Intake HIPAA and Consent 2021

New Client Information

CLIENT RIGHTS

As a consumer of mental health services and marriage and family therapy in Minnesota, you have the right:

  1. To expect that a therapist has met the minimal qualifications of training and experience required by state law;
  2. To examine public records maintained by the Board of Marriage and Family Therapy which contain the credentials of a therapist;
  3. To obtain a copy of the code of ethics from the State Register and Public Documents Division, Department of Administration, 117 University Avenue, Saint Paul, MN 55155;
  4. To report complaints to the Board of Marriage and Family Therapy, (612) 617-2220, University Park Plaza Building, 2829 University Avenue SE, Suite 400, Minneapolis, MN 55414;
  5. To be informed of the cost of professional services before receiving the services;
  6. To privacy as defined by rule and law;
  7. To be free from being the object of discrimination on the basis of your race, religion, gender, or other unlawful category while receiving services;
  8. To have access to your records as provided in Minnesota Statutes, section 144.292;
  9. And to be free from exploitation for the benefit or advantage of a therapist.

FEES AND POLICIES

INITIAL INTAKE APPOINTMENT: 90 minutes $300.00 (+ MN-Care tax if applicable).

COUNSELING AND THERAPY: Individual/couple/family counseling appointments are billed at $200.00 per hour (+MN-Care tax) per therapist involved. One session or appointment is 50 minutes unless otherwise determined by your therapist. All charges are due and payable at the time of each session, unless other arrangements are made. In the event of a missed appointment without 24-hour advanced notification, THE BRIDGING CENTER will charge the regular hourly rate per therapist. Thank you for respecting our services and the financial commitments we have as business owners.

INSURANCE

The Bridging Center does not bill insurance companies for services. The Bridging Center does not complete forms, talk to insurers, or facilitate insurance payments. However, upon client request, The Bridging Center will provide a clinical receipt for you to bill your insurer. It is the client’s responsibility to inquire about and arrange reimbursement from their insurer.

COLLATERAL CHARGES

Phone calls to other professionals or persons you want the therapist to talk to; review of client communication as

agreed upon by client and the therapist; and writing summaries will be charged at a rate of $50.00 per 15 minutes.

EMAIL

Emails are only for scheduling, billing, and providing documents requested by The Bridging Center. Other emails will NOT be responded to.

RECORDS REQUESTS

If a client requests records, they will be charged according to Minnesota State statute.

SERVICES PROVIDED AT THE BRIDGING CENTER

Because The Bridging Center offers a variety of services, the following summarizes the different services and what you can expect (and not expect) from the services you receive.

COUNSELING & PSYCHOTHERAPY

Counseling and psychotherapy is about you; it is a way of talking through your problems in order to begin resolving them. You will need to take an active part in psychotherapy by working on and thinking about the things you talk about with your therapist. Psychotherapy has been shown to have many benefits. Therapy may lead to better relationships, solutions to specific problems, and feeling less distressed about life and unique issues you are facing. However, there are no guarantees of what you will experience, and at times a psychotherapy session may leave you with a range of different and changing emotions.

The Bridging Center recognizes that some clients are Court ordered to participate in counseling and psychotherapy through The Bridging Center. Even so, what you put into this experience is what you will get out of it. We encourage all clients to fully participate in the experience, and find value and outcomes that will improve your life, relationships, and family system.

Unless other arrangements are established between the client and the therapist, it is the client’s responsibility to take the initiative to schedule appointments, put into practice what is learned in counseling, and initiate selfreflection.

REUNIFICATION SERVICES

The Bridging Center offers reunification services for families experiencing estranged relationships. Reunification services includes four (4) distinct phases: 1) Assessment phase; 2) Treatment planning phase; 3) Therapy phase; and 4) Continuation and Support phase. These phases will be thoroughly explained to you during your initial intake meeting. Typically, reunification is a long-term process. The Bridging Center requires a Court order, Parenting Consultant decision, or legally binding agreement in order to engage in reunification. All parties are expected to initiate, cooperate, and participate in the reunification process. If a dispute about the process arises between the parties, The Bridging Center will direct them to their appropriate dispute resolution professionals.

CO-PARENTING SERVICES

The Bridging Center offers education, counseling, and coaching services for parents seeking co-parenting assistance. Typically, co-parenting services address: communication, cooperation, decision-making, developing flexibility, and helping parents keeping their children out of the middle of their conflict, among additional topics as identified by the client. Co-parenting counseling may be an individual experience, a joint process, or a combination of the two.

MEDIATION SERVICES

The Bridging Center offers mediation services. These include Standard Mediation and Child Inclusive Mediation. Mediation providers are qualified neutrals under Rule 114 of the Minnesota General Rules of Practice. All mediation providers at The Bridging Center are also mandatory reporters. See EXCEPTIONS TO PRIVACY above for information about mandatory reporter status. For more information about these services, please contact the office manager.

EDUCATION WORKSHOPS

The Bridging Center offers a variety of education workshops. Your attendance at one or more of these workshops is NOT covered under federal privacy laws. If you have questions about your privacy while attending one of these workshops, please discuss with your therapist or the workshop instructor(s). Fees associated with workshops are set according to the particular workshop and are not billed according to a clinical hour, as stated above.

Please Note: The Bridging Center does not provide evaluative services. The Bridging Center, LLC does NOT make recommendations for parenting time, custody, or for other legal matters. If you require an evaluation, you will be provided names of agencies and/or professionals who do provide evaluation.

CLIENT RECORDS

By Minnesota law, you have a right to your therapy record, which will be provided if you request a copy and after the therapist receives an ROI. However, Minnesota law and HIPAA Rules also list exceptions (MN Statute 144.292 and HIPAA Rule 45CFR 164.524 and 164.501). Under certain circumstances, the therapist may withhold the record if the therapist has reason to believe that releasing the information may cause harm to one or more participants of therapy. The law also provides for alternatives to releasing the record: 1) Provide a summary of services provided; 2) Have a third-party mental health provider review the record to determine if its release would be harmful; 3) A judicial officer orders the release of the records.

 

Name
Address
Type
MM slash DD slash YYYY
If Applicable
Emergency Contact

Electronic Communication
By checking one or more of the options above, you are consenting to the utilization of a means of communication that is vulnerable to breaching your privacy rights. The Bridging Center, LLC cannot and does not guarantee the privacy, as defined by HIPAA, of electronic communications. If you choose to not utilize electronic communication, leave this box blank, and The Bridging Center will NOT contact you via email PLEASE NOTE: Email communication is for the indicated purpose(s) only.
If you consented to electronic communication, please provide us with your email address.

Signature

I hereby consent for The Bridging Center, LLC and/or its staff to provide evaluation and treatment to me.
Name
MM slash DD slash YYYY