EMU Community Behavioral Health Clinic
Consent for Services

The purpose of the Early Childhood Satellite Clinics is to provide access to specialized behavioral health services within the context of preschools/childcare settings. Thus, your family’s services will be provided outside of the EMU Community Behavioral Health Clinic’s location at 1075 North Huron River Drive in Ypsilanti, MI. The trainees and their supervisors will adhere to the same legal and ethical guidelines during Satellite Clinic sessions as they follow within the Clinic. The EMU Community Behavioral Health Clinic supervisors, and trainees are not responsible for any accident or injury that may occur outside the Clinic.

As the parent/guardian of a child receiving services, you will be involved in both the assessment and treatment of your child’s behavioral health concerns. The purpose of the EMU Early Childhood Clinic is to enhance your child’s psychological well being, and services are specifically not intended to be used in any current or future legal proceedings (e.g., custody, divorce, civil, or criminal proceedings).

Generous grant funding is currently covering the cost of all services provided through the Early Childhood Satellite Clinics. However, you will be personally charged a "failure to cancel" fee (equal to the usual session rate of $10 specified below) if you fail to cancel a scheduled appointment at least four hours in advance. This fee will not be covered by grant funding and you will be billed. Furthermore, if your balance reaches four times the usual hourly rate, additional sessions will not be scheduled until (a) this balance is reduced to below four times the hourly rate, and (b) a payment plan is negotiated to clear the remaining balance.

To achieve its training mission and ensure quality of care, all sessions with behavioral health specialists at CBHC - faculty and trainees alike - are video and/or audio-recorded.

Video and/or audio-recording will occur during in-person, telehealth, and offsite sessions. Video- and audio-recordings will be used for purposes of trainee and provider training, consultation, treatment evaluation, administration, research, and/or program evaluation, without payment to you. Trainees or providers in training must have access to the work of faculty or peers, so that they can learn by observing and thereby develop their own clinical skills. In addition, supervisors of graduate student trainees must have access to session content so that they can advise trainees on the most effective ways to conduct valid assessments and deliver treatment, for the highest quality services possible.

This requirement is essential to the EMU Community Behavioral Health Clinic's ability to provide quality care and meet its training mission. Videos are also necessary to educate and train mental health professionals, so they can learn to deliver services to individuals with behavioral health difficulties and in some cases, their parents or care partners. These recordings are not considered part of your clinical record. They are typically deleted shortly after being reviewed in supervision, but they may also occasionally be used for training purposes. They may be shown at workshops or seminars and may become part of a training package to educate students and providers-in-training. Viewers sign confidentiality agreements and are expected to treat materials according to strict professional guidelines. 

We realize that this requirement may cause some concerns, but this requirement is essential to EMU CBHC's ability to provide quality care and meet its training mission. If you do not wish to authorize us to record your work at the Clinic, we will try to provide you information about other area programs that might be able to meet your needs.

Due to the nature of this facility as a training clinic, services cannot be provided on an indefinite basis. It is the policy of the clinic to limit the duration of treatment to one year or less.

Therefore, you are encouraged to invest in the treatment process early and make effective use of services by attending regularly.  Sometimes, however, even if treatment can continue for up to a full year, clients may have to transfer to new behavioral health specialists. Typically, this would occur when a behavioral health specialist completes training at the Clinic. Such a transfer will be discussed with you in advance. If you are transferred to another behavioral health specialist, the new behavioral health specialist (and his/her supervisor) will have access to your old records and will try to review them as soon as possible when beginning to work with you.

Your behavioral health specialist may share information about your treatment in case conferences and other treatment team meetings for training purposes.

Any meeting you have with your provider may be observed or discussed with my provider's supervisor, other behavioral health professionals, trainees or providers-in-training, professional consultants, or staff at the EMU CBHC. When information is shared among clinic personnel (i.e., staff, supervisors, and students), it is shared in a de-identified manner to the extent possible. However, this cannot be guaranteed, particularly when coordination of care is required. For example, this may occur in cases where we are treating family members within a supervisory team or when providers need to consult with one another to develop treatment plans. Every effort will be made to keep the results of services strictly confidential, as provided by law. Information concerning you will be released outside the EMU CBHC only to agencies or individuals specifically designated by you in writing, or as otherwise allowed. Please note that while information may be shared among clinic personnel, it will not be shared with other family members or friends who may be seen at the Clinic, unless you have explicitly consented to this in writing. As an additional safeguard, all Clinic personnel sign Confidentiality Agreements that prohibit them from sharing information with anyone not involved with Clinic operations.

The first few sessions will be dedicated to assessment and evaluation to determine your specific treatment needs.

The goal of these evaluative sessions will be to clarify if the Clinic is suited to serving your specific needs and, if so, to develop a treatment plan with you. If it is determined that the Clinic is not capable of meeting your specific needs, you will be provided information about other options for community mental health practitioners or agencies that may be able to meet your needs. 

This section is not applicable to you since you have chosen not to pursue telehealth. Please move to the next section.

You may receive behavioral health services by phone and/or by two-way interactive video communications and/or by the electronic transmission of information. Referred to as "telehealth," this means that you will be evaluated and treated by EMU behavioral health specialists (trainees and/or supervising faculty) in a different location. Since this is different than the type of service delivery with which you are most familiar, please be advised that:

1. The CBHC behavioral health specialist will be at a different location from you.
2. Details of your personal history, neuropsychological, psychological, psychiatric, or medical examinations, x-rays, tests, photographs, or other images will be discussed with the EMU behavioral health specialist who is at a different location.
3. Telehealth sessions may be video and/or audio-recorded, after you have given permission below to the overall conditions of being seen at the CBHC. Video or audio recordings and other data, including x-rays, images, or photos may be kept, viewed, and used for purposes including teaching, training, technical, scientific, research, or administrative purposes.
4. The CBHC behavioral health provider will keep a progress note of your session in your medical record.
5. The behavioral health specialist, with their supervisor, may determine that due to certain circumstances, telehealth is no longer appropriate for you. At this point, you will discuss alternate treatment options with the behavioral health specialist.
6. Telehealth is voluntary and constitutes a waiver of the usual right to privacy and may possibly increase the risk of disclosure of my neurobehavioral, psychological, psychiatric, or medical data. You have the right to refuse the telehealth session or stop participating in telehealth sessions at any time, as well as the right to limit any assessment or intervention proposed during the telehealth session.

EMU CBHC will conduct telehealth via two primary platforms: 

1. Videoconferencing via HIPAA-compliant software: Zoom.us is a HIPAA-compliant platform and has signed a HIPAA Business Associate Agreement (BAA). This means Zoom.us is responsible for keeping client information secure and reporting any possible breaches in security. Zoom.us does not have access to any identifiable health information and they encrypt all transmitted audio, video, and screen sharing data. 
2. Telephone via Landline or Cellphones: Less commonly than Zoom, the therapist and Client will meet at a set appointment time to conduct individual therapy. Using a landline from the CBH Clinic, the therapist will call the client at the number provided by the client. Due to the nature of this being a training clinic, the session will be recorded via an audio recorder that is not connected to the internet for supervision purposes. The audio file will be stored on a secure server in accordance with the session recording policy that you agreed to by signing our standard Consent for Services form upon treatment initiation. 

In order to utilize Zoom.us, you will need a computer or a smartphone that can download the zoom.us app, access to the internet, and a webcam. For psychological or neuropsychological assessments, a computer is required. Your clinician will explain how to use this software. In the event of technical difficulties, we will contact you via the telephone number you provided to troubleshoot or conduct a session via the telephone. All video sessions may be recorded for supervision purposes via zoom.us (but not saved by zoom.us) and will be stored on a secure local server, in accordance with our standard video storage and security procedures described above. 

It is your responsibility to find an appropriate and secure location for the duration of the scheduled telehealth session and be aware that family, friends, acquaintances, and strangers could either overhear conversations. It is important to be in a quiet, private space that is free of distractions during telehealth sessions. It is also your responsibility to ensure that the communication is conducted via a secure device (appropriate firewall, anti-virus software installed, password protected devices, private/secure internet access rather than public/free Wi-Fi etc.)

Telehealth Assessment Procedures

In some instances, EMU CBHC will only provide a screening assessment of a child or adult's cognitive and psychosocial functioning to guide immediate intervention needs and/or to guide caregivers or school personnel with academic accommodations. Telehealth screening assessments will be brief and may include measures of intellectual ability, academic skills, learning/memory, attention, and psychosocial functioning. This brief assessment may be conclusive or warrant a follow-up assessment. Based on screening results, we may recommend a more comprehensive assessment, likely in person, at a later time. The information on fees below explains how this is handled with respect to billing.

Preparation for a telehealth assessment session requires a pre-screening with your behavioral health specialist before the assessment itself in order to:

1. Assess if appropriate space to conduct the assessment, hardware/software, connectivity, and security are available and reliable.
2. Identify appropriate candidates for telehealth. 

The final determination of whether a client is suitable for a telehealth assessment is made by the clinical supervisor. Please note, this is not intended to be a comprehensive psychological, cognitive, or neuropsychological assessment.

As a general rule, all Clinic staff adhere to strict confidentiality protections.  However, your behavioral health specialist may disclose confidential information without your consent in certain circumstances that include, but are not limited to, the following:

1. If you are evaluated to be a danger to yourself or others, or if you are in the midst of a medical emergency while at the EMU Community Behavioral Health Clinic, during which you are unable to speak on your own behalf; 

2. If you are a child (under 18 years of age) or a vulnerable adult (meaning a condition in which an adult is unable to protect themselves from abuse, neglect, or exploitation because of a mental or physical impairment or because of frailty in advanced age), and we suspect that you may be the victim of abuse, neglect, and exploitation or if you divulge information about such abuse, neglect, and exploitation; or if you share information that leads your behavioral health specialist to suspect that any child or vulnerable adult is being abused, neglected, and exploited; 

3. If you file suit for breach of duty or if you commit a crime on the premises of the Community Behavioral Health Clinic; or

4. If a court order, other legal proceedings, or statute requires disclosure.

Limitations of Telehealth 

There are risks in conducting sessions via telehealth, including but not limited to possible breaches of confidentiality and disruption of service due to technical difficulties. The primary video conferencing software we use, Zoom.us, is HIPAA compliant and communication is secure. However, technology is not always dependable, and the privacy and confidentiality of computer mediated communication cannot be 100% guaranteed. Should we learn of any breaches in confidentiality, clients will be notified as soon as possible.

The Clinic has policies regarding fees, billing, missed appointments, terms of payment.

The EMU CBHC is a low-cost training clinic that does not charge any insurances or third-party payers. Third-party payers and health insurances may not cover the services delivered by trainees. Medicaid and Medicare do not cover the services received at the EMU CBHC. If you are eligible for or enrolled in Medicare, Medicaid, healthcare through the Veterans Administration or some other health insurance, you may seek services through their assigned providers. If you elect to receive EMU CBHC services, therapy services are charged at the rate of $10 per 50- to 60-minute individual session and $5 per group session. Psychological assessment batteries are billed at the flat rate of $500, all of which must be paid before the formal assessment process may begin. A reduced fee application is available to reduce the assessment fee to as low as $300. 

In accordance with the "No Surprises Act", we are required to give you a "good faith estimate" of the costs you can expect to pay for our services.  For psychological assessments, that is expected to be a total maximum of $500.  For individual psychotherapy, until we do an evaluation and we start therapy, it is difficult to estimate the duration of treatment, but a typical course of treatment is 15-20 sessions, which, at $10/session, would amount to around $150-$200.  However, some people have more complex issues that may require up to one year of treatment (our typical maximum allowed at the CBHC), for a total cost of $500 if weekly sessions were attended for the full year.  Group therapy is billed at $5/session, and most groups run in modules of about 8 sessions, for a total estimated cost of $40 per module.  You also may be billed for extensive telephone consultation at the session rate, adjusted for actual time spent. Your assigned clinician will discuss any variations from these estimates with you as your treatment plan is developed and/or modified. 

You will be charged a "failure to cancel" fee (equal to the usual session rate specified above) if you fail to cancel a scheduled appointment at least four hours in advance. Furthermore, if your balance reaches $40, additional sessions will not be scheduled until (a) this balance is reduced to below $40, or (b) a payment plan is negotiated to clear the remaining balance.  Please note that if your balance reaches $40, no future sessions will be scheduled (or, if already scheduled, will be cancelled).  Payment must be made 24 business hours in advance of the intended session time, or it will be cancelled until after payment is processed. Because it is understood that emergencies do occur, there is a one-time fee waiver for a late cancelation or "no show" for therapy services. This one-time fee waiver does not apply to assessment services. 

Important note regarding “no show/no call” situations with assessment cases.

Assessment cases are billed at a flat rate, as detailed above. Therefore, if a client violates the above cancellation policy, it is not possible to charge an “hourly” rate for the missed session. Therefore, behavioral health specialists will discontinue testing and prepare an abbreviated report if a client “no show/no calls” (or calls late) two or more times after the first visit. This short report will summarize whatever data has been obtained and note that the client failed to attend scheduled visits, so the assessment could not be completed.

Regarding telehealth therapy, sessions are billed at the same rate as face-to-face sessions. Your CBH Clinic account will be invoiced accordingly, but we recognize that payment may be delayed until we can meet in person. Alternatively, we have a URL where credit card payments can be made securely.

If you elect to receive services at the EMU CBHC, you must inform your provider of any pending legal action initiated by you or actions brought against you. The purpose of the EMU CBHC services is your enhanced psychological wellbeing, and EMU CBHC services are specifically not intended to be used in any current or future legal proceedings (e.g., custody, divorce, civil, or criminal proceedings), including testimony by doctoral students or supervisors. 

Contraband and weapons (except by law enforcement personnel at the CBHC for matters related to law enforcement) are prohibited at the Clinic.

Masking at the EMU CBHC is optional, however clients and clinicians are expected to comply with requests to mask

The EMU CBHC strives to remain mindful of providing safe spaces for faculty, staff, students, and community members in all situations. As of August 1, 2023 face masks are no longer required in the EMU CBHC reception space for clients, client family members, clinicians, or supervisors. Clients, clinicians, and supervisors are not required to mask in private offices or group rooms unless they are requested to do so by an individual who will also be sharing the space with them. Thus, you may be required to mask if your clinician or, if you are participating in group therapy, another member of your group requests participants mask. Clinicians will also be required to mask should their clients request they do so. Clients are recommended to openly discuss their preferences to mask with their clinician. It is the expectation that individuals who opt to wear masks must be fully respected and supported in their choice and their requests that others mask will be followed. Masking policies are subject to change in response to changing patterns in infection rates and public health recommendations.

Depending on your provider and their supervisor’s opinion, you may receive assessment and treatment services from EMU’s CBHC outside of the EMU Psychology Clinic’s location at 1075 North Huron River Drive in Ypsilanti, MI. Doctoral trainees and their supervisors will adhere to the same legal and ethical guidelines during sessions off-site as they follow within the Clinic. The EMU Psychology Clinic supervisors, staff, and the doctoral trainees are not responsible for any accident or injury that may occur outside the Clinic.

Clinic policies pertaining to the dissemination of assessment reports, outcomes, and information gathering

Should you undergo formal assessment services (which are distinct from clinical intake practices standard within psychotherapy services) results of assessments and testing (including neuropsychological assessments) will be written in a report, of which you will receive a copy. Once you are provided with a copy of the report, you may disseminate the report to whomever you choose. EMU CBHC may only provide a copy of the report to any individuals, offices, departments, and institutions, including those within EMU, with your consent. If the report is provided to individuals, offices, departments, and institutions pertaining to any proceedings or requests for accommodations, benefits, damages, etc., the EMU CBHC, including doctoral students and supervisors, are not responsible for the outcome or disposition of those requests and proceedings.

To complete an assessment, your provider will collect information using various measures, such as questionnaires, observations, and formal testing of your strengths and/or difficulties, throughout your services delivery. To obtain sufficient information needed for a comprehensive assessment, your provider may need to access medical and/or academic records for which a release of information will need to be completed by you. In the absence of such records, any report generated may be missing key information needed to render an accurate opinion.

Clinic policies pertaining to the dissemination of assessment reports, outcomes, and information gathering

At present you have indicated that you are NOT pursuing formal assessment services at the EMU CBHC. Your treatment services will include an assessment period in which you, your clinician, and your clinician's supervisor determine your treatment needs, which is distinct from formal testing and assessment services. In the future should you decide to undergo formal assessment services, results of assessments and testing (including neuropsychological assessments) will be written in a report, of which you will receive a copy. Once you are provided with a copy of the report, you may disseminate the report to whomever you choose. EMU CBHC may only provide a copy of the report to any individuals, offices, departments, and institutions, including those within EMU, with your consent. If the report is provided to individuals, offices, departments, and institutions pertaining to any proceedings or requests for accommodations, benefits, damages, etc., the EMU CBHC, including doctoral students and supervisors, are not responsible for the outcome or disposition of those requests and proceedings.

To complete an assessment, your provider will collect information using various measures, such as questionnaires, observations, and formal testing of your strengths and/or difficulties, throughout your services delivery. To obtain sufficient information needed for a comprehensive assessment, your provider may need to access medical and/or academic records for which a release of information will need to be completed by you. In the absence of such records, any report generated may be missing key information needed to render an accurate opinion.

In the process of receiving services at the EMU CBHC, you may receive phone calls, emails, or text messages to remind you of a scheduled appointment, changes in appointment times, and to otherwise coordinate care. The CBHC maintains two email addresses. Appointment reminders and invoices are sent from an administrative emails (psychclinic_admin@emich.edu). All communications directly with your provider are sent and received from psychclinic_correspond@emich.edu),, to which all CBHC clinicians have access. Please let your provider know if you believe you may know any CBHC clinicians and/or if you have any concerns about this procedure. Your provider will attempt to review and respond in a timely fashion to all communications, including voicemail, emails, and text messaging, however your provider cannot guarantee that all communications will be reviewed and responded to within a specific period of time.

Email, texting, and over-the-phone communication are not substitutes for psychotherapy or assessment services. In particular, electronic communication should not be used for therapeutic purposes or to communicate clinical information. Despite reasonable efforts to protect the privacy and security of information communicated electronically, it is not possible to completely secure the information. Please keep in mind that the use of electronic communication increases the risk of information being intercepted by unintended and/or unknown recipients. Electronic communication can be easy to falsify, and it is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has ben sent. Please also keep in mind that after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

Finally, should you not attend several scheduled appointments in a row, a provider may also initiate a follow-up call and a letter may be sent to you to continue care. 

It is not appropriate, effective, or ethical for the CBHC to conduct assessments or treatment when an individual is intoxicated or otherwise cognitively impaired. If you appear to be impaired, a scheduled session may be rescheduled; should this occur, you will be charged for the original and the rescheduled appointment.