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Terms and Policy

Consent to Treat & Service Agreements

Thank you for choosing Inner Renovations Counseling. 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.  ~Chanel C. Bowen  LPC  LCAS  NCC  BC-TMH


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 Professional 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.  Evening & weekend hours available. Therapy tailored to fit your life in a safe, nonjudgmental, therapeutic environment.


Qualifications and Experience.  I hold a Master of Licensed Professional Counseling Degree from Liberty University and Bachelor of Arts in Psychology.  I am credentialed as a Licensed Clinical Addiction Specialist (LCAS-20774) with the North Carolina Substance Abuse Professional Practice Board.  With the North Carolina Board of Licensed Professional Counselors, I hold the credential - Licensed Professional Counselor (LPC-11446).  I have worked in the field of substance abuse and dual diagnosed mental health disorders since my graduate practicum and internship during which I held the credential Certified Substance Abuse Counselor-I (CSAC-20043).  I obtained the original Distance Credential Counselor (DCC) specialization by the Center for Credentialing and Education (CCE) confirming I have met nationally established web-based counseling criteria and adhere to the National Board of Certified Counselors (NBCC) Code of Ethics.  This credential was recently renamed by the same board to more accurately reflect the knowledge and services provided by those who hold the Board Certified TeleMentalHealth Provider credential.  Additionally, I am a National Certified Counselor having met national requirements of competent counseling awarded by the same board.


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.  My current Community Outreach efforts involve 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.  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 need.  An integrative approach is taken to address the needs of the Whole You and includes methods from solution-focused, cognitive-behavioral, and mind-body-spirit models.  Integrative services include: individual therapy, private yoga sessions, stress-reduction mindfulness, guided meditation and relaxation, small group therapy and small group yoga.


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.


Service Fees, Insurance for In-Office & TeleMentalHealth.  My rates for private practice are based on the reimbursement rates of the insurance company with whom I'm in network, Blue Cross Blue Shield, Cigna & Aetna. I also accept NC Medicaid for certain counties. Please verify before moving forward with services to determine if your insurance and Medicaid is accepted or if you will otherwise be Self-Pay. If you use insurance for counseling services, you are responsible for contacting your insurance company to inquire about specific coverage for mental health services.  Most insurance companies require a full assessment and diagnosis to reimburse you for counseling services.  


The initial assessment and diagnostic formulation is $200.00  

Counseling services are then $140 per hour for Individual Sessions 

$160 per hour for Family/Couples Sessions 

and $50 for Group Therapy Session.  

(Most Services Covered by Insurance. Reduced Self-Pay Rates Available Based on Need)


Each of these services typically lasts 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.


In addition to weekly appointments, 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 service which you may request of me. 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 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.  I currently practice full-time at an agency from 8:00AM to 1:00PM. So private practice appointments (individual and group therapy) are typically set between the hours of 2:00PM to 7:00PM on weekdays.  On certain occasions, weekend appointments may be arranged. This also applies to Clinical Supervision services. Many of my clients find my appointment hours very convenient because it allows them to complete their responsibilities during their work day and engage in self-care and therapy during their personal time.


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.


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.  Fees are $60 per session for Group and Individual Sessions.


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.


Inner Renovations Counseling | Chanel C. Bowen  LPC  LCAS  NCC  BC-TMH

Psychotherapy Associate of Musick Psychiatry | 136 Fairview Rd Ste 125-C | Mooresville, NC  28115

ofc 704-677-7635 | fax 980-435-0398 | cell 704-981-2569

chanelcbowen@outlook.com | InnerRenovations.com


Psychotherapy Services, Risks, and Benefits

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.


Psychotherapy has both benefits and risks. 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 my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.


Psychotherapy Appointments

Appointments will ordinarily be 60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.


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. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or 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.


Confidentiality 

My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.


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, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact Partners Behavioral Health 24/7 Crisis Line 1-888-235-4673  2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice.


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@ncblpc.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).


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 Chanel C. Bowen can be contacted at 704-981-2569 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:

Grievance forms and instructions on how to file a grievance are kept in the lobby or you can see any clinic personnel for a form.  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)


Inner Renovations Counseling | Chanel C. Bowen  LPC  LCAS  NCC  BC-TMH

Psychotherapy Associate of Musick Psychiatry | 136 Fairview Rd Ste 125-C | Mooresville, NC  28115

ofc 704-677-7635 | fax 980-435-0398 | cell 704-981-2569

chanelcbowen@outlook.com | InnerRenovations.com


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


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 (NCBLPC, 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 Acknowledgement of 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 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.

( Type Full Name )
Therapeutic Yoga Participation Liability Waiver

THERAPEUTIC YOGA PARTICIPATION LIABILITY WAIVER


I hereby acknowledge that I have been advised to consult with a physician if I am participating in therapeutic yoga workshops / group classes / individual sessions.  I, the undersigned, acknowledge that I have voluntarily chosen and requested to participate in a therapeutic yoga individual and/or group program with Chanel Bowen and Inner Renovations Counseling.  I understand that I may discontinue participation at any time and that retail fees will be applied before any refunds are given.


I am aware that I am participating in sessions, classes workshops or mentorship programs, including home practice protocols, offered by Chanel Bowen and Inner Renovations Counseling during which I will receive information and instruction about yoga, breathing, meditation and health.  I acknowledge that I am fully aware of the risks and hazards involved, which include physical and/or emotional injury. I agree to take full responsibility for my actions, and any injury that I may incur.


In consideration for being permitted to participate in therapeutic yoga sessions, classes, workshops or mentorship programs, I agree that I, my heirs, assignees, guardians and legal representatives will not make any claim against, sue or attach the property of Chanel Bowen and Inner Renovations Counseling, employees, partners or other clinicians for injury or damage resulting from my participation in these activities.


I acknowledge that I may receive works of authorship by Chanel Bowen and Inner Renovations Counseling resulting from my participation in or attendance of individual sessions, classes, workshops and mentorship programs. I acknowledge these works, including written or audio materials, are the exclusive intellectual property of Chanel Bowen and Inner Renovations Counseling. I agree not to copy them, distribute them or copies of them or prepare derivatives from them.


I have carefully read this agreement and fully understand its contents. I have signed this release freely and voluntarily. I am aware and agree that it is a complete release of liability for any injuries or damages I may sustain due to individual sessions, classes, workshops and mentorship programs with Chanel Bowen and Inner Renovations Counseling.

( Type Full Name )
Informed Consent for Client Portal & TeleMentalHealth Services

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 IR 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, Contact 911 and Partners Behavioral Health 24/7 Crisis Hotline 1-888-235-HOPE (4673)


Client Acknowledgement of Notice and Informed 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 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.


I understand that I have the right to withhold or withdraw my consent to the use of TeleMentalHealth in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Chanel Bowen and InnerRenovations Counseling at 704-981-2569 or 136 Fairview Road Suite 125-C, Mooresville, NC 28117. As long as this consent is active (has not been revoked) Chanel Bowen and InnerRenovations Counseling may provider mental health care services to me via TeleMentalHealth without the need for me to sign another consent form.

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( Type Full Name )