon rate. I understand that it is my responsibility to know the terms of my benefits for mental health services paid for by my insurance company, its affiliates, and/or my employee assistance program (EAP).

1. Knowing the amount of and meeting my deductible is my responsibility.
2. Obtaining and documenting pre-certification for services is my responsibility. If pre-authorization or certification for mental health services is required by my benefit plan and has not been obtained prior to the services rendered, I will be charged the full fee of $125.00 for counseling services.
3. Samaritan Counseling Center is not responsible for any dispute about payments for services between my insurance company and me.
4. If I do not use my insurance or EAP benefits for services, Samaritan Counseling Center will not file for reimbursement retroactively (or at a later date).
5. Verification of benefits does not guarantee claim payment. Payment for services rendered is contingent upon current benefit eligibility, available mental health benefits, medical necessity, and prevailing charges.

PHOTO ID OF "OTHER" PERSON REQUIRED TO BE ON FILE: email picture of "other" person's ID to samaritancenter@sccset.org

*Please note a substitute decision maker is a person authorized to consent, on behalf of an individual, to disclose personal health information about the individual.

ClientWelcome.com is a service used by clinicians to communicate securely with clients, offering appointment reminder services.

Email appointment reminders

ClientWelcome.com will email you appointment reminders and confirmations to your preferred email address. Please talk to your clinician for details and to discuss your preferences for receiving these emails, or to change your email on file. You may block receiving future emails from ClientWelcome.com at any time by clicking the unsubscribe link found in any email you have received from us.

Text (SMS) appointment reminders

ClientWelcome.com will send text message reminders to your preferred mobile phone regarding appointments, usually 1 day before your appointment. Please talk to your clinician for details and preferences for receiving these messages, or to change your phone number on file. Otherwise, to block text messages from ClientWelcome.com please send the text message “STOP” TO (215) 543-7686. If you have previously stopped these messages and wish to allow text messages from us again, please text “START” TO (215) 543-7686.

Phone appointment reminders

ClientWelcome.com will make automated phone call reminders regarding appointments to your preferred phone number, usually 1 day before your appointment. Please talk to your clinician for details and preferences for receiving these messages. The voice is computer generated and entirely automated. Our software will attempt to leave the message on voicemails, and the message is played twice.

It is the required protocol of Samaritan Counseling Center of Southeast Texas that all clients have a credit/debit card on file. Client will be asked to provide credit card information by the administrative representative when scheduling your appointment so please have this information readily available when scheduling. If the client would prefer to pay by cash or check upon arrival to your appointment, that option is still available. Charges to your card will only be processed at the time of check-in for your session or in the event of a short notice cancellation or no-show of appointment. Upon client request, a receipt can either be emailed to the address on file or given to client.

Samaritan Counseling Center of Southeast Texas uses Card Connect, that gives us the ability to store credit or debit card information in a HIPAA compliant, secure server portal. The credit card number is not stored on site, as it is stored in a Trustwave account server. We want to assure you that our software has been thoroughly vetted according to the strict data retention guidelines required by the merchant processing system.

PLEASE COMPLETE FOR VIDEO THERAPY IN THE EVENT YOUR SESSION EVER HAS TO BE CHANGED FROM IN-PERSON TO VIDEO FORMAT

Video Therapy Services involves the delivery of health care services using electronic communications, information technology or other means between a health care provider employed by or otherwise contracted with the center and a client who are not in the same physical location. Video Therapy may be used for diagnosis, treatment, follow-up and/or education, and may include, but is not limited to:

• Electronic transmission of clinical records, photo images, personal health information or other data between a client and Samaritan Counseling Center of Southeast Texas;
• Interactions between a client and Provider via audio, video and/or data communications; and
• Use of output data from clinical devices, sound and video files.

The Provider has received certification and education in Video Therapy Services from an industry recognized provider. The vendor of the electronic systems used in the provision of Video Therapy Services has represented that it incorporate industry standard network and software security protocols to protect the privacy and security of health information.

Possible Risks of Video Therapy

• Information transmitted to your Provider may not be sufficient to allow for appropriate clinical decision making by the Provider and may need to be referred for additional care.
• The inability of your Provider to conduct certain tests or assessments in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency clinical care or treatment for you.
• Delays in clinical evaluation/treatment could occur due to failures of the video technology.
• Security protocols or safeguards could fail causing a breach of privacy.

By accepting this Consent to Video Therapy, you acknowledge your understanding and agreement to the following:

1. I understand that the delivery of health care services via Video Therapy is an evolving field and that the use of Video Therapy in my clinical care and treatment may include uses of technology not specifically described in this consent.
2. I understand that while the use of Video Therapy may provide potential benefits to me, as with any clinical care service no such benefits or specific results can be guaranteed.
3. I understand that my provider may determine in his or her sole discretion that my condition is not suitable for treatment using Video Therapy, and that I may need to seek clinical care and treatment in-person or from an alternative source.
4. I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these Video Therapy services.
5. I agree and authorize my provider and center to share information regarding the Video Therapy exam with other individuals for treatment, payment and health care operations purposes as allowed by law.
6. I understand that I can withhold or withdraw my consent at any time by emailing or providing other such written notification to my provider with such instruction, without affecting my right to future care or treatment. Otherwise, this consent will be considered renewed upon each new Video Therapy consultation with my Provider.
7. I understand that I will be informed of the physical location of my provider, and any other people present at the site.
8. I acknowledge that my provider and I have discussed emergency procedures.

Client Consent To The Use of Video Therapy

I have read this consent to Video Therapy carefully and understand the risks and benefits of the use of Video Therapy in the course of my treatment. I hereby authorize provider to use Video Therapy in the course of my diagnosis and treatment.