Thank you for choosing Inner Renovations Counseling, PLLC. Please review the Professional Disclosure Statement, Client Rights, Privacy Policy, Emergency Protocol, & Other Service Descriptions contained in this Informed Consent.  You will be prompted for your electronic signature to submit this form to consent to treatment. This, along with initial assessment questions must be completed before the first session. Please contact me if you have any questions.  ~ Chanel C. Bowen  LCMHC  LCAS  CCS  NCC 

NC LICENSED MH/SA PROVIDER PROFESSIONAL DISCLOSURE STATEMENT

Theoretical Orientation.  I combine clinical skill with compassion to help people of diverse backgrounds Reclaim their Joy. Providing Faith-Forward Counseling and Therapeutic Yoga, I help navigate unique situations to restore mind, body, spirit balance.  With professional guidance, clients engage in a "Personal Inner Renovations Project" to work towards lasting change and transformation from the inside out. Licensed by both the NC Board of Licensed Clinical Mental Health Counselors and the NC Substance Abuse Professional Practice Board, I'm trained in mindfulness-based methods that address co-occurring Mental Health and Substance Use Disorders.  I work from a Cognitive-Behavioral framework with a specialization in Dialectical Behavior Skills Training to help you develop a toolbox of skills to reduce stress and anxiety, manage strong emotions and symptoms of depression. You'll organize your thoughts in a way that improves how you feel and interact with life.

You Will Learn Distress Tolerance, Interpersonal Effectiveness, Mindfulness, and Emotion Regulation Skills.  Combine Counseling & Therapeutic Yoga, or choose one that's right for you. Options for video eCounseling and sessions at my Lake Norman office.  

Qualifications and Experience.  I hold a Master's Degree in Licensed Professional Counseling from Liberty University (April, 2014) and a Bachelor's Degree in Psychology (May, 2010).  I am credentialed as a Licensed Clinical Addiction Specialist (LCAS-20774) with the North Carolina Addiction Specialist Professional Practice Board.  With the North Carolina Board of Licensed Clinical Mental Health Counselors, I hold the credential - Licensed Clinical Mental Health Counselor (11446), since 03/12/2015.  I have worked in the field of substance use and dual diagnosed mental health disorders for the past seven years, since my graduate practicum and internship in May 2013 during which I held the credential Certified Substance Abuse Counselor Intern (CSAC-20043).  I am a National Certified Counselor (NCC-794175) credentialed by the Center for Credentialing and Education (CCE) confirming I have met nationally established and adhere to the National Board of Certified Counselors (NBCC) Code of Ethics. As a Certified Clinical Supervisor (CCS-20807) credentialed by the NC Addiction Specialist Professional Practice Board, I supervise interns and professionals in the substance use field. By providing individual and group supervision based on knowledge of the performance domains, we focus on the treatment, prevention, and reduction of conditions and symptoms of substance use disorder as it is my role to ensure that industry standards, state and federal guidelines, and ethical, best practices are being adhered to.

Dual-Licensed for Co-Occurring Disorder Treatment.  In addition to licensed mental health counseling, I have a specialization in working with individuals with various substance use disorders/addiction behaviors. They often have co-occurring mental health conditions which trigger substance abuse as they attempt to self-medicate symptoms and cope with stressors.  This ignited my passion to provide alternative and unique services such as Yoga to teach new ways of managing and overcoming MH/SA symptoms. I have been Program Coordinator of Level 2.1 Intensive Outpatient Programs, working closely with individuals whose substance use and risky behaviors have taken over their lives. I provide services to address disordered thinking and develop the skills to help reestablish oneself as a healthy and fulfilled adult.  Community Outreach efforts have involved coordination with NCDHHS and local agencies to implement and sustain SAMHSA-sponsored Substance Abuse Treatment opportunities in the state-targeted response to the Opioid/Opiate Epidemic and Prescription Pain Pill Addiction Public Health Crisis. I reach out to underserved populations to increase community awareness of treatment options.  I believe all people deserve access to mental health and/or substance abuse services and opportunities to improve life quality.

Psychotherapist in Private Practice - Inner Renovations Counseling, PLLC.  A Person-Centered approach is taken to ensure that treatment planning is individualized.  I encourage self-examination and reflection so that you can identify your own beliefs and behaviors that help versus hinder your personal success.  As we work together, the counseling relationship progresses and more of your unique needs are discovered.  We tailor your treatment by providing the services and mode of delivery that are relevant to your present needs.  I integrate Cognitive-Behavioral methods to equip clients with a toolbox of skills such as Core Mindfulness, Emotion Regulation, Distress Tolerance, and Interpersonal Effectiveness in our efforts to improve thoughts, feelings, and behaviors. Integrative services include: individual therapy, private yoga sessions, stress-reduction and relaxation training, and guided meditation.  We determine if Therapeutic Yoga is appropriate for your treatment needs based on medical history and group therapy is offered when there are enough voluntary participants.  A faith-based approach follows evidence-based tenets that believing in a power greater than oneself increases likelihood of sustained recovery efforts. There is no discrimination on the basis of religion or imposition of the same, and comprehensive clinical services are provided to clients of all backgrounds and belief systems.

Yoga for Behavioral Health Practitioner.  My professional training of Yoga for Behavioral Health began with Subtle Yoga Founder, Kristin Kaoverii Weber.  Teamed with MAHEC Department of Mental Health Education, I receive ongoing training for Behavioral Health Professionals who incorporate evidence-based yoga and mindfulness practices into therapeutic services. In addition to over 15 years of a personal yoga practice, advanced training continues with Davidson Yoga Therapy Director, Samantha Leonard, to apply yogic techniques as coping skills, stress relief, and symptom management of mental health, chronic pain, and supported medical conditions.

Private-Pay Service Fees for In-Office & TeleMentalHealth Services.  Inner Renovations Counseling, PLLC and Chanel C. Bowen, LCMHC, LCAS, CCS provide services out-of-network and operate under the private-pay model.  Clients pay the full service rate at time of treatment (*see Private Pay Exceptions).  If you have private insurance, you may opt to use your benefits by submitting your own claims for reimbursement with your insurance company if your plan includes out-of-network benefits.  Provider may offer options to use your insurance via Alma Membership (insurance claims and billing managed for Cigna, Aetna, UnitedHealthCare+), granting your benefits can be verified and you approve their service to process your claims at no additional cost to you.  For non-Alma, VA, or EAP clients, the following rates apply.

Rates to be paid at time of service unless otherwise discussed/agreed upon by provider are as follows:

$200.00    Initial Assessment / Diagnostic Formulation

$150.00    Individual Counseling / Therapeutic Yoga - 60 minutes

$125.00    Individual Counseling / Therapeutic Yoga - 45 minutes

$100.00    Individual Counseling / Therapeutic Yoga - 30 minutes

$65.00      Group Therapy - 60 minutes

Rates for TeleMentalHealth Services are the same as In-Office Visits.  Clients have the option of having counseling in traditional office setting or via video conference through secure web-based application. Web-based services and methods of encryption meet the highest standards of HIPAA-Compliance with Business Agreements with all third-party systems.

Reimbursement for Insurance Claims, Veterans Affairs and Alma Member Referral

Inner Renovations Counseling, PLLC and Chanel C. Bowen, LCMHC, LCAS, CCS (The Practice) provide services to clients with or without insurance benefits.  For those with benefits, it is the client's responsibility to seek reimbursement from their private insurance carrier using the receipt obtained after full payment is made at time of service.  The Practice connects clients with an optional user-friendly application that assists in seeking reimbursement of out-of-network benefits if included in their plan.  Clients must contact their own insurance carrier to verify if they have out-of-network benefits and for complete details on the best way to receive direct payment.  The aforementioned does not include Medicaid or Medicare, neither of which is accepted at this time.

* Private Pay Exceptions:

Community & Veteran's Affairs Referrals.  The Practice believes in community involvement and providing services to military-connected individuals in need of mental health and substance use treatment.  Referrals are accepted from the U.S. Veteran's Affairs agency wherein provider may be reimbursed by client's benefits based on pre-authorization.

Alma Referrals.  As a member of Alma, Chanel C. Bowen, LCMHC, LCAS, CCS accepts referrals from participants of their program, which includes the use and processing of private insurance completed by their internal team.  Alma clients are invoiced through the Alma portal, and any fees not covered by their program are due to be paid directly to The Practice at time of service.

Employee Assistance Programs.  The Practice may partner with companies to provide services to employees in need of brief treatment options based on provider availability, client's benefits, and pre-authorization.  Participants of Employee Assistance Programs receive services for the initial number of authorized sessions and should be prepared to transition to a private pay client if opting to continue services beyond what is initially authorized.

Clinical Supervision Services.  I provide supervision services for counselors that are working towards Certified Substance Abuse Counselor and Licensed Clinical Addiction Specialist credentials with the NC Substance Abuse Professional Practice Board.  Observation of counselor's skills is accomplished by audio, video, or in person.  Clients must be notified and consent obtained for audio and video recordings which are destroyed after observation complete.  Supervision sessions are typically 60 minutes long and focus on acquiring full licensure, 12 core functions of substance abuse treatment, DSM-V Diagnosis and ASAM placement criteria, development of counseling skills and exam preparation.  

$65.00     Group Supervision (per session)

$100.00   Individual Supervision (per session)

Client Requests for Additional Professional Time and Services.  If a client requests services in addition to standard therapeutic services rendered, fees may be assessed. Depending on frequency of need and service, clients may be charged a prorated individual therapy session for other professional services that are requested. Such requests include but are not limited to: providing written reports, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other such service that would otherwise be scheduled appointment time.  If you anticipate you will request that I become involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality or enter into service agreement with me. I do not make it a practice to testify on behalf of clients unless required to do so by court order. If your case requires my participation as your therapist, you will be expected to pay per hour for the professional time even if court ordered on behalf of other parties. 

Use of Diagnosis.  Depending on the health insurance company, it is possible that a diagnosis of a mental health condition is requested by the company before reimbursing for counseling services.  It is important to note that not all concerns for which people seek counseling qualify for reimbursement.  Any diagnosis that is made becomes a permanent part of your insurance records.

Office Hours.  

MONDAY - THURSDAY       9:00AM   - 6:00PM

FRIDAY                            9:00AM  - 12:00PM

SATURDAY - SUNDAY        CLOSED  

Appointment Scheduling.  In-Office and TeleMentalHealth appointments are available. Clients can contact the office to schedule appointments or schedule them on their own using the Secure Client Portal with their assigned login and password.  On certain occasions, weekend appointments may be arranged. This also applies to Clinical Supervision services.

Cancellation Policy.  If you are a no-show for your scheduled therapy session, and did not notify counselor at least 24 hours in advance, you may be invoiced for half the cost of your scheduled session. If there are more than 3 no-shows without contacting counselor, you are discharged from services due to lack of engagement.  There may be no further notification from the practice as your lack of attendance would be considered voluntary self-termination from counseling services.

Confidentiality.  One of the greatest factors of the therapeutic relationship is comfort in knowing that what you share with me will be honored, respected, and only used for the purpose of helping you discover more about yourself and helping you move towards your goals.  Our consultations and information provided is kept confidential, but is documented after each session in my Service Notes and becomes a part of your clinical record which is accessible to you at your request.  There are certain limitations to confidentiality such as  (a) you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.

Psychotherapy has both benefits and risks.  Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life.  However, psychotherapy has been shown to have benefits for individuals who undertake it.  Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  But, there are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

Comprehensive Assessment & Treatment Planning.  The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about the diagnoses, treatment plan, or methods, we should discuss them whenever they arise. If at any time you feel a change is needed, I can assist in coordinating a referral to another mental health professional for a second opinion.

Professional Records.  I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. A third party professional biller who helps with claims and payments as applicable may access client information in order to complete financial aspects of services.  Appropriate Business Associate Agreements are maintained with such professional service providers and all laws of confidentiality and HIPAA compliance apply. 

Except in unusual circumstances wherein a client may be a danger to themselves, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted, confusing, and potentially upsetting to untrained readers.  For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Parents & Minors.  While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child's agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. 

Contact and Availability.  I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible.  If you feel unable to keep yourself safe, 1) call 911 and ask to speak to a mental health professional on call, 2) go to your Local Hospital Emergency Room, or 3) contact a 24/7 helpline and speak with a live person such as the National Suicide Prevention Lifeline at 1-800-273-TALK.  I will make every attempt to inform you in advance of planned absences. You may call the main number 980-888-8284 and select Option 6 for my 24/7 Answering Service that can relay emergency messages to me at any time.

Other Rights.  If you are unhappy with anything happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

Complaints.  Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organizations below should you feel I am in violation of any of these codes of ethics.  I abide by the ACA Code of Ethics (http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx)

North Carolina Board of Licensed Professional Counselors

PO Box 7781 | Greensboro, NC 27417

Phone: 844.622.3572

Fax: 336.217.9450

E-mail: Complaints@ncbLCMHC.org

North Carolina Substance Abuse Professional Practice Board

P.O. Box 10126 | Raleigh, NC 27605

Phone:  919-832-0975

Fax: 919-833-5743

EMERGENCY & CRISIS SITUATIONS

Online or text communication methods should NOT be used in cases of emergencies.  You should contact 911 for emergencies that require immediate first-responder intervention. 

For behavioral health crises, call Partners Behavioral Health 24/7 Crisis Hotline

1-888-235-HOPE (4673).

Counselor After Hours

980-888-8284 x6

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to: 
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated

Your choices in the way that we use and share information:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and share your information, raise funds

Our Uses and Disclosures

- Provide treatment to you and coordinate with other providers
- Engage in inter-office exchanges of client status
- Interact with insurance or other agencies to bill for your services
- Help with public health and safety issues
- Comply with the law if there is a court order
- Mandatory report abuse, harm to self or others

Compliance Officer Vernon J. Bowen can be contacted at 980-888-8284 Opt 5 for assistance.

CLIENTS RIGHTS & GRIEVANCE POLICY

Client Rights:

I understand my basic rights as a client. These rights include:

The right to receive care suited to your needs

The right to receive services that respect your dignity and protect your health and safety

The right to be informed of the benefits and risks of your treatment

The right to participate in planning your own treatment, as able

The right to be promptly and fully informed of any changes in the plan of treatment

The right to accept or refuse treatment

The right to prompt and confidential treatment

The right to exercise all civil, political, personal and property rights to which you are entitled as a citizen.

The right to be free of physical or verbal abuse

The right to review your chart with staff supervision

The right to file a complaint, without fear of discrimination or retaliation, if you think these rights have been restricted or denied & to have them investigated by the program within a reasonable period of time

The right to receive a written notice of the address and telephone number of the state licensing authority

The right to obtain a copy of the program's most recent completed report of licensing inspection from the program upon written request

Grievance Policy:

I understand that if I have a complaint/grievance, I should:

Request a grievance form and instructions on how to file from the Compliance Officer or from the Practitioner.  All grievances will be addressed and responded to within one week of submission.  Appeals can be made to the Disability Rights North Carolina Protection and Advocacy for Persons with Disabilities at 1-877-235-4210.  This is the Agency designated under federal and state law to protect and advocate the rights of persons with disabilities.

I understand that I have a right to contact the agencies below at any time to discuss my complaint/grievance:

Partners Behavioral Healthcare | www.PartnersBHM.com | Toll free 24 hours/day 7 days/Week Access

1-888-235-4673    TTY 1-800-749-6099

Corporate Office                Elkin Regional Office                Hickory Regional Office                              

901 S. New Hope Rd            200 Elkin Business Park Dr.        1985 Tate Blvd., Suite 259

Gastonia, NC 28054             Elkin, NC 28621                        Hickory, NC 28602

704-884-2501                      336-835-1000                           828-327-2595

North Carolina Division of Mental Health / Developmental Disabilities / Substance Abuse Services

www.ncdhhs.gov/mhddsas

Advocacy and Customer Service Section: 919-715-3197

Judy Beavers-judy.beavers@dhhs.nc.gov

Disability Rights North Carolina: Formerly Governor's Advocacy Council for Persons with Disabilities (GACPD)

Address : 2626 Glenwood Avenue Suite 550, Raleigh, NC   27608

Telephone: Voice (919) 856-2195 Toll Free Voice (877) 235-4210, TTY 888-268-5535

Fax: (919) 856-2244

Email: info@disabilityrightsnc.org

DHHS CARE-LINE: 1-800-662-7030 (Voice/Spanish)

CONSENT TO TREAT | OUTPATIENT PSYCHOTHERAPY | MH AND/OR SA

Inner Renovations Counseling, PLLC

Chanel C. Bowen  LCMHC  LCAS  CCS  NCC  RYT

18135 W Catawba Ave  |  Cornelius, NC  28031

ofc  980-888-8284| fax 704-765-4675

chanelcbowen@outlook.com | InnerRenovations.com

The Privacy Policy, Emergency Contact Protocol, Fee Schedule, Clients Rights, Limitations of Confidentiality and Service Descriptions have been provided as a part of Informed Consent and Service Agreement. By moving forward with counseling and other services, you acknowledge that you understand the information discussed and provided and agree to the same.

You understand that you have the right to express grievance and have your issues reviewed internally and by governing agencies who monitor and protect the rights of patients while ensuring service providers do no harm. Additionally, you are provided with Professional Disclosure Statement and Informed Consent that is specific to Counselor's Licensing Boards (NCBLCMHC, NCSAPPB, and NBCC) which contains contact information of the same. Counselor provides services and operates within the bounds of the ethics, statutes, best-practices, and laws of the aforementioned governing bodies to deliver competent and quality counseling services and you understand that appropriate referral can be made as to not operate outside of the scope of counselor's expertise. You understand that either party can terminate this service contract at any time if appropriate termination is accomplished. You agree to take a cooperative part in the therapeutic process, acting within the best interest of your health and well-being.

CLIENT FINANCIAL AGREEMENT

1.    Valid Form of ID and Payment Method required on file.  A) Take a digital photo of the front and back of your identification card and upload it via the Secure Client Portal as prompted.  B) Add a form of payment to be saved on file; charged for amount due on day of service.  C) Visa, MasterCard, Discover, American Express accepted; if opting to pay with cash or money order day of service, your card on file is not charged.

2.    Private-Pay Service Fees for In-Office & TeleMentalHealth.  Inner Renovations Counseling, PLLC and Chanel C. Bowen, LCMHC, LCAS, CCS provide services out-of-network and operate under the private-pay model, which means private insurance is not accepted and billed by the practice.  Clients pay the full service rate at time of treatment.  If you have private insurance, you may opt to submit your own claims for reimbursement with your insurance company if your plan includes out-of-network benefits.  

3.    Rates to be paid at time of service unless otherwise discussed/agreed upon by provider are as follows:

$200.00    Initial Assessment / Diagnostic Formulation

$150.00    Individual & Family Counseling / Therapeutic Yoga - 60 minutes

$125.00    Individual & Family Counseling / Therapeutic Yoga - 45 minutes

$100.00    Individual & Family Counseling / Therapeutic Yoga - 30 minutes

$65.00      Group Therapy - 60 minutes

Rates for TeleMentalHealth Services are the same as In-Office Visits.

4.    No-Show / Cancellation Fee.  Appointments can be cancelled or rescheduled on your own via the Secure Client Portal or by calling 980-888-8284.  If we are not notified at least 24 hours in advance, your card on file may be charged a $25.00 no-show/cancellation fee, or added to your account balance for payment before your next session.  More than 2 consecutive no-show or last minute cancellations of any client may result in discharge from services due to lack of engagement.

5.    Full payment is due at the time services are rendered.  Exceptions as indicated in detail in the Informed Consent | Professional Disclosure document include: U.S. Veteran's Affairs, Alma Referrals (responsible day of service for fees not covered under program), and Employee Assistance Program participants (must transition to private-pay client after initial authorization period ends in order to continue services).

6.     Forms & Fees: There is a $15 fee for completing FMLA, sick leave, AFLAC, disability, and other such forms. This fee must be paid before the forms are completed. There is also a $5 fee each time records/forms must be faxed/mailed to other entities on your behalf. It is client's responsibility to disclose if you are involved in such a process and whether these forms will be required to be completed as a part of your participation in services PRIOR to entering treatment.  Failure to do so may result in inability to fulfill requests. Please note, standard time for records requests to be fulfilled is 7-10 business days.

7.     Registration: All clients must complete the registration information form, which will be entered into our HIPAA-compliant electronic records system to maintain accurate information. We must obtain a copy of your driver's license and have a valid payment card on file.

8.    Financial Hardship: A discount can be offered to our clients that prove financial hardship with completion of appropriate forms. Please be advised discounts are only valid when the charges are paid at the time of service. If the charges are not paid at the time of service, the discount will be removed and payment of the full charge will be expected before the next visit. If a balance remains, you will receive a monthly statement that is due upon receipt. 

9.    Credit and collection: Any account balance over 90 days will be subject to review for collection action. Partial payments will not be accepted unless otherwise negotiated. If an account is sent to collection, it is the policy of this office to discharge the patient and possibly immediate family members from the practice. You will at that time be notified by regular and certified mail that you will have 30 days to find alternative care. During that 30-day period provider will be able to treat you only on an emergency basis.

10. Phone management fee: There will be a $20 charge for managing symptoms, coordinating care, and attending to needs by phone if the length and content of call is beyond brief and general inquiry, but does not meet criteria for counseling session. The phone management fee must be paid at time of receipt of invoice.

FINANCIAL POLICY 

ADDENDUM A:  Court Fees, Legal Tasks and Appearances

The purpose of this addendum to the Inner Renovations Counseling, PLLC | Chanel C. Bowen, LCMHC, LCAS, CCS (The Practice & Provider) Financial Policy is to explain fees associated with letters, court appearances, and other such documentation/services that may be requested by/for clients involved with the legal system (i.e., court-ordered treatment, subpoenas and court orders for records and/or appearance, custody/separation/divorce matters, disability claims, criminal and civil cases, etc).

It is the responsibility of the client to inform The Practice & Provider of involvement in legal matters prior to the first session to be included in assessment of needs.  If legal matters arise during episode of care, The Practice & Provider must be informed as soon as possible for reassessment of needs. Continuation of services is at the discretion of The Practice & Provider based on needs assessment, legal requirements, resources and availability. Appropriate referral will be made in the event The Practice & Provider are unable to accommodate requests or complete services that are not court-ordered.

If Inner Renovations Counseling, PLLC | Chanel C. Bowen, LCMHC, LCAS, CCS is involved in client legal matters, the client is responsible for fees as outlined in this addendum in addition to standard service fees outlined in Financial Policy.  For clients involved in legal matters, it is your responsibility to inform The Practice & Provider prior to the first session or as early as you are aware of your involvement in a legal matter.  Client must acknowledge, consent, and sign understanding of the following:

- Chanel C. Bowen, LCMHC, LCAS, CCS (The Provider) is not a court appointed evaluator, mediator, or representative for child custody, separation, divorce or other family matters and cannot determine or recommend arrangements for the same.

-  The Provider's records or testimony may not solely be in your favor or best interest.

-  The Provider can only confirm and testify to facts and provide professional opinion.

If The Provider's records and/or participation are requested or required the following assumptions are made:

       - You would like me to present as a fact witness and/or expert witness

       - You and/or legal representatives are requesting/requiring my professional opinions or confirmation of facts on one or more specific areas related to counseling and/or psychology as it pertains to your case.

      - A substantial block of my time is required, including: preparation, time required out of my office, unavailability to provide services to other clients during that time, travel, and other related tasks.

My practice is not currently positioned for me to fulfill legal requests and provide these services pro bono. Should client or legal representatives require my presence in court, preparation and submission of records, or other tasks related to their legal matters, 

fee structure is as follows:

RETAINER:  A retainer of $1500.00 is due in advance if counselor is required to participate in client legal matters and proceedings.  If a subpoena or notice to meet attorney(s) or appear in court is received without a minimum of 72-hour notice, there is an additional $250.00 "Express" charge.  Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500.00 (in addition to the retainer of $1500.00).

COURT APPEARANCE: Minimum charge for a court appearance is $1500.00 (covered by retainer), does not include additional following fees:

o   DEPOSITIONS:  $200/hour

o   TIME IN TESTIMONY:  $200/hour

o   TIME AWAY FROM OFFICE DUE TO CLIENT LEGAL MATTERS:  $200.00/hour

o   LEGAL-RELATED PHONE CALLS:  $150/hour

o   PREPARATION TIME (including submission of records):  $150.00/hour

o   ALL ATTORNEY FEES & COSTS incurred by The Practice & Provider as a result of legal action.

o   FILING DOCUMENT WITH COURT:  $100.00/document

o   LETTERS TO A 3RD PARTY:  $30.00/letter (in addition to preparation time)

o   MILEAGE:  $0.40/mile

If you have any questions about the financial policy, please reach out as soon as possible to be assisted with your needs so that you can focus on treatment and reaching your mental health goals. Contact 980-888-8284 with questions or concerns or email wecare@innerrenovations.com

CLIENT BEST PRACTICE FOR ELECTRONIC HEALTH RECORD AND IDENTITY SAFETY

Clients records are encrypted and secured in our electronic records and web-based applications in the delivery of services. However, you express agreement that the above Service Provider is not responsible for data exposure that occurs as a result of client not sufficiently protecting their own personal information while using TMH Services and the Inner Renovations Counseling, PLLC, Client Portal.  Reduce and avoid exposing private information by following these and other best-practices to protect your information:  select complex username and passwords with alphanumeric and symbol combinations, do not share your login information with anyone, use lock codes on devices so others are unable to access, turn off screens and devices when not in use, schedule therapy for times when you will have maximum privacy, keep information in a safe place, notify administrators if you need password resets in the event your data has been compromised.  By signing this document, you express your understanding and acceptance of best practices to protect your identity while receiving TMH services.

Secure Client Portal allows for additional services and online access to resources such as:

1. Online Journal accessible in between sessions so that you may keep track of your feelings and experiences to be addressed at your next session.  

2. Ability to send secure messages via the Client Portal if general support is needed in between sessions.

3. Request or Reschedule Appointments online and receive email reminders of upcoming sessions.

4. Receive Resources, Handouts and Homework from counselor via your portal, as well as send material to counselor in the same manner.

5. Complete Assessments, Treatment Consents, and Other Forms that are safely transferred and stored in your Electronic Records connected to your Secure Client Account.

A part of our work together will include setting and honoring healthy boundaries. Clients that are unable to maintain healthy boundaries while accessing Portal Services (i.e. making multiple requests or seemingly being in crises that require daily intervention and support) may be referred for higher level of care services if it is determined that client needs may exceed what can be supported via eCounseling, and/or it is determined that client require more than what is offered in my 1-2 counseling sessions per week modality.

Please Note: Client Portal Communication method should NOT be used in cases of emergencies.

For emergencies:  1) call 911 and ask to speak to a mental health professional on call, 2) go to your Local Hospital Emergency Room, 3) contact a 24/7 helpline and speak with a live person such as the National Suicide Prevention Lifeline at 1-800-273-TALK. You may call the main number 980-888-8284 and select Option 6 for my 24/7 Answering Service that can relay emergency messages to me at any time.

TELEMENTALHEALTH INFORMED CONSENT

As a client receiving behavioral services through TeleMentalHealth technologies with Inner Renovations Counseling, PLLC, I understand:

Introduction of TeleMentalHealth:

      TeleMentalHealth is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client who are not in the same physical location. 

      The interactive technologies used in TeleMentalHealth incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. 

Software Security Protocols: 

      Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. 

Benefits & Limitations: 

      This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face to face communication. There are benefits and limitations to this service. 

Technology Requirements: 

      I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. 

Exchange of Information: 

      The exchange of information may not be direct and any paperwork exchanged will likely be provided through electronic means if I am not meeting with practitioner in physical office location.

      During my TeleMentalHealth consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology. 

Local Practitioners: 

      If a need for direct, in-person services arises, it is my responsibility to contact practitioners in my area or to contact my behavioral practitioner's office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office. 

Self-Termination:

      I may decline any TeleMentalHealth services at any time without jeopardizing my access to future care, services, and benefits. 

Risks of Technology: 

      These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. 

Modification Plan: 

      My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed. 

Emergency Protocol: 

      In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other   means.  

      In emergency situations I will contact 911 in the event there is a medical or other emergency that requires immediate response.

      I will contact Partners Behavioral Health 24/7 Crisis Hotline 1-888-235-HOPE (4673) for mental health crisis.

      I will understand that my practitioner can be reached via 24 Hour Answering Service at 980-888-8284 x6 if not available during regular business hours at 980-888-8284 x1.

      I will contact my Emergency Support Person (Family / Friends) Identified in my Electronic Records and give permission for my practitioner to do the same.

Disruption of Service: 

      Should service be disrupted during a video TeleMentalHealth session, practitioner can be called at 704-981-2569.  

      For other communication, the text messaging feature in the video application can be used for further instruction on how to proceed with the counseling session and/or for rescheduling information as needed.

Practitioner Communication: 

      My practitioner may utilize various means of communication in the different circumstances.

      Messages regarding my treatment or containing Private Health Information will be sent via Secure Client Portal.

      General Practice Information and Updates may be sent to the email address on file, with my ability to opt-out.

      Practitioner may contact client by phone when information needs to be discussed regarding treatment, scheduling, billing, or for wellness check.

      My practitioner will respond to communications and routine messages within 1-2 business days.

Client Communication: 

      It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications. 

      I will take the necessary precautions to ensure that my communications are directed only to my practitioner or other designated individual(s).

      I must properly store communication exchanged with my practitioner using password protection and secure devices.

Laws & Standards: 

      The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent. 

Client Acknowledgement of Informed Consent

CONSENT TO TREAT & SERVICE AGREEMENT

I, the client, confirm that I have received all aforementioned documents and hereby enter into service agreement and contract with Inner Renovations Counseling, PLLC and Chanel C. Bowen for assessment, treatment planning, psychotherapy and other therapeutic services and understand my rights as a client.  I understand that I have the right to withdraw consent at any time by providing a written request to the treating clinician.  This consent to treatment expires in 12 months from date of signature unless otherwise specified.  My signature below indicates that I have Read, Understand, and Agree to the Services and Terms contained within this Informed Consent and voluntarily begin services.

CRISIS & EMERGENCY CONTACT CONSENT

I, the client, hereby authorize Inner Renovations Counseling, PLLC and Chanel C. Bowen to release or receive specified information in and from my records via oral and written communication as needed in the event of crises. I acknowledge at the discretion of the provider, missed sessions without contact may result in a welfare check by way of provider initiating phone call to my identified Emergency Contact to ensure my safety.  Crisis-related information may be delivered and received by my identified Emergency Contacts (family member, legal guardian, et al.) as well as Any Crises Responders, including, but not limited to First Responders, Mobile Crisis Teams, Peer Support Specialist, Law Enforcement, Primary Care Providers, Residential Providers, LME-MCO personnel and care coordinators, EMS Workers and Other Medical personnel.

ACKNOWLEDGMENT OF FINANCIAL POLICY & ADDENDUM A

I, the undersigned client, understand my financial responsibility for services rendered by The Provider.  I have read and understand this policy and that the practice requires my signature and I agree to be bound by its terms. I understand I may ask for a copy of this policy which I signed. I also understand and agree that such terms may be amended by the practice on an annual basis.

AUTHORIZATION FOR RELEASE OF INFORMATION TO PAYORS AS APPLICABLE

I, the undersigned client, authorize the release of any medical or other information necessary to process claims as applicable, I also request payment of private and/or government benefits either to myself or to the party who accepts assignment.  I hereby irrevocably assign and transfer to Chanel C. Bowen operating as private practice Inner Renovations Counseling, PLLC [hereinafter referred to as The Provider], all rights, title, and interest in the benefits payable for services rendered by the same, provided in any insurance policy(ies) under which I am insured.  Said irrevocable assignment and transfer shall be for the purpose of granting The Provider an independent right of recovery on said policy(ies) of insurance but shall not be constructed to be an obligation of The Provider to pursue any such right of recovery.  

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ACKNOWLEDGEMENT OF EHR/IDENTITY SAFETY & CONSENT TO RECEIVE TMH SERVICES

I understand that TeleMentalHealth is the use of electronic information and communication technologies by a mental health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Chanel Bowen and InnerRenovations Counseling, PLLC providing mental health care services to me via TeleMentalHealth.  I understand that the laws that protect privacy and the confidentiality of medical and mental health information also apply to TeleMentalHealth. I understand, as always, my insurance carrier will have access to my medical / mental health records for quality review/audit. I understand that I will be responsible for any payments, copayments or coinsurances that apply to my TeleMentalHealth visit.

SIGNATURE ACKNOWLEDGMENT OF COMBINED INFORMED CONSENT

I, the client, confirm that I have received all aforementioned documents and hereby enter into service agreement and contract with Inner Renovations Counseling, PLLC and Chanel C. Bowen, LCMHCS, LCAS, CCS for assessment, treatment planning, psychotherapy and other therapeutic services and understand my rights as a client.  I may revoke my consent orally or in writing at any time by contacting Chanel Bowen and InnerRenovations Counseling, PLLC at 980-888-8284 or 18135 W Catawba Ave., Cornelius, NC  28031. As long as this consent is active (has not been revoked) Chanel Bowen and InnerRenovations Counseling, PLLC service professionals may provide mental health care services to me at the local office and via TeleMentalHealth without the need for me to sign another consent form.

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