Informed Consent for Mental Health Services

1. What Counseling Is  

Counseling is a process that can help you explore challenging situations that may be confusing and painful in your life with the goal of developing awareness and skills to live more effectively. It can often provide assistance in dealing with personal problems, making life decisions (e.g., selecting a career or academic major), and improving personal relationships. The counselor doesn't make decisions for you or change you; he/she creates an atmosphere in which you can do these things for yourself.    

Counseling can, in some cases, evoke unpleasant memories and/or arouse strong emotions related to events in your life. Should feelings like these arise they will be dealt with in the context of the counseling process.  

2. Professional Ethics & Confidentiality  

A professional code of ethics governs the counseling relationship. A key aspect of ethical practice is confidentiality. Information you share with your counselor will not be divulged to anyone who is not involved in the treatment process without your written permission. However, there are some limits as outlined in the Notice of Privacy Practice for Western Michigan University. This document is available for you to review upon request.  

A brief record is made of your counseling contacts. This information, which is confidential, is maintained in a secure database. Counseling records are entirely separate from all other aspects of the University and will be released only with your written permission. You can review your counseling records in compliance with HIPAA regulations.

In addition, your case may be brought to a multidisciplinary case review committee for the purpose of coordinating care and treatment recommendations. This review committee is comprised of Sindecuse Health Center professionals who include counselors, psychologists, social workers, psychiatrists, other physicians and medical providers.  

Your signature below shows your understanding of and consent to case review and consultation between members of the SHC - multidisciplinary case review committee.  

3. Referrals  

On occasion, when your counselor feels that the services of another professional may be helpful, he/she may suggest a referral. This may include counseling with another provider, a consultation for medication or other medical treatment, career testing, academic skills development, etc .  

4. Counseling/Assessment Questionnaire

• Assessments are used to help determine your personal counseling needs and assess your progress. Your cooperation will be beneficial to the counseling process. A counselor will review the results of your assessment information and determine the most appropriate services for you.  
• The frequency of appointments is based upon your individual needs as determined by your counselor's professional judgment and available resources.  
• Although every effort is made to provide services as soon as possible, there are times during the academic year when a wait list for individual counseling is necessary.  
• It is important to be prompt in keeping appointments. Counseling time is very valuable. If you must cancel a session, you are required to cancel within four (4) hours prior to your appointment time and inform the receptionist. Late cancellation and no-show fees are detailed in a section below.
• Occasionally you may be asked to complete a brief evaluation questionnaire about the services you received. This anonymous feedback is very helpful to us in continuing to provide quality services.  
• For the benefit of your treatment it may be necessary for other professional staff to discuss aspects of your case with each other. This will remain confidential among those staff members, and will only occur when appropriate. 
• Counseling Services is also a training agency for advanced graduate students in the helping professions. The professional services they render are closely supervised by counseling faculty. If you work with a trainee you may be asked to audio or videotape your sessions for supervision purposes.  
• If you feel an urgent need to contact a mental health counseling resource when we are closed, you may call Gryphon Place Help Line at (269) 381-4357. You can receive emergency psychiatric treatment 24 hours a day through the Borgess Medical Center Emergency Room, 1521 Gull Road, (269) 226 -4815.  

Please let your therapist know if you have any questions about the above information.   

1. Introduction  

This informed consent explains the nature of psychiatric services provided, your rights and responsibilities, confidentiality, and how your health insurance will be utilized. Your understanding and agreement to these terms are essential for effective treatment.  

2. Nature of Psychiatric Services  

Psychiatric services at Sindecuse include psychiatric evaluations, medication management, and consultations. These services are designed to address various mental health conditions such as anxiety disorders, depression, bipolar disorder, schizophrenia, ADHD, and other psychiatric concerns.   

At Sindecuse Health Center, your care will be provided by licensed mental health professionals who are dedicated to supporting your well-being. Additionally, because Sindecuse is a training facility, you may also be seen by psychiatry residents in the advanced stages of their professional education. These residents work under the close supervision of experienced licensed professionals, supervision to maintain the highest standards of care maintained. Your treatment plan may involve both direct care from licensed professionals and services provided by supervised residents, offering you a comprehensive and collaborative approach to your mental health care.  

Medication Management:  

• Evaluation and Prescription: A psychiatrist will evaluate your symptoms and medical history to determine whether medication may be an appropriate part of your treatment plan. If prescribed, the psychiatrist will explain the potential benefits, risks, and side effects of the medication.  
• Ongoing Monitoring: Regular follow-up appointments will be scheduled to monitor the effectiveness of the medication, manage any side effects, and make adjustments as necessary.  
• Combination with Therapy: Medication management is often most effective when combined with psychotherapy or other therapeutic interventions, which may be provided by other departments at Sindecuse.  

3. Confidentiality  

Confidentiality is fundamental to psychiatric care. Information shared during your sessions is protected by law and will not be disclosed without your written consent. However, there are certain exceptions, including:  

• If there is a risk of harm to yourself or others.  
• If there is suspected abuse or neglect of a child, elderly person, or dependent adult.  
• If a court order mandates the release of records.  
• If there is a medical emergency requiring disclosure to medical personnel.  

4. Use of Health Insurance  

We accept a variety of health insurance plans to cover psychiatric services. By using your health insurance, you agree to allow Sindecuse Health Center to bill your insurance provider for services rendered. This process involves sharing necessary information with your insurance provider, such as diagnostic codes, treatment plans, and medication information.  

Understanding Insurance Coverage:  

• It is your responsibility to understand your insurance benefits and coverage for psychiatric services.  
• You may be responsible for any co-payments, deductibles, or services not covered by your insurance plan.  
• Some insurance plans may require pre-authorization or limit the number of sessions or medications covered.  

5. Client Rights and Responsibilities  

As a client, you have the right to:  

• Receive considerate and respectful care.  
• Participate actively in your treatment plan.  
• Be informed about your diagnosis, treatment options, and the risks and benefits of medication.  
• Ask questions about your treatment and express any concerns.  

You also have the responsibility to:  

• Attend scheduled appointments or notify us within 24 hours if you cannot attend.  
• Adhere to the no-show policy, which includes a $100 charge for missed appointments without sufficient notice.  
• Follow the prescribed medication regimen and report any side effects or concerns promptly.  
• Provide accurate and complete information about your health, including any other medications or treatments you are receiving.  
• If you have seen a previous provider(s) for this concern, we must have those records in hand before an initial appointment is made. This may include records from hospitalization, providers/therapists and other attended programs.  

6. The Psychiatric Process  

Engaging in psychiatric care is a crucial step toward managing your mental health. However, the outcome of your treatment largely depends on your active participation, adherence to prescribed medications, and engagement with any recommended therapeutic interventions.  

Please understand that psychiatric treatment, including medication, may involve side effects and requires close monitoring. While medications can be effective in managing symptoms, there are no guaranteed outcomes. Your commitment to following the treatment plan and communicating openly with your psychiatrist will be crucial to your progress.  

We cannot promise that your symptoms will resolve entirely or that your circumstances will change. However, we are committed to supporting you, monitoring your progress, and adjusting your treatment plan as needed. Your active involvement in your care, both in following medical advice and applying the recommendations in your daily life, will play a key role in your recovery.  

7. Termination of Services  

You may choose to discontinue psychiatric services at any time. It is recommended you discuss your decision with your psychiatrist to develop an appropriate plan for tapering off medication, if needed. Sindecuse Health Center also reserves the right to terminate services if it is determined that psychiatric care is not beneficial, if policies are not adhered to, if a higher level of care is needed to adequately address your concerns, or if there is inconsistency with appointments or engagement in behaviors that disrupt the therapeutic process. In such cases, we will assist in referring you to an appropriate provider or facility that can offer the necessary level of care.  

8. Acknowledgment and Consent  

By signing below, you acknowledge that you have read and understood this informed consent document. You agree to the terms outlined and consent to receive psychiatric services at Sindecuse Health Center, including the use of your health insurance for payment of these services.  

1. Introduction  

This informed consent outlines the nature of the mental health services provided, your rights and responsibilities, confidentiality, and how your health insurance will be utilized. Your understanding and agreement to these terms are crucial for effective treatment.  

2. Nature of Mental Health Services  

Mental health services at Sindecuse include individual therapy, group therapy, crisis intervention, case management, and consultation services. These services are designed to address various mental health concerns such as performance issues, anxiety, depression, stress, trauma, sports trauma, relationship issues and attachment, and more.  

At Sindecuse Health Center, your care will be provided by licensed mental health professionals who are dedicated to supporting your well-being. Additionally, because Sindecuse is a training facility, you may also be seen by student interns in the advanced stages of their professional education. These interns work under the close supervision of experienced licensed professionals, with weekly supervision to ensure the highest standards of care are maintained. Your treatment plan may involve both direct care from licensed professionals and services provided by supervised interns, offering you a comprehensive and collaborative approach to your mental health care.  

Our therapeutic approach is comprehensive and may include both top-down and bottom-up therapies, depending on your needs.  

Top-Down Therapies:  

Top-down therapies focus on the cognitive processes, helping you to understand and change your thoughts, beliefs, and behaviors. These approaches may include:  

• Cognitive-Behavioral Therapy (CBT): Focuses on identifying and changing negative thought patterns and behaviors.  
• Mindfulness-Based Therapy: Emphasizes being present and fully engaged in the moment to reduce stress and improve mental well-being.  
• Psychodynamic Therapy: Explores unconscious processes and past experiences to gain insight into current behavior.  

Bottom-Up Therapies:  

Bottom-up therapies emphasize the regulation of the nervous system and address trauma by working through bodily sensations and physiological responses. These therapies may include:  

• Accelerated Experiential Dynamic Psychotherapy (AEDP): Focuses on healing trauma by fostering emotional processing and connection within a safe, therapeutic relationship.  
• Brainspotting: Targets specific eye positions to process and release stored trauma in the body.  
• Eye Movement Desensitization and Reprocessing (EMDR): Utilizes bilateral stimulation to help reprocess traumatic memories.  
• Somatic-Based Therapies: Involve body-focused and sensory-based interventions that help regulate the nervous system and release trauma stored in the body.  

Please note that these are examples of the therapeutic approaches we offer, and your treatment plan may include a combination of these or other therapies, customized to support your unique needs and goals. 

3. Confidentiality  

Confidentiality is a cornerstone of mental health care. Information shared during therapy sessions is protected by law and will not be disclosed without your written consent. However, there are exceptions to confidentiality, which include:  

• If there is a risk of harm to yourself or others.  
• If there is suspected abuse or neglect of a child, elderly person, or dependent adult.  
• If a court order mandates the release of records.  
• If there is a medical emergency requiring disclosure to medical personnel.  

4. Use of Health Insurance  

We accept a variety of health insurance plans to cover mental health services. By using your health insurance, you agree to allow Sindecuse Health Center to bill your insurance provider for services rendered. This process requires the sharing of necessary information with your insurance provider, including diagnostic codes, treatment plans, and session dates.  

Understanding Insurance Coverage:  

• It is your responsibility to understand your insurance benefits and coverage for mental health services.  
• You may be responsible for any co-payments, deductibles, or services not covered by your insurance plan.  
• Some insurance plans may require pre-authorization or limit the number of sessions covered.  

5. Client Rights and Responsibilities  

As a client, you have the right to:  

• Receive considerate and respectful care.  
• Participate actively in your treatment plan.  
• Ask questions about your treatment and express any concerns.  
• Request changes to your treatment or seek a second opinion.  

You also have the responsibility to:  

• Attend scheduled appointments or notify us within 24 hours if you cannot attend.  
• Adhere to the no-show policy, which includes a $100 charge for missed appointments without sufficient notice.  
• Actively engage in the treatment process.  
• Provide accurate and complete information about your health and mental health history.  
• If you have seen a previous provider(s) for this concern, we must have those records in hand before an initial appointment is made. This may include records from hospitalization, providers/therapists and other attended programs.

6. The Therapeutic Process  

Choosing to seek therapy is a significant and positive step toward your well-being. However, it's important to understand that the outcome of your treatment largely depends on your active participation and engagement in the therapeutic process. Therapy can, at times, be challenging and may involve recalling and addressing unpleasant events or feelings, which could lead to discomfort, including emotions such as anger, depression, or anxiety.  

While therapy can offer many benefits, including improved mood, enhanced coping strategies, and better relationships, there are no guaranteed outcomes. Change is a gradual process, and the effectiveness of therapy is influenced by your commitment to the process, both during sessions and in applying the insights and recommendations provided in your daily life.  

Please know that we cannot promise that your behavior or circumstances will change. However, we are committed to supporting you, striving to understand you, helping you recognize patterns, and working with you to clarify your goals. Your willingness to engage with the therapeutic process, both in and out of sessions, will be instrumental in your journey toward achieving the changes you seek.  

7. Termination of Services  

You may choose to discontinue therapy at any time. It is encouraged that you discuss your decision with your therapist so that an appropriate termination plan can be developed. Sindecuse Health Center also reserves the right to terminate services if it is determined that therapy is not beneficial, if policies are not adhered to, if a higher level of care is needed to adequately address your concerns, or if there is inconsistency with therapy sessions or engagement in therapy-disrupting behaviors. In such cases, we will assist in referring you to an appropriate provider or facility that can offer the necessary level of care.  

8. Acknowledgment and Consent  

By signing below, you acknowledge that you have read and understood this informed consent document. You agree to the terms outlined and consent to receive mental health services at Sindecuse Health Center, including the use of your health insurance for payment of these services.  

If you have questions or need further clarification, please ask your therapist in the Mental Health Department directly.  

Attending regularly scheduled appointments is necessary to provide quality care as demonstrated by the treatment plan. This policy ensures that patients/clients are aware that their mental health care may be terminated for non-participation. 

Counseling Services  

• You are required to cancel appointments more than 4 hours in advance in order to avoid a late cancellation fee of $20.  
• If you do not show for your appointment your student account will be charged $20.  
• Additionally, if you cancel or no-show 2 appointments in a row you will need to contact clinic for discussion on your mental health care needs.  

Psychiatry, Social Work and Dietitian Services  

• You are required to cancel appointments more than 24 hours in advance in order to avoid a late cancellation fee of $100.
• If you do not show for your appointment your WMU account will be charged a $100 no-show/late cancel fee.  
• In the event that you do not show for an appointment or late cancel (< 24 hours) an appointment for two (2) consecutive appointments  in a row or three (3) appointments within a twelve-month period, your provider may pursue closing your case .
• Psychiatric services will be provided by the Sindecuse Health Center  psychiatric provider for a maximum of 30 days from the last scheduled appointment.  

Providers will assist as able to connect patients/clients with appropriate services if no longer receiving care at Sindecuse Health Center.   

Sindecuse Health Center is a trainee facility, and trainees may be involved in your care.  

Counseling Services  

• Social Work interns and graduate students may be involved in your care  

Psychiatric Services  

• Psychiatric residents may be involved in your care  

Social Work Services  

• Social Work interns and graduate students may be involved in your care.  

All trainees are under the close supervision of experienced licensed professionals to maintain the highest standards of care. Your treatment plan may involve both direct care from licensed professionals and services provided by supervised trainees, offering you a comprehensive and collaborative approach to your mental health care. You may decline working with a trainee at the point of service but you acknowledge that this may delay, limit or reduce care options for you at Sindecuse Health Center.