Group Counseling Forms
Please sign the statement below. This information is kept private and is sent directly to our administrator. If you prefer to sign by hand you can download the following:
Please either drop these forms off or mail them to:
CCM Attn: Admin
42 S. 2nd St.
Easton, PA 18042
1. HIPAA PRIVACY STATEMENT
Notice of Policies and Practices to Protect the Privacy of Your Health Information
This Notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Uses and Disclosures for Treatment and Health Care Operations
CCM may use or disclose your Protected Health Information (PHI) for treatment purposes with your consent. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“Treatment” is when CCM provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when CCM consults with another health care provider.
“Use” applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.
Uses and Disclosures Requiring Authorization
CCM may use or disclose PHI for purposes outside of treatment when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when CCM asks for information for purposes outside of treatment, CCM will obtain an authorization from you before releasing this information. CCM will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes CCM has made about conversations during a private, group, joint or family counseling session. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that CCM has relied on that authorization.
Uses and Disclosures with Neither Consent nor Authorization
CCM may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If CCM has reasonable cause, on the basis of our professional judgment, to suspect abuse of children with whom we come into contact in our professional capacity, we are required by law to report this to the proper authorities.
Adult and Domestic Abuse: If we have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides protective services.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release the information without your written consent, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If you express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and we determine that you are likely to carry out the threat, we must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
Client’s Rights:
Right to Request Restrictions- You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.
Right to Receive Confidential Communication by Alternative Means and at Alternative Locations- You have the right to request and receive confidential communication of PHI by alternative means at alternative locations. For example, you may not want a family member to know you are seeing us. Upon request, we will send communications to another address or phone number.
Right to Inspect and Copy- You have the right to inspect and obtain a copy of PHI in our mental health record for as long as the PHI is maintained in the record. However, we reserve the right to deny your access to PHI under certain circumstances. On your request, we will discuss with you the details of the request and denial process.
Right to Amend- You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. However, we reserve the right to deny your request. Upon your request, we will discuss with you the details of the amendment process.
Right to an Accounting- You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.
Counselor’s Duties:
We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
If we revise our policies and procedures, we will provide you with a revised notice by mail or in person.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, please bring this to our attention.
You may also file a formal grievance in writing with the Executive Director of CCM.
Effective Date, Restrictions and Changes to Privacy Policy
This notice will be in effect as of November 1, 2014.
3. COUNSELING AGREEMENT
In the interest of full disclosure about the counseling you will be receiving, please read through this following agreement, sign and date it at the bottom. This form must be signed and included with the intake form in order to begin counseling.
Description of Counseling
The mission of Cornerstone Counseling Ministries is to provide Christ-centered counseling services and life-skills training to individuals, families, the church body, and community. We are committed to developing solutions with our clients to address their physical, personal, emotional and spiritual wellbeing. We look to Christ as our model, relying on the Holy Spirit’s guidance and power to bring about transformed hearts and renewed hope for the glory of God.
Although counselors at CCM are guided by a Christian worldview, your counselor will be sensitive to your religious/cultural differences and perspectives. Based on your counseling needs, you may be advised to take appropriate tests/inventories or seek medical treatment to facilitate the counseling process. CCM adheres to the Code of Ethics as prescribed by the American Association of Christian Counselors and/or American Counseling Association.
Referral Policy/Disclaimer
Clients will be referred outside of CCM when treatment required is beyond the scope of care available at CCM. Though CCM strives to be responsible and professional in the referral procedure, it is your full right and responsibility to select the professional of your choice. CCM is not liable for any services provided or not provided by the referred professional.
Counseling Fees
Please reference our fee schedule that includes a sliding scale fee structure available for those with a qualifying income level. Use of the sliding scale must be accompanied with verification of income, such as the most recent tax return. Payment is due at the beginning of each session and accounts must be kept current in order to continue counseling at CCM. Cash or checks are accepted forms of payment (checks made payable to Cornerstone Counseling Ministries).
***Please note that we are unable to accept insurance. ***
Confidentiality
To release information without your consent would violate commonly accepted codes of counseling ethics. There are situations, however, in which we are required by law to reveal information without your consent. Please see the “Notice of Policies and Practices to Protect the Privacy of Your Health Information” given to you at your initial session for details. All counselors at CCM participate in regular peer supervision and some participate in additional supervision and/or consultation. During this supervision or consultation your personal identity will be concealed. The purpose of supervision is to ensure quality of care received at CCM.
Rights as a Client
You are entitled to information about any procedures, methods of counseling, techniques and possible duration of counseling.
You have the right to end counseling at any time without any moral, legal or financial obligations other than those already accrued.
You have the right to expect confidentiality within the limits described in the Notice of Policies and Practices to Protect the Privacy of Your Health Information.
You have the right to request in writing the release of your records to any person or agency.
You have the right to authorize your counselor to consult with another professional about your counseling in writing.
You have the right to file a grievance in writing with the Executive Director of CCM if you have concerns that your rights as a client have been violated.
Mediation & Arbitration
All disputes arising out of or in relation to this agreement to provide services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the counselor and client. The cost of such mediation, if any, shall be shared equally.
Cancellation Policy
CCM requests that you notify your counselor at least 24 hours before your scheduled appointment time if you need to cancel a session. Failure to do so will result in charges for the missed appointment. This charge should be paid before or at the time of your next appointment to continue in the counseling relationship. Exceptions are for sudden illnesses and emergencies only.
Contacting Your Counselor
For scheduling and canceling your appointments, you must contact your counselor directly by dialing CCM’s main number 610-295-9499 and then leave a message. Your call will be returned within 24 hrs. For emergencies after-hours, please contact 911, or your local emergency room.
Social Media
During the duration of a client’s treatment at CCM, the counselor will not engage in a social media relationship with the client and/or communication with a client through any social media platform. Counselors will clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.
Case Consultation
Information shared in a consulting relationship is discussed for professional purposes only. When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client.
4. Teletherapy Consent Form
Teletherapy will be used at CCM as aid in the counseling process during times when face-to-face counseling is difficult or discouraged. It is necessary for us to have your written permission to use these electronic helpers.
I (We), the undersigned, do consent to teletherapy tools for my (our) counseling sessions. This consent is being given in consideration of the professional services being rendered by Cornerstone Counseling Ministries. I (We), the undersigned, realize that I (we) am/are fully responsible for my (our) own participation in any and all exercises and interactions suggested by my (our) counselor(s). I (We) release and discharge the clinic and the counselor(s) who work with me (us) from any liability for the effect of these exercises on me (us) during the counseling session or thereafter.
I (We), the undersigned, acknowledge that the purpose and value of teletherapy tools has been fully explained to me (us) and that my (our) consent to such tools is given freely and voluntarily.
I (we) understand that I (we) have the following rights with respect to teletherapy:
I (we) have the right to withhold or withdraw consent at any time without affecting my (our) right to future care or treatment.
The laws that protect the confidentiality of my (our) medical information also apply to teletherapy. I (we) understand that the information disclosed by me (us) during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in our Informed Consent Form.
I (we) understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Cornerstone Counseling Ministries, that: the transmission of my (our) information could be disrupted or distorted by technical failures; the transmission of my (our) information could be interrupted by unauthorized persons.
In addition, I (we) understand that teletherapy based services and care may not be as successful as face- to-face services.
I (we) understand that I (we) may benefit from teletherapy, but that results cannot be guaranteed or assured.
I (we) accept that teletherapy does not provide emergency services. If I (we) am/are experiencing an emergency situation, I (we) understand that I (we) can call 911 or proceed to the nearest hospital emergency room for help. If I (we) am/are having suicidal thoughts or making plans to harm myself, I (we) can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
I (we) understand that I (we) am/are responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my (our) teletherapy sessions, (2) the information security on my (our) computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
5. Group Therapy
Group therapy is a unique kind of therapy where a group of people, who are likely experiencing similar challenges during a period of their lives, come together to share their experiences. Members are able to give and receive help and perspective from their peers. We aim to maintain a safe environment that is conducive to sharing and acceptance. We aim to help each member grow and trust one another so that everyone will feel respected and valued.
What to Expect
The sessions consist of processing relevant topics, giving and receiving feedback to one another with help and prompts from the professional counselors. This helps each member understand the topic from a different perspective. This also helps with one's reflection about his or her situation, encouraging insight and personal growth.
Confidentiality
We respect everyone's right to privacy and confidentiality and we shall make every effort to maintain it. Please see the “Notice of Policies and Practices to Protect the Privacy of Your Health Information” given to you at your initial session for details. All counselors at CCM participate in regular peer supervision and some participate in additional supervision and/or consultation. During this supervision or consultation your personal identity will be concealed. The purpose of supervision is to ensure quality of care received at CCM.
Conduct and Relationships
For the safety of all involved, it is necessary that the following are adhered to by the group members and facilitators:
Discussions within the group sessions are not allowed to be discussed outside the group sessions with anyone. Confidentiality is expected in order to build trust with fellow members.
No one should be under the influence of illegal substances.
Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior.
Refrain from having a relationship with a fellow member other than therapeutic while engaged in the sessions.
The Therapist(s)
The therapist(s) should maintain a professional relationship with the participants. The therapist(s) should abide by their Code of Ethics regarding professional relationships. Any non-professional relationship with a participant may result in a "dual relationship" and may affect the goals of the session.