RISTIAN

COUNSELING

JC CHRISTIAN COUNSELINGt\it
1821 Oregon Pike, Suite 212, Lancaster, PA 17601
Phone: (717) 278-8326, FAX: 1-866-285-7198

ON-LINE CONSENT TO TREATMENT

1. I hereby voluntarily consent to receiving counseling services at JC Christian Counseling

including such diagnosis and therapeutic methods deemed necessary or advisable by our
counselors.

2. I am aware that the practice of counseling is not an exact science and I acknowledge that
no guarantees have been made to me regarding the results of my treatment! counseling
care. I am aware that I may refuse the counseling offered to me and terminate my
treatment.

3. I hereby authorize JC Christian Counseling to retain, preserve, and use for research or
teaching purposes information provided in the sessions without disclosure of my name or
any other personal identification.

4. I understand that referrals may be made to other professionals (such as psychiatrist,

psychologist, etc.) by my counselor. JC Christian Counseling (which includes the
referring counselor) is not responsible for payment to other professionals on my behalf or
for the client receiving counseling care.

Signature of Client or Responsible Party Date

Witness Signature Date

*If signed by Responsible Person, complete one of the following:

a.) Client is unable to consent because he/she is a minor, ----,yearsof age.

b.) Client is unable to consent because '
 JC CHRISTIAN COUNSELING1;a
1821 Oregon Pike, Suite 212, Lancaster, PA 17601
Phone: (717) 278-8326, FAX: 1-866-285-7198

ON-LINE COUNSELING POLICY

INITIAL SESSION EVALUATION

All new clients are seen initially as a consultation for the purpose of evaluating the nature of personal needs and
difficulties, discovering the desirability of counseling or referral, and recommending the type(s) of counseling. In
some cases, the counselor may suggest a psychiatric or psychological evaluation for which a referral will be
provided. Initial sessions for adolescents are to be attended with an adult who is the responsible party.

INITIAL INFORMATION FORMS

Each client is asked to provide information to the Counselor that will be documented on an Intake Form; this
provides information helpful to the counselor and basic information for administrative purposes. In addition, this
Counseling Policy, Consent for treatment and the Fee Policy must be signed prior to services. This information is
kept strictly confidential.

APPOINTMENTS AND CANCELLATIONS

All appointments and cancellations of appointments are made directly through the office. If one is unable to keep a
scheduled appointment, the Office must be notified at least 24 hours in advance, to RESCHEDULE your
appointment. This can be accommodated by leaving the office a message on the voice mail system or by sending an
email.Clients will be cbarged one-half of their fee for cancellations made with less than 24 hours notice.
Unforeseen emergency situations will be taken into account.

TERMINATION
On-Line Counseling Sessions are paid for prior to receiving the service. Therefore; if you decide that you would not
like to receive Online counseling services with us at IC Christian Counseling after your payment has been made,
then contact the office within three days prior to your scheduled appointment or three days after the initial intake
process (via telephone call, or email), sign the refund form and receive a full refund. If you contact us after the three
day refund period then you will receive a partial refund. If you contact us on the day of your scheduled appointment,
no refund will be provided.

If a client does not make contact with the office within 24 hours of the appointment time and does not attend their
appointment, lack of communication that will be considered a "no-show". Two consecutive no-shows may result in
immediate termination of services, at the discretion of the counselor, and no refund will be provided.

If a client makes the decision to terminate counseling, it is requested that a termination session be scheduled with the
client's counselor (rather than termination by phone or email).This is to allow time to draw closure to the
therapeutic process and to provide adequate aftercare.

EMERGENCIES
On-Line Counseling does not provide "emergency services". If a client has an urgent concern, call the office and
we will try to schedule an appointment with your counselor as soon as possible. Please contact your local Crisis
Intervention Center for emergencies, or 911.

Page 1of2
CONFIDENTIALITY
Legally and ethically, the relationship between counselor and client is of a confidential nature. This means that any
and all information which is given to the counselor during any session cannot be divulged by the counselor without
the client's written consent. However, in the event that a clear and present danger of physical harm to the client
and/or others (particularly towards children) becomes apparent, the counselor is legally and ethically required to
inform those who have a direct need to know.

NOTIFICATION OF REFERRING PERSON

If a client is referred to this office by a professional person (physician, clergyperson, etc.), it is this office's policy to
notify the referral source of the facts of that individual's commencing and terminating therapy. This is a matter of
professional courtesy and is important to the client's on-going relationship with that person.

IN THE INTEREST OF OUR WORKING tOGETHER, I AGREE TO ABIDE BY THE POLICIES ON

TIDS STATEMENT AND SIGNIFY THAT I HAVE RECEIVED AND UNDERSTAND mE
INFORMATION CONTAINED HEREIN.

CLIENT'S SIGNATURE DATE

COUNSELOR'S SIGNATURE DATE

IN THE EVENT WE MUST CONTACT YOU BY TELEPHONE TO REMIND YOU OF, OR CHANGE,
YOUR APPOINTMENT, MAY WE CONTACT YOU:

YES NO
AT HOME? 0 0
AT WORK? 0 0
OTHER (LIST LOCATION AND PHONE): _

CLIENT'S INITIALS

MAY WE SEND INFORMATION ADDRESSED TO YOU TO YOUR HOME ADDRESS: 0 YES 0 NO

CLIENT'S INITIALS

Page 2 of2
 HRISTIAN
COUNSELING

JC CHRISTIAN COUNSELINGlja
1821 Oregon Pike, Suite 212, Lancaster, PA 17601
Phone: (717) 278-8326, FAX: 1-866-285-7198

ON:LINE FEE POLICY

I, agree to provide payment at the time in which

the counseling appointment is scheduled for either myself or for the individual in which I am

signed as the responsible party.

Credit Card Option:

I authorize JC Christian Counseling to run the credit card that I have provided each time that I

schedule my appointment, unless I terminate counseling care or provide an alternative of

payment. (Appointments that are rescheduled will follow the counseling policy)

Adolescent Client

I, (the parenti responsible party), am the legal

guardian! responsible party for and is aware that

payment is required at the time the appointment is scheduled. If an organization (such as a

Church, Children Services or Child Welfare agency) is providing payment for services; Please

contact JC Christian Counseling to discuss payment details and authorization.

Client Signature Date Witness Date

Responsible Party Date

 CHRISTIAN
COUNSELING

JC CHRISTIAN COUNSELINGtlja
1821 Oregon Pike, Suite 212, Lancaster, PA 17601
Phone: (717) 278-8326, FAX: 1-866-285-7198

'"THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO TIDS INFORMATION."" ·"PLEASE REVIEW IT CAREFULLY.""
NOTICE
EFFECTIVE DATE: 8/17/09
To Clients of JC Christian Counseling:

JC Christian Counseling is committed to providing the highest level of service possible to our clients as well as to abiding
by federal, state and local law (Health Insurance Portability and Accountability Act of 1996 (HIPAA). Confidentiality
between JC Christian Counseling and clients is necessary to develop the trust and confidence important for therapeutic
intervention.
With your Consent, certain Protected Health Information (PHI) may be disclosed for the purpose of carrying out treatment,
payment, or health care operations on your behalf JC Christian Counseling will disclose only the minimum amount of
information required for these purposes.
PHl that may be disclosed: Name, Address, Telephone Number, Social Security Number
Past, present, or future physical or mental health or condition, i.e., diagnosis
Dates and times of sessions
Treatment provided and progress or outcome
Past, present, or future payment for the provision of health care services
For example, PHl may be disclosed to staff of this office in the course of professional supervision to ensure appropriate and
quality treatment. PHl may be disclosed to your health insurance company to ensure reimbursement for treatment. PHl may be
disclosed to appropriate personnel to provide you with appointment confirmation. Also, with your Consent, your name, address
and phone number may be used to develop a mailing list so you may receive newsletters or materials about other related benefits
and services that may be of interest.
pm may be disclosed without your consent: a) in the event of an emergency, and after attempts have been made to contact
you; b) in the event that you might pose a threat to yourself or society; c) in the event that it is required by federal, state or local
law.
Other uses or disclosures of PHl will be made only after written Authorization has been obtained from you. You may revoke
authorization, in writing, at any time, except to the extent that JC Christian Counseling has already acted on the authorization.
In reference to pm, you have the right:
1. To request restrictions on certain uses and disclosures ofPHl, although JC Christian Counseling is not
required to agree to your requested restrictions.
2. To receive confidential communications ofPHl;
3. To inspect and copy PHl;
4. To amend PHl;
5. To obtain a paper copy of this Notice from JC Christian Counseling upon request.
JC'Christian Counseling is required by law:
1. To maintain the privacy of PHI and provide you with this Notice of its legal duties and privacy practices
with respect to PHl;
2. To abide by the terms ofthe Notice currently in effect;
3. To provide a revised Notice -- in the event that JC Christian Counseling changes its privacy practices,
which practices will apply to all PHI maintained by JC Christian Counseling -- by sending an email to you've
provided in our records the revised Notice.
You may enter a complaint to JC Christian Counseling or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated. A complaint may be filed with JC Christian Counseling by contacting in writing. JC Christian
Counseling will respond to your complaint, in writing, within two weeks of receiving your complaint. JC Christian Counseling
will not retaliate against any person for filing a complaint.

For questions concerning this Notice, please contact JC Christian Counseling by phone at 717-278-8326.

I have been notified of my rights to confidentiality, privacy (according to HlPAA) and the protection of health information.

Client Signature or Responsible Party Date