I am and/or the client is suffering from a condition that requires treatment and care.  I am requesting that SOBT Therapy, LLC provide treatment and care necessary for me or the client.  The procedure(s), treatment, and therapy to be performed and the advantages and disadvantages, risks, and potential complications, as well as alterative procedure(s), treatment(s), and therapy have been explained to me by a counselor/therapist at SOBT Therapy, LLC. I consent to the rendering of such care and additional routine related services deemed appropriate by my counselor/therapist, that may include routine diagnostic procedures and such counseling/therapy services as my and/or the client's counselor/therapist or other SOBT Therapy, LLC clinical staff consider to be necessary.

I understand that SOBT Therapy, LLC participates in practicums, internships, or other training programs for mental health professional providers; that all care rendered by these individuals will be supervised; I consent to care and treatment from individuals in training and supervision; and I consent to the review of my clinical records (by those who exercise the right to know) containing treatment by the same individuals.

I understand that no substantial procedures will be performed upon me and/or the client unless and until I have and/or the client has the opportunity to discuss the procedures and consent to same, barring emergency or unexpected circumstances. I understand that I and/or the client has the right to consent, or refuse to consent, to any proposed intervention, procedure, treatment, or test.

RESULTS ARE NOT GUARANTEED AND ACCEPTANCE OF RISK

I understand that the practice of behavioral health is not an exact science. I understand that diagnosis and treatment of my and/or the client's condition(s) involves risks, including an exacerbation or onset of symptoms resulting in injury and/or death. I acknowledge that no guarantees have been made to me and/or the client as to the results of evaluation, treatment, therapy, or any intervention at SOBT Therapy, LLC. I am and/or the client is aware of and understands the risks of injury and/or death, including relapse, that may result from my treatment, therapy, and/or interventions at SOBT Therapy, LLC. I am fully aware of and accept all such risks, I/the client wishes to proceed with treatment, therapy, and any other interventions at SOBT Therapy, LLC.

PATIENT-PROVIDER RELATIONSHIP

I understand that the patient-provider relationship is a two-way street, and that I, as the client or the client's representative, have a duty to reasonably follow orders, directives, instructions, education, and other information provided by my clinical provider at SOBT Therapy, LLC. I understand that failure to reasonably follow orders, directives, instructions, educations, and other information provided by my clinical provider at SOBT Therapy, LLC may impact the outcome of my/the client's care.

Equally, the therapeutic relationship, though intimate in nature, is a professional one.  Sexual intimacy is never appropriate.  Situations where the professional relationship has violated this mandate should be reported to the Board of Licensed Professional Counselor Examiners.

INDEPENDENT CONTRACTORS AND EMPLOYEES

I understand that the providers working at SOBT Therapy, LLC are not employees or agents of SOBT Therapy, LLC; rather, they are independent contractors who have been granted privilege of using its facilities and equipment for the care and treatment of clients. I agree that SOBT Therapy, LLC will not be liable for the acts or omissions of such independent contractors. I understand that I am/the client is not under the control of my/client's counselor and his/her/their colleagues, and because these counselors are not employees of SOBT Therapy, LLC, I agree that SOBT Therapy, LLC and its staff will not be liable for any act or omission in me/the client following the instructions of the counselors.

ADDITIONAL CARE BEYOND GENERAL SERVICES

I understand that SOBT Therapy, LLC normally provides treatment for substance use disorders and mental illnesses in an outpatient private practice setting. If I am/the client is in a condition that requires continuous additional care and treatment beyond what SOBT Therapy, LLC is able to provide, I know/the client knows it must be arranged by me/the client and I/the client agree that SOBT Therapy, LLC shall in no way be responsible for failure to provide additional clinical care or therapy or special duty care and is hereby released from any and all liabilities arising from this fact. SOBT Therapy, LLC provides outpatient 45 to 106-minute individual, couple, family and group therapy sessions and is not a crisis or emergency center.  In the event of a medical or a mental health emergency, please call 911 or go to the nearest emergency room.  If you need support outside of SOBT Therapy, LLC's office hours, you may contact the Colorado Crisis Services at 1-844-493-8255.  You may also text the word "TALK" to 38255.  The National Suicide Prevention Lifeline is also available at 1-800-273-8255 or via text at 838255.  If you are a veteran and are in crisis/need immediate support, you can find support by calling the Veterans Crisis Line at 1-800-273-8255 then pressing 1.  If in need of NON-EMERGENCY support related to a sexual assault/abuse, you can reach the Rape Abuse and Incest National Network (RAINN) at 1-800-656-HOPE.  The Gay, Lesbian, Bisexual, and Transgender Hotline at 1-888-843-4564 as well as The LGBT National Youth Talkline at 1-800-246-7743 are also available for your needs.

PERSONAL ITEMS OF VALUE

I/the client understand and agree that any personal items of value will be my/the client's responsibility upon my/the client's admission to SOBT Therapy, LLC. I/the client hereby release SOBT Therapy, LLC from loss and/or damage to my personal items of value, including, but not limited to bringing the valuable items into, and depositing the valuable items with, SOBT Therapy, LLC. Additionally, I/the client release SOBT Therapy, LLC from loss and/or damage to my personal items of value that are sent home on my behalf by SOBT Therapy, LLC. I/the client take full responsibility for any item of value left in my/the client's possession at the time of admission, and I/the client understand that SOBT Therapy, LLC is not responsible for money or personal property.

PAYMENT FOR SERVICES

I, as the client or representative of the client, agree that I obligate myself to pay the account of SOBT Therapy, LLC in accordance with the rates and terms of SOBT Therapy, LLC. All charges are due before (on the morning of) services are rendered and I waive all claims of exemption. If the account requires a collection agency or an attorney in order to receive funds due, I shall pay reasonable attorney's fees, costs, and collection expenses, whether suit is filed or not. All accounts not paid in full at the time of service may bear interest at the legal rate.  I HEREBY AGREE TO PAY ALL SUMS DUE PER SOBT Therapy, LLC's list of "Fee/Rates for Services".

INSURANCE ASSIGNMET

I, as the client or representative of the client, hereby assign to and authorize payment directly to SOBT Therapy, LLC of all benefits due to me under Medicaid, or any health insurance policy providing benefits for services rendered at SOBT Therapy, LLC. I understand that I am responsible for all charges not paid.  Those charges must be paid within thirty (30) after being billed by SOBT Therapy, LLC.  I, as the client or representative of the client, understand that SOBT Therapy, LLC files for reimbursement from my insurer as a courtesy and the failure of my insurer to make a payment does not relieve me of my obligation to pay.

INFORMATION AND MATERIALS RECEIVED

I have been given and have reviewed, or I have declined, the following information provided by SOBT Therapy, LLC: HIPAA Rights Information/Grievance & Complaint Process/Patient rights and responsibilities/Advanced Directives information

INFORMATION RELEASE

I, as the client or representative of the client, hereby authorize SOBT Therapy, LLC to disclose all or any part of my/the client's record to health care facilities to which I/the client might be transferred, to any person who needs to know the information for operations at SOBT Therapy, LLC, to any person involved in my care or treatment (including, but not limited to) any consultant or physician and their employees and staff, to the Center for Medicare & Medicaid Services, any other governmental or accrediting agency and their employees and agents, or to any entity that may be liable to SOBT Therapy, LLC, or to a family member or employer of the client for all or part of the SOBT Therapy, LLC charges. These entities include medical service companies and their agents or assigns, insurance companies and their agents or assigns, worker's compensation carriers and their agents or assigns, welfare funds (Medicaid) and applicable government agencies, the patient's employer, the patient's attorney, the personnel, officers, directors, advisors, and contractors of SOBT Therapy, LLC and any parent companies, and state licensing agencies. I understand that this consent to release information is not a condition of admission, and this consent does not extend to records concerning test results for Human Immunodeficiency Virus ("HIV"), treatment for use of drugs or alcohol or treatment relating to a mental disorder. I understand that a separate written release is required for disclosure of the above excluded records. Except as specifically waived above, I claim all rights to confidentially of patient medical records which may exist under the laws of the State of Colorado and the United States.

MAINTENANCE AND STORAGE OF MY MENTAL HEALTH RECORDS

SOBT Therapy, LLC will store and maintain your mental health record (consisting of disclosure statement, contact information, reasons for therapy, progress notes, admins/general etc.) for a period of seven (7) years after the termination of therapy or the date of our last contact, whichever is later. SOBT Therapy, LLC isn't able to guarantee a copy of your mental health record will exist after the period of seven (7) years.

SOBT Therapy, LLC will keep client information electronically on SOBT Therapy, LLC's laptop computers, desktop computers, and/or some mobile devices. In order to maintain security and protect this information, SOBT Therapy, LLC may employ the use of firewalls, antivirus software, changing passwords regularly, and encryption methods to protect computers and/or mobile devices from unauthorized access.  SOBT Therapy, LLC may also remotely wipe out data on mobile devices if the mobile device is lost, stolen, or damaged.  SOBT Therapy, LLC might use electronic backup systems such as external hard drives, thumb drives, or similar methods.  If such backup methods are used, reasonable precautions will be taken to ensure the security of this equipment and it will be locked up for storage.  SOBT Therapy, LLC uses a cloud-based service for storing or backing up information.  The cloud-based backup system SOBT Therapy, LLC uses is called CounSol and the email service provider SOBT Therapy, LLC uses is called EnGuard. 

AVAILABILITY AND RESPONSE TO MESSAGES

SOBT Therapy, LLC regularly conducts business during the hours of 9AM to 6PM on Mondays to Fridays.  Some therapists, however, have hours outside of the hours mentioned above.  Your therapist will inform you of their office hours directly.  Though SOBT Therapy, LLC has a dedicated patient coordinator/administrative assistant who works five days out of the week (Mondays to Fridays) and the providers are happy to help you with questions or concerns that you might have, it is not possible for them to be available to read/listen to emails/text messages and voicemail messages (and respond to them) as they come in or on a 24/7 basis.  SOBT Therapy, LLC's patient coordinator/administrative assistance will make every effort to return messages that are sent directly to the SOBT Therapy, LLC's main number within 24 to 48 hours and during SOBT Therapy, LLC's patient coordinator/administrative assistance's regular business hours.  Your provider will inform you directly how long your provider will take to return any messages that you leave for your provider by contacting them directly.

I have read the information contained in this form.  This information was also discussed verbally with me.  I understand and accept the information as a client or as the client's responsible party.

Your Privacy Rights as a Client

A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the protected health information SOBT Therapy, LLC has regarding you in the designated record set. There are some limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask SOBT Therapy, LLC staff for the appropriate request form.

B. Amendment of Your Record. You have the right to request that SOBT Therapy, LLC amend your protected health information.  SOBT Therapy, LLC is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. To make a request, ask SOBT Therapy, LLC staff for the appropriate request form.

C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures SOBT Therapy, LLC has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations.  In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed authorization, or disclosures made prior to July 16, 2010.  There are other exceptions that will be provided to you, should you request an accounting of disclosures. To make a request, ask SOBT Therapy, LLC staff for the appropriate request form.

D. Additional Restrictions. You have the right to request additional restrictions on the use or disclosure of your health information. SOBT Therapy, LLC does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To make a request, ask SOBT Therapy, LLC staff for the appropriate request form.

E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from SOBT Therapy, LLC by alternative means or at alternative locations. For example, if you do not want SOBT Therapy, LLC to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask SOBT Therapy, LLC staff for the appropriate request form.

F. Copy of this Notice. You have a right to obtain another copy of this notice upon request.

Additional Information

A. Privacy Laws. Mental health providers are required by state and federal law to maintain the privacy of protected health information. In addition, SOBT Therapy, LLC is required by law to provide clients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of this notice.

B. SOBT Therapy, LLC will keep and store clients' records in a secure place and in a manner that both assures that only authorized persons have access to the records and protects the confidentiality of the records and of the information contained of the records.

C. If your provider is not available to handle your records, the owner of SOBT Therapy, LLC will maintain your record by following federal and state law.  If the owner of SOBT Therapy, LLC is not able to handle your records, the owner or the owner's estate shall designate an appropriate person to handle the disposition of records for the following conditions: 1. Disability, illness or death of the professional counselor; 2. Termination of the professional counselor's practice; 3. Sale or transfer of a practice.

D. SOBT Therapy, LLC shall retain your records for a period of seven years, commencing on either the termination of professional counseling services or the date of last contact with the client, whichever is later.  In cases where the client is a child, the record shall be retained for a period of seven years commencing either upon the last day of treatment or when the child reaches eighteen years of age, whichever comes later, but in no event shall records be kept for more than twelve years. 

E. Terms of Old Notice and Changes to the Notice. SOBT Therapy, LLC is required to abide by the terms of this Notice, or any amended notice that may follow. SOBT Therapy, LLC reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When Old Notice is revised, the revised Notice will be posted in SOBT Therapy, LLC service delivery sites and will be available upon request.

F. Complaints Regarding Privacy Rights. If you believe anyone at SOBT Therapy, LLC has violated your privacy rights, you have the right to complain to SOBT Therapy, LLC's management. To file your complaint, call 303-601-2593.  It is the policy of SOBT Therapy, LLC that there will be no retaliation for your filing of such complaints. You also have the right to complain to the United States Department of Health and Human Services Regional office by sending your complaint to the Office of Civil Rights, US. Department of Health and Human Services, 1961 Stout Street Room 1426, Denver, CO 80294; (303) 844-2024; (303) 844-3439 (TTY). You may also file a formal complaint to either or both the following

agencies: Alcohol and Drug Abuse Division/Colorado Department of Human Services, 4055 S. Lowell Blvd, Bldg KA, Denver, CO 80126, Phone (303) 866-7480, and/or

DORA, 1560 Broadway, Suite 1350, Denver, CO 80202, Phone (303) 894-7800.

G. Confidentiality of Alcohol and Drug Abuse Patient Records.

1. The confidentiality of alcohol and drug abuse patient records maintained by SOBT Therapy, LLC is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:

a. The patient consent in writing,

b. The disclosure is allowed by a court order, or

c. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

2. Violation of the Federal law and regulations by a program is a crime. Suspected violation may be reported to appropriate authorities in accordance with federal regulations.

3. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

4. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. (See 42 US.c. 290dd-3 and 42 US.c. 290ee-3 for federal laws and 42 CFR Part 2 for Federal regulations).

H. Additional Information. If you desire additional information about your privacy rights at SOBT Therapy, LLC, please call 303-601-2593.  For a faster response, we encourage you to please send an email to: theoffice@sobttherapy.com