EMU Community Behavioral Health Clinic
Consent for Services

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by a guardian of a child or vulnerable adult for a telehealth assessment. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by an adult seeking a telehealth assessment for themselves. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by a guardian of a child or vulnerable adult for telehealth therapy. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by an adult seeking telehealth therapy for themselves. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by a guardian of a child or vulnerable adult for an assessment. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

To ensure that you will be re-directed to the appropriate sections of the form, please confirm that this form is being filled out by an adult seeking an assessment for themselves. If this is not the case, please go back to the previous section and check the boxes that are appropriate for you.

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, and they are typically deleted shortly after being reviewed in supervision, but they may also occasionally be used for training purposes within EMU.  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 it is essential to our ability to provide quality care. 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.

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. 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. Telephone via Landline or Cellphones: 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. 

2. 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. 

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

Via telehealth, 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 minor, elderly, or disabled person and we suspect that you may be the victim of abuse or if you divulge information about such abuse; or if you share information that leads your behavioral health specialist to suspect that any child or vulnerable (elderly or disabled) adult is being abused;

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.

Specifically, 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 (and non-negotiable) rate of $200, all of which must be paid after an initial consultation, but before the formal assessment process may begin.

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. You also may be billed for extensive telephone consultation at the session rate, adjusted for actual time spent. 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. 

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 assessments, we must first screen for eligibility (at no cost to you) to ensure that you have the proper environment and technology to support a valid and reliable assessment. This will be individualized based on the nature of your request; your behavioral health specialist will discuss what is involved, and you can decide if you would like to continue. Thereafter, we have adopted a plan for splitting the standard $200 psychological assessment fee across a $50 screening assessment and, if warranted, the later $150 more comprehensive in-person assessment. The latter in-person assessment would typically occur about 6-12 months after the screening. Your behavioral health specialist will discuss this option with you if it fits your circumstances based on screening results. After the initial screening assessment, if a further comprehensive assessment is recommended, you are free to decline or pursue the additional assessment at the additional ($150) cost.

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.

Contraband and weapons (except by law enforcement personnel) are prohibited at the Clinic.

It is not appropriate or effective 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.