OFFICE POLICY FOR THERAPY AT TNT YOUTH MINISTRY

Appointments: All professional services are provided by appointment only. Your appointment has been scheduled just for you. The typical appointment is one hour in length. Your appointment will begin on time and I ask that you be prompt. If you are late, your appointment will still end at the same time, unless extended by the therapist.

Cancellations: You are free to cancel an appointment as needed and reschedule. If you need to cancel call the office at 717-381-1688 or if it is last minute call me at 717-381-1687. I would ask that cancellations be made 24 hours in advance of your appointment so that your time can be used by someone else.

Fees: Please be advised that TNT Youth Ministry does not charge for Mike's services. Mike is supported full time by TNT Youth Ministry. If you wish to make a donation for Mike's services, we would appreciate that you make your check payable to TNT Youth Ministry. Our suggested donation is $40-80 for a one-hour session with Mike, but we will certainly not turn you away if you can't afford this. Your support is appreciated and allows us to continue to serve our community.

Emergencies: If you call the TNT office with an emergency, and my assistant is not available, hang up and call 911. If you are in crisis, do not leave a message on my voicemail. Rather hang up immediately and call The Crisis Intervention Hotline for Lancaster Co 717-394-2631.

Confidentiality: All your records are kept confidential and will only be shared with other professionals with your expressed written consent. Likewise, other professional records deemed important for your treatment and care will only be requested with your expressed written consent. You have the right to see your file and notes if you have a concern. It is advisable that these notes are not requested to support legal action. Please consult an attorney before making such a request.

I have read and acknowledge that I understand these office policies:

Client Signature____________________________________________Date:____________

Parent Signatures for Childen under 14 years of age: ____________________________

____________________________

PRIVACY POLICIES IN THERAPY

I understand that under the Health Portability and Accountability Act of 1996 (HIPPA) that I have certain rights to privacy concerning my protected health information. I understand that any use of this information will be to:

Direct and plan my treatment with other healthcare professionals that may be involved with my treatment both directly and indirectly.
To conduct normal healthcare operations such as assessments and treatment plans.

I certify by my signature below that I have read and accepted office policies concerning confidentiality and privacy. I also acknowledge that I understand that I have the right to request in writing limitations on sharing of my private information.

I also certify by my signature below that I have discussed the limitations to my privacy. I understand that my therapist is a State mandated reporter and is required by law to share information when there is a harmful threat made to others or to myself; when there is suspected child or elder abuse both past, present, or in the future; when records are requested by a court as a result of a court action in which you are involved; or when you are being evaluated by an employer or court.

For your safety and protection, I am mandated to request an emergency contact number of a person with whom you feel safe and willing to share knowledge that you are receiving treatment.

Emergency contact: __________________________Relationship_________________________

Address: _________________________________________Phone: _______________________

I certify that I am 14 years old or older, have read and understand these documents:

Client signatures: ___________________________________________Date: _______________

___________________________________________ Date: _______________

___________________________________________ Date: ______________