Welcome to CommonSense Wellness Network

This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your provider(s).

By agreeing to this informed consent, I agree to engage in in-person as well as online mental health or medical services with my provider(s) (in accordance with their state license and credentials), and I understand my provider(s) (or their overseeing supervisor/practice) is associated and contracted with CommonSense Wellness Network. Thus, by signing this informed consent I understand that "teletherapy" and "online services" include consultation, treatment, and transfer of personal data through HIPAA-secure means including emails, telephone conversations, video-conference, audio messages, video messages, and text-based messages. By signing this consent I also understand that teletherapy and online services involve the communication of my mental health, medical records, and personal information both orally and visually.

By agreeing to this consent, I understand that my provider and CommonSense Wellness Network abides by all laws (state and federal) including the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws protecting private health information (PHI).

Moving forward, I understand I will be working with the provider(s) listed on my CSWN EHR. Please note: all CommonSense Wellness Network providers practice as separate entities, however interns and providers under supervision operate within the entity of their supervisor. I understand my provider utilizes CommonSense Wellness Network for overhead purposes. If my provider has a supervisor, I understand the supervisor for my provider may have access to my clinical files, per New York State regulations. Additionally, while only my providers and their supervisors have access to my clinical notes and treatment plans, all providers of CommonSense may be able to see my basic demographic and billing information due to sharing an electronic health record system. Moreover, I understand my provider will ensure I sign a release before consulting another CommonSense provider (or any other provider) on my case. NOTE: if a provider is being supervised, you can confirm this by checking their website bio: www.commonsensemh.com

USING INSURANCE: I understand utilizing insurance for services comes with pros and cons. Specifically, use of insurance requires the use of diagnosis by mental health and medical providers. Diagnosis involves its own pros and cons, including accessibility to additional services and accommodations (possible pros) as well as possible stigma and discrimination (possible cons). Using insurance may also result in a longer wait time for a CommonSense provider, as each of our providers take different insurance panels (if they take insurance at all) and some providers who take my insurance may be full and may have a waitlist.

Moreover, in general, I understand that using insurance means my insurance company has access to my chart and records. I also understand use of insurance will result in a pre-existing condition on my insurance and health records.

LEGAL INVOLVEMENT POLICY: By entering into therapy, I understand I am agreeing that our mutual goal is for you to help me in achieving my therapy goals, not to address any legal issues I may have. However, in the event I do require your testimony or involvement in any legal proceeding, you (the provider) will do so only with my written consent. You will be unable to disclose information pertaining to other family members or parties involved in treatment without their written consent to disclose this information. I understand your fee (the provider's) is $200 per hour for court appearances and for preparation for court testimony including, but not limited to, consulting with attorneys, reviewing the file, report/letter writing, and time spent traveling to court and waiting to testify. There are additional fees for parking and mileage. A retainer for court expenses will be due and payable two weeks prior to any scheduled court appearance. In the event of a settlement or cancellation of the appearance with less than 24 hours' notice, a charge will be levied for the time originally set aside for the appearance. I understand these services are not reimbursable by my medical insurance.

CANCELLATION POLICY: If I cancel any type of service (in-person or online), I must give at least two business days notice by telephone and without such notice I am responsible for the service fee. The fee will either be my self-pay rate for the specific service/session, or a pre-set fee in the event I am using insurance. Moreover, I understand that insurance companies do NOT pay for missed services.

IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and my provider offers, we can meet in-person. If I attend therapy in-person, I understand:

• I can only attend if I am symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If I am experiencing symptoms, I can switch to a telehealth appointment or cancel. If I need to cancel, I will not be charged a late cancellation fee.
• I must follow all safety protocols established by the practice, including:
  • Following the check-in procedure;
  • Washing or sanitizing my hands upon entering the practice;
  • Adhering to appropriate social distancing measures;
  • Wearing a mask, if required;
  • Telling my provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
  • Telling my provider if I or someone in my home tests positive for COVID-19.
• My provider may be mandated to report to public health authorities if I have been in the office and have tested positive for infection. If so, my provider may make the report without my permission, but will only share necessary information. My provider will never share details about my visit. Because the COVID-19 pandemic is ongoing, my ability to meet in person could change with minimal or no notice. By signing this consent, I understand that I could be exposed to COVID-19 if I attend in-person sessions. If a member of the practice tests positive for COVID-19, I will be notified. If I have any questions, or if I want a copy of this policy, I understand I can ask for such.

NO SURPRISES ACT
Most clients at CommonSense utilize insurance with their provider, however provider ability to take insurance varies based on the provider, their credentials, and a number of other factors. As a result, some clients pay out of pocket for services, and most will pay on a sliding scale based on their income.

The No Surprises Act requires us to outline what a client may pay if they were to be charged the full fee at CommonSense Wellness Network for services, and what this cost could add up to in the most extreme case based on various factors.

Please note: clients paying out of pocket for services complete a financial agreement, and often this agreement is for much lower than the full fee would entail at CommonSense. The numbers below reflect the most extreme possibility of such an agreement:

Case scenario: working with a nurse practitioner
intake fee (may be applied up to once a year, code 90792): $300
follow up fee (15 min code: 99213; 30 min code 99214): $200 (usually 15-30 minutes)

If a client were to work with a nurse practitioner at these rates, and meet with them a couple times a month for a year (note this is not standard frequency for psychiatric care in private practice, however this is probably the most frequent, and expensive, such care could become in extreme cases. Generally sessions are more frequent at first and then taper to a lesser frequency over time), the total for a year would be $5,300.

Case scenario: working with a mental health counselor or social worker
intake fee (may be applied up to once a year, code 90791): $225
follow up fee: $200 (53 minutes, code 90837)

If a client were to work with a therapist at these rates, and meet with them once a week (this frequency, as well as meeting every other week, are standard frequencies for psychotherapy. However, various factors may determine appropriate frequency and the most a therapist in private practice may see a client would be two to three times a week - and generally for a specific and limited period of time), the yearly cost for services would be $10,425 (weekly) and $5,225 (every other week).

PLEASE NOTE: frequency of sessions within a private practice setting, especially over the course of a year, can NEVER be guaranteed, as many factors may impact the frequency of services. Additionally, yearly cost projections are difficult to establish because services are generally charged for at the time of session (known as "fee-for-service"). Ultimately, you (the client) must agree to any change in service frequency prior to such change, and you would do so knowing the service fee per session. This allows you to establish your own informed cost projections, and those most accurate and consistent to your individual care.

When determining eligibility for sliding scale, clients are not required to provide documentation or proof of income. Additionally, CSWN may suggest applying the "1/1000" rule - where a client's (or family) gross yearly income is divided by 1/1000, and this equates to the sliding scale fee.

Example: client making 100k a year would pay $100 per session with a therapist.
Sliding scale for licensed therapists (mental health counselors and social workers) may go as low as $85 per session. For limited-permit and pre-licensed therapists, including interns, the sliding scale may go as low as $60 per session.

Sliding scale for nurse practitioners is generally full fee only (if insurance cannot be utilized).

ADDITIONALLY, I understand the following in regards to teletherapy and online mental health services:

I understand that my electronic PHI (private health information) is maintained by a HIPAA-secure cloud-based service, its technical support staff, as well as select data may also be kept on designated equipment (hard drives) owned by CommonSense Wellness Network. I understand other HIPAA-secure software and cloud-based services may also be utilized in my care. Moreover, I understand that I may have utilized e-mail, especially at the start of services, with CommonSense Wellness Network and that this medium is not the most secure form of communication. CommonSense Wellness Network utilizes HIPAA-secure, encrypted e-mail that is serviced through a BAA to reduce this risk.

I understand that my electronic PHI may also be stored on additional HIPAA-secure software, including software used for billing, scheduling, and prescribing purposes (when applicable).

Specifically with e-mail and any secure text message communication between myself and CommonSense Wellness Network, I understand that such text may be saved and backed up on a back-up, digital cloud-vault service utilized by CommonSense Wellness Network in the event my provider loses access to our text communication (such as due to technical failure).

I understand that teletherapy and online mental health and medical services are often not sufficient in the event of a crisis or emergency, as these services do not provide adequate assistance in these instances. Moreover if I am in crisis or someone I know is a threat to themselves, I should call the 988 Suicide & Crisis Lifeline (call or text 988), the Trans Lifeline at 877-565-8860, contact local crisis services, or call 911.

I understand that there are risks and consequences from teletherapy and online mental health services, including but not limited to the possibility of (despite reasonable efforts by CommonSense Wellness Network): the transmission of my information disrupted or distorted by technical failures; the transmission of my information interrupted by unauthorized persons; and/or the electronic storage of my medical information accessed by unauthorized persons.

I understand that security measures, including the following, will be taken to ensure my information is kept confidential: all information is maintained on a HIPAA-secure cloud service and HIPAA-secure software, as well as transmitted via HIPAA-secure video conference or messaging programs. Moreover, staff passwords and information are never shared, and all computer equipment is password protected and only accessed by staff and independent contractors.

I understand that my provider may use AI-based features provided by existing online services (such as the CSWN EHR and Google Workspace) used by CommonSense Wellness Network for the purpose of practice management, such as managing documentation, and in the event my provider wishes to utilize AI services during their session with me (such as transcription services), I understand a separate informed consent must be completed.

I understand that teletherapy and online mental health services may be best accompanied by in-person services. Moreover, clients engaged in teletherapy and online mental health services may receive services, in person, at an office as well as with an outside, local provider. I also understand my provider may recommend I receive in-person services as well, whether through CommonSense Wellness Network or elsewhere, and that I may be better suited for such services.

I understand I am responsible for A. providing the necessary computer, telecommunications equipment, and reliable internet access for my teletherapy and online mental health sessions, B. any information I transmit via my computer (and that such information is truthful and honest), and the security of such, and C. arranging a location with sufficient lighting and privacy that is free from distractions or intrusions during my teletherapy and online mental health sessions. If such conditions cannot be met, options for in-person services may be presented and appropriate.

I understand, as described above, that I have a right to access my mental health and personal information and copies of mental health records in accordance with HIPAA and applicable state law.

Finally, I understand that CommonSense Wellness Network utilizes computerized billing, therefore, my agreement below acts as a signature on file. I authorize the release of any payment and medical information necessary to process claims and claim related items for myself and/or my family members. I hereby authorize payment directly to CommonSense Wellness Network of the insurance benefits otherwise payable to me for their professional services. I understand that I am financially responsible to CommonSense Wellness Network for all charges not covered by this assignment. In the event that my insurance company fails to meet its obligations with respect to payment of my claims, I give permission to CommonSense Wellness Network to file a complaint to the State Insurance Commissioner using my name as the complainant. I also understand that I will be informed, in writing, if this occurs.

As described above/in the informed consent, I understand that teletherapy and online mental health services are often not sufficient in the event of a crisis or emergency, as these services may not provide adequate assistance in these instances. Moreover if I am in crisis or someone I know is a threat to themselves, I should call the National Suicide Prevention Hotline at 1-800-273-8255 (where I can receive 24/7 support), the Trans Lifeline at 877-565-8860, contact local crisis services, or call 911.

This form is in addition to the Consent for Services form. Please read carefully.

I understand I have the following rights with respect to any services provided by my provider, as well as I understand the following about therapy and medical services:

I have the right to withhold or withdraw my consent at any time without affecting my right to future care or treatment.

I have the right to decline any treatment at any time, as well as the right to refuse any questions asked of me. I also have the right to end services at any time, however I am responsible for any sessions and services received thus far.

I have the right to engage and participate in treatment planning and goal development with my provider(s), and my engagement with CommonSense Wellness Network and course of therapy is in many ways dictated by me, the client.

I have the right to know the cost of any therapy and medical services I engage in with my provider(s).

The laws that protect the confidentiality of my medical information in person also apply to teletherapy and online mental health services. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including if I am at imminent risk of suicide, someone else's life is at risk, or a known child or elderly individual is being harmed (per state law and mandated reporter requirements). If I am assessed to be a possible harm to myself, my provider will take any and all measures to protect my confidentiality legally, as well as work with me to develop an agreement and safety plan. Moreover, confidentiality in these instances may be breached if I am unable to agree to a safety contract and agreement.

I have the right to request information about the qualifications of my provider(s), as well as those of any licensed professionals supervising my provider, as well as request a summary of my treatment including any documented diagnosis, progress, and treatment summary.

I have the right to be treated with dignity and respect regardless of my sexual orientation, race, gender identity, ethnicity, sex, physical or mental ability.

I understand that there are potential risks and benefits associated with any form of psychotherapy and medical services, and that despite the efforts of CommonSense Wellness Network and my provider, issues I am facing and navigating may not improve and in some cases may even worsen during this time. Moreover, I understand that I may benefit from various forms of therapy including those offered by my provider, however results cannot be guaranteed or assured.

I understand that my provider(s) is responsible for my clinical care, and that CommonSense Wellness Network's role is to support my provider. Moreover, I understand that CommonSense Wellness Network itself does not provide clinical services, rather it provides the means for my provider to engage in clinical services.

I have the right to file a complaint with applicable government agencies or professional associations if I believe I have been treated unethically.

My information will not be shared with any outside entities or other providers without my written consent, except: in the event of crisis or emergency (also see above), if my treatment involves the services of business associates that CommonSense Wellness Network is partnered and contracted with (under a BAA, or business association agreement), and for the purposes of obtaining payment for services from my insurance company or (if all else fails) a collection agency.

My treatment and sessions will not be recorded or videotaped without my explicit and written permission. Additionally, I understand that I am not permitted to record and share in-person or online therapy and medical sessions in any way, and doing so may result in immediate termination by my provider and a referral for services elsewhere.

I understand my information may be requested by a court or judge and that my provider will only release information required and necessary to fulfill the request of any received subpoenas or court orders. Moreover, such requests will always be communicated to me, the client, and my provider(s) will always approach these situations with me, the client, as first and top priority.

Lastly, I understand it is my responsibility to provide accurate information to my provider(s) and CommonSense Wellness Network, to treat my provider(s) and CommonSense Wellness Network providers in general with respect and dignity, and to make every effort possible to meet payment agreements arranged by myself and my provider(s). It is also my responsibility to provide current and accurate contact information including a billing address, phone number, and (if applicable) e-mail.

Each self-pay financial agreement is with one, specific provider, and may not apply to all of your providers within the CommonSense network. It is important to understand which provider this agreement is in regards to — please consult with CommonSense administrative staff, or your assigned providers, with any questions prior to completion of this form. IF you work with multiple CSWN providers and you indicate this agreement as applying to a CSWN provider who you have NOT discussed such terms with (or with CSWN staff), then this agreement may not be applicable to them. Moreover, fee agreements established with one CSWN provider do not automatically apply to all of your CSWN providers by default.

This form documents and asserts above-mentioned client and their provider agree to a self-pay financial plan for the duration of the client's work with said providers, unless otherwise noted (if/when future agreements are made).

For reference, full fee per session is as follows:
— Mental health counselor pre-licensed: $100 follow-up (53 min); $100 intake (45 to 60 min)
— Licensed mental health counselor or social worker: $200 follow-up (53 min); $225 intake (45 to 60 min)
— Nurse practitioner: $200 (15 to 30 min) or $300 (45 min) follow-up; $400 psychiatric assessment (45 to 90 min)

CommonSense Wellness Network does not discriminate based on client's ability to pay, and will make every attempt to offer sliding scale and pro-bono options when they are available. However, these cannot be guaranteed as sliding scale and pro-bono slots are limited and subject to provider availability. Please see our website or informed consent for more information regarding our sliding scale.

Note: the full fee for any CSWN mental health counselor/social worker provider is $225 for intake, $200 for follow ups (such as when billing insurance), however in the event of self-pay with a pre-licensed provider, the $100 rate indicated above is the highest a client would be charged per paid 53 min session, as such arrangements are subject to an automatic, lower sliding scale.

While you are responsible for any fees described in this agreement, please refer to our website and informed consent for examples of yearly service cost projections. These projections are required by the No Surprises Act and may not reflect your specific, agreed-upon fee or frequency of treatment.

For those agreeing to a sliding scale fee, changes in session fee must be agreed upon by the client and provider.

PLEASE NOTE: frequency of sessions within a private practice setting, especially over the course of a year, can NEVER be guaranteed, as many factors may impact the frequency of services. Additionally, yearly cost projections are difficult to establish because services are generally charged for at the time of session (known as "fee-for-service"). Ultimately, you (the client) must agree to any change in service frequency prior to such change, and you would do so knowing the service fee per session. This allows you to establish your own informed cost projections, and those most accurate and consistent to your individual care.

When determining eligibility for sliding scale, clients are not required to provide documentation or proof of income. Additionally, CSWN may suggest applying the "1/1000" rule — where a client's (or family) gross yearly income is divided by 1/1000, and this equates to the sliding scale fee.

Example: client making $100k a year would pay $100 per session with a therapist. Sliding scale for licensed therapists (mental health counselors and social workers) may go as low as $85 per session. For limited-permit and pre-licensed therapists, including interns, the sliding scale may go as low as $60 per session.

Sliding scale for nurse practitioners is generally full fee only (if insurance cannot be utilized).

Session fees are due at the time of session. Unpaid fees by the client (over 30 days, unless otherwise agreed upon with the therapist) may be subject to billing collection, including and up to having such fees sent to a collection agency.

What this means: If you consent, your provider may use an AI tool to generate a draft progress note from a de-identified transcript of your session. All identifying information is removed before processing. The draft is reviewed and edited by your provider before becoming part of your record.

Your rights: You may withdraw this consent at any time by contacting your provider. Refusing consent does not affect the quality of your care.

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