HOPE Consent Form

Teletherapy and Telemedicine Consent Form

(1) "Teletherapy" and "Telemedicine" includes consultation, treatment, emails, telephone conversations, and other medical information using interactive audio, video, or data communications.

(2) Teletherapy and Telemedicine occurs in the state ofNC (USA), and is governed by the laws of that state. In a manner of speaking, I am using this modality to visit my therapist in their NC office, where we meet to do our work.

(3) The laws that protect the confidentiality of my medical information also apply to teletherapy. Unless we explicitly agree otherwise, our teletherapy exchange is confidential. I will not include others in the session or have others in the room unless agreed upon.

(4) I accept that Teletherapy and Telemedicine does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.

(5) In the event our Teletherapy and Telemedicine is not in my best interests, my therapist will explain that to me and suggest some alternative options better suited to my needs.

(6) I understand there are risks and consequences from Teletherapy and Telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I am responsible for information security on my computer.

I have read, understand, and agree to the above information.



Client Consent for Clinical Services

COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling Involves sharing sensitive, personal. and private information that may at times be distressing. During the course of counseling. there :nay be periods of increased anxiety or confusion. The outcome of counseling is often positive; however. the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.


All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate.


  • The counseling staff works as a team. Your therapist may consult with other counseling staff to provide the best possible care. 'I'hese consultations are för professional and training purposes.
  • If there Is evidence of the clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
  • A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a therapist to testify in a court hearing.

Should emergency medical services be needed from a physician or hospital you have the right to seek help where available / needed. We appreciate prompt arrival for appointments. Twenty-four hour notice of cancellation allows us to use the time för others. I have read and discussed the above information with my therapist. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the Counseling Services.




42 CFR Part 2 and HIPAA

REMINDER: Information disclosed pursuant to patient consent must be accompanied by the notice prohibiting redisclosure.

A "treating provider relationship " exists when a patient receives, agrees to receive, or is legally required to receive diagnosis, evaluation, treatment, or consultation, for any condition, from an individual or entity who undertakes or agrees to undertake that diagnosis, evaluation, treatment, or consultation. An in-person encounter is not required for a treating provider relationship to exist.

This consent form is for use when a patient wishes to authorize the disclosure of their substance use disorder information to an individual or entity with which the patient has a treating provider relationship.

I, , authorize

to disclose

Assessment and treatment records:   

(describe how much and what kind ofinformation may be disclosed, including an explicit description ofwhat substance use disorder information mav he disclosed; as limited as possible)

to HOPE Counseling & Consulting Services, Inc., 326 N Spring St, Winston Salem, NC 27101 for purpose of treatment / counseling services at HOPE Counseling

I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:

(describe date/event/condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent)

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form.

Date: July 25, 2024


Client Rights / Grievances

Client Rights:

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

  1. The right to impartial access to care without discrimination due to race, color, sex, age, religion, national origin, sexual orientation, political belief, or mental or physical handicap.
  2. The right to receive care that is suited to his/her needs in the least restrictive environment available.
  3. The right to be fully informed of the charges for services provided.
  4. The right to be fully informed of the charges for services provided.
  5. The right to be fully informed of the charges for services provided.
  6. The right to be infomed, in a manner that is understandable, about the benefits, side effects, and risks of the medications prescribed.
  7. The right to accept or refuse service unless a physician, licensed psychologist, or licensed clinical social worker feels that refusal would be unsafe for them self or others.
  8. The right to be informed, of the name, business telephone number and business address of the person supervising his/her plan of care.
  9. The right to be free from any physical or verbal abuse or sexual activity or coercion by staff.
  10. The right to review and obtain copies of his/her service record, unless the Director determines that the access requested is not therapeutically in your best interest.
  11. The right to exercise all civil, political, personal, or property rights to which he/she is entitled as a citizen.
  12. The right to the pursuit of employment, education, and religious expression.
  13. The right (where applicable) to have property and residence treated with respect.
  14. The right (where applicable) to have property and residence treated with respect.
  15. The right to treatment, access to medical care/habilitation, regardless of age/degree of MH/IDD/SA disability.


Fee Assessment and Collection Practices

Insurance: We are in network with most Insurance Companies that operate in this area. We do all the billing and assist with authorizations. Your insurance will often even pay for your assessment. If you have insurance it is often helpful for you to contact your insurance company and ask for authorization after your assessment and prior to entering counseling. This ensures the most likelihood that they will assist you with cost. We will contact your insurance company for authorization and benefits.

**In the rare case that they do not immediately authorize your counseling services, they will usually cover your services if you contact them and insist they provide authorizations and re-authorizations. Insurance companies do not handle substance abuse & mental health counseling, in the same manner, they do your typical doctor's treatment, despite the Parity Act. To save you money, client/patient involvement is sometimes necessary to ensure they assist you with paying for treatment. Insurance will usually pay for your DWI or alcohol and drug counseling programs except, typically, ADETS or education. However, keep in mind that this is for health insurance coverage for people who want treatment and follow the service plan.

Self-Pay/Cash: Allows those without insurance to pay cash for services. Our self-pay cost is among the lowest in the area. Payment plans may be arranged for post-trial DWI clients on a case-by-case basis.

Cancellations: Appointment times are set to accommodate our clients' schedules as often as possible. In order to receive the most success from therapy, it is in the client's best interest to keep their scheduled appointments on a regular basis. We encourage our clients to discuss any need to change an appointment. If you are unable to keep your scheduled appointment, we require that you contact our office at 336-631-1948. Once an appointment has been scheduled, we have a cancellation policy, which requires 24-hour notice.

**If you neglect to cancel your appointment with at least 24 hours advanced notice or miss an appointment entirely, there will be a late cancellation or "no show" fee of $25.00. By law, we are not permitted to submit a claim to any insurance company for late cancellations and missed appointments. At HOPE Counseling & Consulting Services, we recognize that unforeseen circumstances do occur. We do permit our clients a one-time exception to our late cancellation or "no show" fee within a six-month span during treatment.

I certify that I have read and understand this Fee Assessment and Collection Practices.

Date: July 25, 2024

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Signature Certificate
Document name: HOPE Consent Form
lock iconUnique Document ID: de9314635c519131199e22e681900559c11d8bce
Timestamp Audit
October 6, 2022 10:41 pm EDTHOPE Consent Form Uploaded by Linda McRae - info@thereishopeinc.com IP