What to Expect

Whether you’ve participated in therapy before or it’s your first time, we’re happy you’re here and we hope to make the process as enjoyable as possible. We encourage you to ask any questions you may have throughout the scheduling process or in your first few sessions. Below is a general idea of what you may expect once you reach out for services.

Scheduling

In order to schedule your first therapy appointment at Blackberry Counseling Center, you can either call us at (217) 471-4229 or email us at contact.blackberry@blackberrycounselingcenter.com. Our goal is to get you scheduled as soon as possible with a therapist at the practice or provide you local referrals.

It may be helpful for you to be prepared to answer the following:

What are you seeking counseling for?

In order to make sure we’re able to meet your needs, it is helpful to have a brief description of what you’re seeking therapy for. Some examples may include: depression, anxiety, substance abuse, conflict with family, poor life enjoyment, recent death in the family, etc.

What times/days may work for you to meet with a therapist?

We try our best to accommodate client's needs when scheduling sessions though sometimes this may not be possible given clinician availability.

Will you be utilizing insurance?

f you’re planning on using health insurance, please have your insurance information available. We will collect all your insurance information and verify your benefits. We try to provide you with your insurance benefits prior to your first appointment. You may owe towards your deductible, owe a co-pay, or a co-insurance. You are also encouraged to contact your insurance carrier to verify your mental health benefits.

**We are currently only in network with Blue Cross Blue Shield PPO, AETNA, and CIGNA, Medicare. We will bill out of network insurance providers but it will be your responsibility to contact them to find out what your out of network insurance benefits are. We will also allow out of pocket payment for services.

Are there any needs related to building accessibility?

Our office building, offices, and bathroom are all handicap accessible. In addition, we will continue to offer telehealth services. If there are any additional needs you'd like us to be aware of please do not hesitate to let us know.

Your First Sessions

After you’re scheduled with a therapist, you will be given access to a virtual client portal where you're able to complete paperwork prior to your first session, unless otherwise specified.

Therapy sessions are approximately 53 minutes long. The first few sessions, the clinician will be completing an evaluation, in order to identify a diagnostic impression and treatment goals for therapy. This process may take one or more sessions. At Blackberry, our priority is helping you find the best fit therapeutically as well as to find the best fit for a therapist, our clinicians are prepared to discuss clinician fit with their clients and will provide the appropriate referrals as needed. These first sessions are also a good time to discuss any questions you may have about therapy, Blackberry Counseling Center policies, procedures, billing, etc.

No Surprises Act

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

Notice of Privacy Practices

At Blackberry Counseling Center, we are committed to treating and using protected health information responsibly. This Notice describes the procedures we use to protect your information, and the circumstances under which your personal health information may be disclosed. It also describes your rights as they relate to this information. The rules for confidentiality of mental health records are recorded in the Illinois Mental Health and Developmental Disabilities Confidentiality Act and in the privacy rules of the Health Insurance Portability and Accountability Act. We strongly suggest you review these provisions in order to fully understand our procedures and your rights.

We strive to protect your personal health information.

At Blackberry, every effort is made to keep your personal health information private. Some of our procedures will be evident to you. For example, when you call to discuss an issue with office staff, we may ask you for some piece of identifying information to confirm your identity. Others happen behind the scenes. Computer data is password protected at the workstations and every effort is made to prevent others from viewing your personal health information. If you have any concerns about your privacy, please bring them to our attention.

You are entitled to copy or review your mental health records.

You have the right to inspect and/or copy your health record. Emails that include clinical information may be included as part of the record. If, after reviewing your record, you believe that any statement is in error, you have a right to request that the person who made the entry make a correction. Anytime you request a revision, your request and the action taken must be noted in the record. If a professional chooses to stand by a statement with which you disagree, you have the right to add a written amendment stating why you believe the entry is in error. Any time that section of the record is released, your amendment must be included.

The following individuals can access a mental health record without written authorization.

1) an adult recipient of services; 2) the parent or guardian of a child who is under 12 years of age; 3) the recipient if he is 12 years of age or older; 4) the parent or guardian of a recipient who is at least 12 but under 18, if the recipient does not object or if the therapist does not find that there is a compelling reason for denying access, but nothing in this statement is intended to prevent a parent or guardian of a child who is at least 12 but under18 from requesting and receiving the following information: current physical and mental condition, diagnosis, treatment needs, services provided, and services needed; 5) a legal guardian of a recipient who is 18 or over; 6) an attorney, guardian ad litem, or power of attorney or other person who is legally authorized to access the records. We are happy to provide you with assistance in understanding the record.

In the following circumstances, we may release your records without your permission.

There are circumstances that impose limitations on a client’s right or ability to maintain privileged communication. A therapist may disclose a record without consent: 1) to a supervisor, consulting therapist, or member of the staff team participating in the provision of services, a record custodian, or a person acting under the supervision of the therapist; 2) when a therapist believes a clear and immediate danger exists to one or more persons; 3) when disclosure is necessary to provide a recipient with emergency medical care or access to needed benefits when the recipient is not in a condition to waive or assert his or her rights; 4) when abuse or neglect of a child is suspected; 5) when a therapist is consulting with an employer, attorney, professional liability company, or other relevant business associate concerning the care or treatment he or she has provided, including disclosure to business associates who may help us pursue payment (but each of these recipients shall be held to HIPAA privacy standards and may not redisclose the information); 6) when a recipient introduces his or her mental condition or any aspect of services received for such condition as an element of a claim or defense; and, 7) in certain other legal situations where the court has decided that disclosure is directly relevant to the issue being investigated. Furthermore, as part of the Illinois Firearm Concealed and Carry Act (PA98-063), clinicians are required to notify the Illinois Department of Human Services of anyone who is determined to be a “clear and present danger” to themselves or others or determined to be developmentally or intellectually disabled.

Additional rights.

You have the right to request restrictions on certain uses and disclosure of personal health information. However, Blackberry is not required to agree to a requested restriction, and in some situations, is prohibited by law from agreeing to a requested restriction. You have the right to request and receive an accounting of disclosures that we make to other individuals. Blackberry reserves the right to change the terms of its Privacy Policy and to make the new Policy provisions effective for all personal health information that it maintains. You will be notified of any changes to the Policy. If you believe your privacy has been violated, first bring the matter to the Office Manager of the office where you are receiving services. If you have a dispute that cannot be resolved, please contact the Privacy Officer, Brittany Male or her designee, at (217) 471-4229. You may also file a complaint with the Office for Civil Rights, U.S. Dept of Health & Human Services, 200 Independence Ave; S.W., Room 509F, HHH Building, Washington, DC 20201. There can be no retaliation for filing a complaint.

Your signature below indicates consent to treatment and that you have read the information in this document and agree to abide by its terms during our professional relationship.

Signature: _____________________________________Date:_______________

Print Name: _______________________________________________________

**Second Signature for Couples Only

Signature: _____________________________________Date:_______________

Print Name: ______________________________________________________

**For Minors

Child/Minor 12 to 17 Printed Name:________________________________________

Child/Minor 12 to 17 Signature for Assent:_____________________________________

Date: _________________________

Parent Printed Name:___________________________________________________

Parent Signature: _____________________________________________________

Date: _________________________

Parent Printed Name: __________________________________________________

Parent Signature: _____________________________________________________

Date: _________________________

Information, Authorization, and Informed Consent

We encourage you to carefully read the following document as it contains our business policies as well as information regarding our services. If you have any questions, please feel free to ask them at your appointment or call ahead to discuss them.

Therapeutic Services

At Blackberry we see the relationship between therapist and client as collaborative. Throughout the therapeutic relationship, clinicians may utilize different methodologies or techniques in order to best address the presenting issues and meet the therapeutic goals. As a client, playing an active role in therapy both in sessions and outside of sessions increases success in therapy.

Due to the very nature of psychotherapy, as much as we would like to guarantee specific results regarding your therapeutic goals, we are unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is our intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless. Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and your therapist are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.

If you’re new to therapy, you may have uncertainty about what to expect. The first few sessions, the clinician will be completing an evaluation, in order to identify a diagnostic impression and treatment goals for therapy. This process may take one or more sessions. Additionally at this time, you and the clinician may discuss if outpatient therapy is a good fit. A key to therapeutic success is the client clinician relationship, if you do not feel that it is a good fit with your clinician take a moment to discuss this with them. Again, our clinicians are prepared to discuss clinician fit with their clients and will provide the appropriate referrals as needed. These first sessions are also a good time to discuss any questions you may have about therapy, Blackberry Counseling Center policies, procedures, billing, etc.

As an additional note, Blackberry clinicians DO NOT participate in legal proceedings unless court ordered, in order to protect the therapeutic process and relationship. If your clinician is court ordered, you will be expected to pay for the professional time even if your clinician is called to testify by another party.

Professional Relationship

Psychotherapy is a professional service we will provide to you. Because of the nature of therapy, your relationship with your therapist has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and your therapist were to interact in any other ways, we would then have a “dual relationship,” which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist’s interests and the client’s interests, and then the client’s (your) interests might not be put first. In order to offer all of our clients the best care, our judgment needs to be unselfish and purely focused on your needs. This is why your relationship with your therapist must remain professional in nature. You should also know that therapists are required to keep the identity of their clients confidential. As much as we would like to, for your confidentiality we will not address you in public unless you speak to us first. We also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, we will not be able to be a friend to you like your other friends. In sum, it is our duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

Sessions

Initially, sessions are usually scheduled on a weekly basis for 53-minute sessions, although some sessions may be longer or more frequent based on presenting issues and symptoms.

The Blackberry cancellation policy requires 24 hour notice and application of the policy is determined by your clinician regarding the reason for the cancellation if less than 24 hours in advance. In order to best serve all clients, this is extremely important to respect the cancellation policy. If able to do so, clinicians will reschedule, but it is not guaranteed when canceling less than 24 hours in advance. Cancellations or no-show/no-calls that occur less than the 24 hour notice will result in a fee of $100.00, collected on the date of the missed appointment.

Professional Fees

The following fees are contingent upon the type of therapy service provided and will be collected at the time of service.

53-60 Minute Diagnostic Evaluation $220.00

53-60 Minute Psychotherapy Session $190.00

45 Minute Psychotherapy Session $150.00

30 Minute Psychotherapy Session $100.00

Family Session Without Client $150.00

Extended Session Add On $190.00

Crisis Session $200.00

Crisis Add On 30 Minute Session $100.00

Group Therapy $50.00

Other Services (See Below)

*Other Services may include report or letter writing, telephone conversations/consultations with other professionals or individuals who are part of your treatment, attending meetings with other professionals you have authorized, preparing records or treatment summaries, and the time spent performing any other services you may request of the clinician. These are out of pocket charges that cannot be submitted to insurance.

15 Minutes $50.00

30 Minutes $100.00

45 Minutes $150.00

60 Minutes $200.00

Request for Copy of Records $20.00 (may vary based on request)

Review of Records $190.00

Legal $500.00/per hour.

Payment and Insurance

If Blackberry Counseling Center is not an in-network provider for your insurance, you will be expected to pay the entire session fee, for each session at the time of the session. If we are an in-network provider of your insurance network, then we’re happy to bill your insurance company directly as a convenience offered to you.

You must keep the us informed immediately regarding any changes to your insurance if we are billing your plan on your behalf. You will be responsible for the payment of any copayments or deductibles associated with your policy at the time of the session as well as any uncovered services as identified above. Merely because an insurance company authorizes services, they often do not guarantee payment and you will be ultimately responsible for the cost of services provided which are not reimbursed by insurance providers for whatever reason they are not covered. You (not your insurance company) are responsible for full payment of fees, so it is important to confirm exactly what mental health services your insurance policy covers. If you must obtain authorization from your primary care physician or your insurance company prior to treatment or office visit it is your obligation unless agreed upon to the contrary. Any secondary insurance claim filing is your responsibility.

If you have health insurance, but your therapist is an out-of-network provider, you must pay the full private pay rate and Blackberry will provide you with a bill suitable to present to your insurance company to secure any out-of-network reimbursement your plan provides. Failure to keep payments current may result in termination of services. . If you do not have insurance or Blackberry is not in your insurance network, and/or you do not have your insurance card, then full payment is due at the time of service. We accept payment in the form of cash, check, VISA, or Mastercard.

Telemental Health

Blackberry Counseling Center utilizes telehealth services for client’s safety and convenience, if applicable. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to telemental health:

I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
I understand that there are risks and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
I understand that there will be no recording of any kind of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
I understand that the privacy laws that protect the confidentiality of my protected health information (“PHI”) also apply to telemental health unless an exception to confidentiality applies.
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, I will call Blackberry Counseling Center at (217)471-4229.

These are the names and telephone numbers of my local emergency contacts (including local physicians; crisis hotline; trusted family, friend, or adviser). I also understand that my provider has provided me with a crisis resource list for the county I live in and I am to use the resources if I become concerned about my safety.

__________________________________________________________________

(Name) (Telephone Number)

__________________________________________________________________

(Name) (Telephone Number)

__________________________________________________________________

(Name) (Telephone Number)

Communication

Blackberry clinicians are not immediately available by phone. Clients have the option to leave a voicemail, contact their clinician via email, or message their clinician through our secure client portal. In the event of an emergency, clients should present to their nearest emergency room, dial “911” for emergency assistance, or contact the following crisis intervention services: Kane Co: 630/966-9393; Kendall Co: 630/553-1400; DeKalb Co: 866/242-0111; DuPage Co: 630/627- 1700. Clinicians will make an effort to return phone calls or emails within 48 hours during normal business hours. If a clinician will be unavailable for an extended period of time, clients will be provided with the name of a clinician back-up to contact if necessary.

I authorize Blackberry Counseling Center to communicate with me in the following ways: (Please Check & Initial)

□_____Call / □_____ Leave a message - Cellular phone ______________________________ □_____Call / □_____ Leave a message - Home phone _______________________________ □_____Call / □_____ Leave a message - Office phone _______________________________

Because email and texting are inherently insecure, these modes of communication are not allowed unless you specifically direct the Practice to utilize this mode of communication. Please note that the regular use of email or texting is not HIPAA compliant and does not meet the ethical standards of therapists in the State of Illinois. Absent your specific direction to use these modes of communication, the Practice will only utilize them in cases of emergency. Please do not email or text content related to your therapy sessions. If you choose to communicate by email or text, there is no contemplation of privacy. While it is unlikely that anyone will see or acquire copies of any such communication, they are, by their nature, not secured.

□_____Communicate by Email: _________________________________________________

□_____Communicate by Text: __________________________________________________

Technology

In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to us that we maintain your confidentiality, respect your boundaries, and ascertain that your relationship with me remains therapeutic and professional. Therefore, we have developed the following policies:

Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with your therapist. By providing your cell phone number to BCC, you agree and acknowledge that BCC may send a text message to your cell phone number for any purpose, including marketing purposes.

Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please discuss this with your therapist. You also need to know that we are required to keep a copy of all emails and texts as part of your clinical record.

Facebook, LinkedIn, Instagram, Pinterest, Etc: It is our policy not to accept requests from any current or former client on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. Blackberry Counseling Center has a business Facebook page. You are welcome to follow this page for helpful information. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to Blackberry Counseling Center.

Google, etc.: It is our policy not to search for our clients on Google or any other search engine. We respect your privacy and make it a policy to allow you to share information about yourself with your therapist as you feel appropriate. If there is content on the Internet that you would like to share with your therapist for therapeutic reasons, please print this material out and bring it to your session.

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that we are open to any feelings or thoughts you have about these and other modalities of communication.

Professional Records

The Illinois laws and ethical standards of therapy require that providers keep treatment records for 10 years . You are entitled to receive a copy of your records, or a prepared summary instead. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them in the presence of your clinician to discuss the content. This may require an appropriate fee for any professional time spent in responding to information requests.

Confidentiality

The privacy of all communications between a client and a clinician are protected by law, and can only be released to others with your written permission except for rare occasions such as the following:

Legal

As a reminder, Blackberry does not participate in legal proceedings unless court ordered. In most legal proceedings, you have the right to prevent your clinician from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your clinician’s testimony if they determine the issues demand it. That said, Blackberry clinicians are not child custody specialists. Finally, if a client is in therapy or is being treated by order of a court of law, the court may require that confidential information be shared.

Abuse or Neglect

If your clinician believes that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of a child, elderly person, or disabled person, your clinician may be required to file a report with the appropriate state agency. The clinician may be required to share information regarding the client and their treatment, without your consent, in order to protect others from harm.

Self or Other Risk

If your clinician believes that a client threatens serious bodily harm or death to another individual, the therapist may be required to take protective actions, even without the client’s consent. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens or attempts to harm themselves, the clinician may be obligated to seek hospitalization for the client or to contact family members or others who can help provide protection, even without the client’s consent. When possible, your clinician will discuss this with you prior to taking action.

Consultation

Finally, it may be helpful to consult with other professionals to support your treatment. During consultation, every effort is made to avoid revealing identifying information about the client. The consultant is also legally bound to keep the information confidential.

I understand that by signing this document, I am stating that I have been given a copy of the Blackberry Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act. I will ask for explanation and clarification of any part of the notice I do not understand.

By signing, I am demonstrating my understanding of the benefits and risks. I have had the opportunity to ask questions regarding the content in this document and have received answers to my satisfaction. I voluntarily consent to participate in therapy, including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein.

Signature: _____________________________________Date:_______________

Print Name: _______________________________________________________

**Second Signature for Couples Only

Signature: _____________________________________Date:_______________

Print Name: _______________________________________________________

Minors Outpatient Services Contract

(**ages of 12 and 17)

Clients between the ages of 12 and 17 have certain rights in terms of confidentiality and consenting to treatment. Any minor between 12 and 17 years old may request counseling services or psychotherapy on an outpatient basis and it does not require the consent of a parent or guardian for eight 90-minute sessions. If therapy is recommended to continue past the eight 90 minute sessions, consent of both parents.guardians would be required to continue counseling services, unless there is proof of sole custody outlined in a divorce decree or other legal document. In that case, only the parent with sole custody must sign the informed consent. If the minor does not allow for consent from a parent/guardian, then counseling services will be discontinued and referrals will be provided.

If a parent claims sole custody of a child/minor, then a copy of the most updated divorce decree or other legal document outlining parental responsibilities must be provided to the clinician and only that parent will be required to provide informed consent. The non-custodial parent may; however, be notified of the child’s involvement in therapy if deemed appropriate.

In terms of confidentiality, parents/guardians have the right to request and inspect their child’s record, current physical and mental condition, diagnosis, treatment needs, services provided, and services needed, including medication, if any. That said, clients between 12 and 17 have the right to deny a parent/guardian access to inspect their records, as long as the therapist finds the reasons to be compelling to deny access.

Similar guidelines apply to communication regarding a minor’s treatment. It is recommended that clients between the ages of 12 and 17 discuss these limits and expectations with their clinicians and parents/guardians early in the therapeutic process. When possible, the clinician will discuss any information with the client prior to sharing with the parent/guardian and navigate through any objection the client may have.

Client’s between the ages of 12 and 17 may request to privately review their records with the assistance of their clinician, free of charge.

Clients between the ages of 12 and 17 must co-sign any Release of Information completed for the clinician to communicate with any other providers or individuals who are part of the client’s treatment. Additionally, they have the right to revoke the Release of Information at any time.

Child/Minor 12 to 17 Printed Name:________________________________________

Child/Minor 12 to 17 Signature for Assent:_____________________________________

Date: _________________________

Parent Printed Name:___________________________________________________

Parent Signature: _____________________________________________________

Date: _________________________

Parent Printed Name: __________________________________________________

Parent Signature: _____________________________________________________

Date: _________________________