WELCOME
We are pleased that you have chosen Sagemont to receive counseling services. In order for you to make a fully informed decision about utilizing our services, we’d like to share some information about us, and what we do in counseling. Each one of our counselors is a highly trained professional in fields such as theology, psychology, counseling, marriage & family therapy, and pastoral counseling. The following information provides a brief description of our counseling philosophy as well as an explanation regarding the nature of our professional relationship.

COUNSELOR VALUES
We consider ourselves to be Christian counselors. As such, in addition to being clinically professional, our counseling approach is Christ-centered and biblically based. While we meet and accept people, where they are, spiritually, we seek to involve God in the therapeutic process. Therefore, one of our primary goals is to encourage people to establish, develop or enhance a meaningful relationship with Him as they engage in counseling.

CONFIDENTIALITY POLICY
The Sagemont Counseling Ministry is concerned about your privacy. As Christian counselors, we believe that God expects us to be trustworthy. We also believe that a sense of safety and security is a fundamental component of your healing process. So our goal is to provide an environment in which you can place your confidence and trust.

Under both federal and state law, confidentiality means that communication with us and any records pertaining to your identity, evaluation or treatment will be kept secure and private. Where federal and state laws differ, we comply with the stricter standard to ensure that your right to confidentiality is respected at all times.

However, information may be released in the following circumstances:

1. We will disclose information and notify the proper authorities or other appropriate parties if you admit to serious and imminent thoughts of suicide.
    
2. If someone else’s life is in danger, we will report it to the intended victim and/or the proper authorities.
    
3. We may disclose your health information to appropriate authorities if we reasonably suspect that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes.
    
4. We are required by law to report any suspicion of child abuse. If we believe that a child is at risk of being abused, has already been abused, or that someone who previously abused children is still a threat, we have no choice but to report it to Child Protective Services and/or the police.
    
5. We are obligated by law to report suspected abuse of an elder person, 65 years or older, or a dependent adult.
    
6. If you are engaged in family, marital or couples counseling, information shared with us in any individual meeting may, at our discretion, may be shared with the other party, if we believe it to be in the best interest of the work we are doing together.
    
7. We may use or disclose your health information to a physician, or other healthcare provider who is providing treatment to you, or who is coordinating or managing mental health care or related services.
    
8. If we deem that consultation is required in order to better serve you, we may disclose necessary information to our supervisor, peers and/or ministers who may be directly involved in your situation.
    
9. We may use or disclose your health information to obtain payment for services that we provide to you. Confidentiality cannot be assured if you choose to utilize insurance benefits, managed care organizations or other third-party payers who request information. For example, we may include information with a bill to a third-party payer that identifies you, your diagnosis and procedures performed.
    
10. We may utilize certain health information in connection with the business aspects of running our practice. This includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating counselor performance, clinical supervision, conducting training programs, certification, licensing or credentialing activities.
     
11. A judge has the power to order us to release information if you are involved in a court case in which our professional relationship is deemed relevant.
     
12. If you were to file a formal complaint or a malpractice suit, your confidentiality would be waived.

We will disclose your personal information if you sign a written consent that authorizes the release of identified information to a specified recipient. If information in your client file also contains documentation related to a secondary client (i.e. a spouse, parent and/or child, etc.) a release of information form must be signed by each responsible party.

Written records of client communications are stored in a way that protects confidentiality and privacy rights, and electronically stored records are protected by password restrictions, backup systems, virus security software, and firewall protection.

Office personnel may contact you (by telephone, voicemail message, email, postcard, flier or letter) to provide appointment reminders or to inform you of other services that may be of interest to you.

If you have any concerns or questions about this policy you should raise them with us at the earliest possible time so that we can resolve them in a manner consistent with your best interests.

YOUR RIGHTS

1. A recently implemented federal program called the Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives you the right to put into writing any request that you believe is necessary to restrict the possible misuse of your protected health information. All requests will be honored except as the law specifically outlines the use of your personal health information for treatment, payment and healthcare operations.
    
2. HIPAA states that once you give your consent for the use of your personal information for treatment, payment and healthcare operations by signing the Professional Services Agreement, you may revoke the consent in writing at any time, except to the extant that we have taken action based upon your prior consent. If we believe that we cannot honor your written request for restriction of healthcare information, we will discuss our reasons with you, and if necessary, terminate our professional agreement formally in writing.
    
3. Under HIPAA you have the right to request in writing, receive and inspect copies of your protected health information held in this office. HIPAA has guidelines regarding what information must be included in response to your request. If the information that you request is outside those guidelines, we have the right to deny your request. Requests within the guidelines will be honored; however, there is a reasonable charge for labor and copying charges. You must allow reasonable time for preparation as well.
    
4. You have the right to amend any of your protected health information by a written request. If your request is outside the guidelines of the law, we have the right to deny your request to amend records.

Copies of this document will always be available in our waiting areas or from our staff. If a revision to this document becomes necessary, updated copies will be available.

If you believe that we do not adhere to the stated intentions described in this document and/or you believe your right to confidentiality has been violated, please talk with your counselor or the Center’s director. Address your concerns to Mike Schumacher, Director, Sagemont Counseling Ministry, 11514 Hughes Road, Houston, TX 77089. We will take your concerns seriously.

If there is no resolution, you may file a complaint with the Department of Health and Human Services, Office of Civil Rights.

FEES
Typically, an individual, marital or family counseling appointment will last fifty minutes. Counseling fees vary depending upon whether you are a member of Sagemont Church or not.

SAGEMONT MEMBERS – While Sagemont members are encouraged to make a financial contribution to help defray the costs associated with the counseling ministry, current and active members of Sagemont Church are eligible to receive their initial counseling session at no charge. Subsequent appointments, if necessary, will include a standard fee of $30.00 per visit, payable at the time of service.

NON-SAGEMONT MEMBERS – Clients who are not members of Sagemont Church are charged a standard fee that is based upon the clinical credentials and qualifications of the counselor providing services, according to the following categories:

• Licensed Professional Counselor (LPC) $70.00
• Licensed Marriage & Family Therapist (LMFT) $70.00

The length of group counseling sessions will normally run ninety minutes, but may vary depending on the nature of the subject matter. Sagemont members may attend most group counseling sessions at a reduced charge ($15.00). For the non-Sagemont participant, the regular fee for most therapeutic groups is $20.00.

LEGAL MATTERS
If you request that we be involved in consultation related to a legal issue on your behalf, you will be billed at the rate of $100.00 per hour for all the time spent on your case, including meeting with your attorney, court appearances, writing reports, travel and preparation time.

Because we lack the required clinical credentials, we are not qualified to render child evaluations in matters of divorce, custody disputes or other legal issues related to the assessment of children.

FINANCIAL AGREEMENT
Counseling fees will be determined prior to the initial session. Please understand that payment of your bill is part of your treatment. Payment is due in full at the conclusion of each session. We do not bill insurance companies for services rendered. However, we can provide you with the necessary paperwork for you to file a claim with your insurance company should you desire to do so. We accept cash or check. Appointments will not be extended beyond any unpaid session, and additional counseling appointments will not be scheduled until payment is received.

CANCELLATION POLICY
The time scheduled for your session is reserved for you. If you miss an appointment without canceling, or if you cancel with less than a 24-hour notice, you will incur a fee of $30.00 charged to your credit card. If you are late for a session, we will use the time remaining, but you will be charged the full rate.

CONSENT FOR TREATMENT
You have the right to a clear description of the nature of our professional relationship. You also realize that you have treatment options other than those offered through the Sagemont Counseling Ministry, including no counseling at all, and that no guarantee or assurance has been made to you as to the results that may be obtained from counseling. In fact, it is not unusual that you may even feel worse during the early stages of the counseling process.

Your signature below verifies that:

1. You have freely elected the counseling services offered by Sagemont in good faith and without duress.
    
2. You are aware that counseling through Sagemont is not a crisis response service. Normally, you can reach us during regular office hours (8:30 AM to 5:00 PM – Monday through Friday) by calling (281) 481-8770. After hours, leave us a voice message at (281) 481-7133. In the case of a medical emergency or significant crisis, you should proceed to the nearest emergency room.
    
3. You have been informed of the published fees for services provided by the Sagemont Counseling Ministry, and have made an individual financial agreement for services rendered to you.
    
4. In order to help you most efficiently, we may ask your approval to audiotape select counseling sessions. Since your authorization is required, you would be notified prior to any recording.
    
5. You realize that minors will not be counseled without the written consent of their biological parents, or the adult who has been court appointed as managing conservator.
    
6. You understand that you may request access to treatment information contained in your client file, and that this release will be authorized unless we deem it to be clinically inappropriate.
    
7. Your signature holds harmless and indemnifies the counselor and this ministry from any and all liability, claims or expenses related to the counseling you receive.