We/I give consent for Carolina Healthy Hearts & Minds, PLLC (CHHM) to provide services to myself/ my child/ my ward.

 

We/I will participate in Outpatient Therapy Services and follow all treatment recommendations which address identified goals on my person-centered plan that I will work towards in time frames and methods to achieve the goals.

 

CHHM services have been described and we/I understand that my CHHM workers help provide services that will help me reach my goals, if necessary and agreed upon by all parties involved.

 

We/I have been explained the benefits, risks and alternatives to planned services and the ways that CHHM can support the achievements of the desired outcomes.

 

Any fees or costs have been explained to us/me.

Individual counseling private pay: $140/ session

Couples counseling: $175/ session

EAP sessions available upon approval/authorization

Late cancellation Fee: $65 responsibility of client

All payments are due on the date of services and bills must be paid within 90 days or client will be discharged from treatment.

 

In Network Insurances:

BCBS

Cigna

United Health Care

Medcost

Aetna

Tricare

CBHA (Carolina Behavioral Health- Atrium)

Consumer Rights

As a consumer of this program, you have certain rights, which are set out in the Rules and Regulations to assure the rights of consumers in North Carolina. A summary of your rights is set out below.

 

RIGHT TO NOTIFICATION

You must be informed of your rights every year (12 months) while in the program, and you have the right to see and get a copy of the NC Regulations and the Policy upon request. Also, you must be told what the program’s rules of conduct are, and you have a right to have a copy.

 

RIGHT TO DIGNITY

You have the right to be treated with respect and dignity at all times. You have the right to be called by your preferred or legal name, to be protected from abuse, and to request help in applying for services or benefits for which you are eligible.

 

RIGHT TO SERVICE

You have the right to receive services within Carolina Healthy Hearts& Minds, PLLC mission, capacity and applicable laws and regulations. Carolina Healthy Hearts & Minds, PLLC cannot deny services to you solely on the basis of your race, national origin, sex, age, religion, sexual preference, human immunodeficiency virus status, handicap, or ability to pay. If you think Carolina Healthy Hearts & Minds, PLLC has discriminated against you, you can contact any program employee, the owner of Carolina Healthy Hearts & Minds, PLLC, or the County’s Consumer Representative.

 

RIGHT TO QUALITY SERVICE

You have the right to receive services in a manner that is non-coercive, protects your right to self-determination, and allows you to participate in decisions regarding the services provided, unless those rights have been limited by law or court order. You have the right to receive services that are in accordance with all statutory and regulatory requirements. You have the right to participate in the formulation of your individualized treatment or service plan and in the periodic review of this plan.

 

HOURS IN WHICH THE SERVICES ARE AVAILABLE

Normal hours of operation for Carolina Healthy Hearts & Minds, PLLC in Cabarrus County are Tuesdays, Wednesdays, Thursdays evenings, and Saturdays are available by appointment only.

 

Mental Health Crisis Hotlines 24/7

CHHM does not offer crisis support 

 Please call 911 for emergencies or go to your nearest emergency room.

Call for Mental Health Crisis 988

Suicide Helpline: 800-273-8255

Crisis Text “start” to 741741

NAMI- 800-451-9682

Hopeline NC: 877-235-4525

Atrium Behavioral Health 24/7: 704-444-2400

Cabarrus County, NC

Daymark Recovery: 866-275-9552

Partners: 888-235-4673

Mecklenburg County, NC

704-566-3410 option 1

 

RIGHT TO CONFIDENTIALITY

You have the right for your confidentiality to be upheld within the limits of the law and to provide informed consent when information is released to another organization or individual outside of Carolina Healthy Hearts & Minds, PLLC. Your records will be released only with your consent or the consent of your authorized representative except by court order, in emergencies or as otherwise required or permitted by law. You have the right to inspect and to have copies of your records at your own expense, except where it would be harmful to you. In that situation, a lawyer, doctor or psychologist you choose can see the records on your behalf. If you feel there are mistakes in your record, you can ask to have them corrected, and if the company doesn’t change what you think is an error, you can place your statement about the error in your record.

 

RIGHT TO REFUSE SERVICES

No consumer shall be subject to treatment without consent of the consumer or parent or legal guardian. You have the right to refuse services, unless those rights have been limited by law or court order, and to be informed of the consequences of such refusal. Consent may be withdrawn at any time by the person who gave consent. If treatment is refused, the qualified professional shall determine whether treatment in some other modality is possible. If all appropriate treatment modalities are refused, the voluntarily admitted consumer may be discharged.

 

CONSUMER RESPONSIBILITIES

It is your responsibility to actively participate in the services. This includes but is not limited to being honest with the Carolina Healthy Hearts & Minds, PLLC staff, following through on recommendations, and keeping scheduled appointments. CHHM reserves the right to discontinue services if it is determined that you do not participate in services to the best of your ability, consistently miss appointments, or if in the professional opinion of CHHM this agency is unable to provide the help you need.

 

RIGHT TO CONSENT

A treatment or service which presents a “significant risk” – that is, one that might cause some injury or have a serious side effect - may not be administered unless you or your authorized representative first give informed consent to it.

 

RIGHT TO SUPPORT AND ADVICE

The North Carolina’s regional advocate is "The Disability Rights of North Carolina.” The Disability Rights of North Carolina is a statewide agency established to protect and advocate for the rights of persons with disabilities. You can call them at 919-856-2195.

 

LIABILITY AND IMMUNITY

CHHM personnel who violate or abuse any right or privilege of a consumer are liable for damages as determined by law. All persons acting in good faith, reasonably, and without negligence in connection with the treatment of a persons shall be free from all liability, civil or criminal, by reason of such acts. The right for your confidentiality to be upheld within the limits of the law and to provide informed consent when Carolina Healthy Hearts & Minds, PLLC must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide. It is the legal duty of CHHM to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care, and for other services relating to your health care.

 

The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within CHHM, as well as reasons why your health information could be sent to other service providers outside of this agency.

 

This Notice describes your rights regarding the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures CHHM uses to protect the privacy of your health information.

 

Please review this document carefully and ask for clarification if you do not understand any portion of it.

 

Client Acknowledgment

I have read and understand the CHHMs Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.

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Court and Legal Proceedings Fees:

-Preparation: $100.00 per hour; billed in 15-minute increments

-Travel: $500/day flat rate for out-of-town travel not including lodging expenses

-Time in court: $200.00/hour

-Supervised Therapeutic Visitation: $200.00/hour (includes court summary)

 

I have read the above, understand and agree with the provisions and associated fees of this policy. PLEASE READ THIS CAREFULLY and if you have any questions, py to pay in full Late Arrival Policy.

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Carolina Healthy Hearts & Minds, PLLC would like to make sure that you access high-quality treatment services when you need it. To ensure we provide everyone with quality services, please be aware of the following appointment policy:

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 Scheduled Appointments: If you cannot make your scheduled appointment, you must call us at least 24 hours in advance to let us know. This allows us enough time to offer your appointment to another client. Failure to provide at least 24 hours’ notice counts as a missed appointment.  If 24 hour notice is not received, you will be charged a flat rate of $65 (excludes My Group EAP). This fee is not covered by insurance and is therefore the sole responsibility of the Client.

 

Missed Appointments: Missed appointments will be documented in your record with us. If you miss more than four scheduled appointments you will be informed that Carolina Healthy Hearts & Minds, PLLC will be unable to provide additional services and you will be discharged from the practice.

 

Late Arrivals: If you arrive more than 15 minutes late for your scheduled appointment you will be given one of the following options:

 

* You may reschedule the appointment.

 

Appointment Reminders:  Please note that appointment reminders are provided as a courtesy of CHHM.  In the event that you do not receive a reminder, making your scheduled appointments remains your responsibility.  We encourage you not to rely on CHHM reminders as your only means of remembering your appointments.

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