mountain view medical center (mvmc) behavioral health

Revision Date: 07.09.2021

Mountain View Medical Center (MVMC)

Behavioral Health Client Rights

In Case of a Mental Health Emergency, Please Call:

Washington County 24 Hour Crisis Hotline: 503-291-9111 Crisis Text Hotline: 741741 Or go to your nearest Emergency Department. Vision & Mission:

“Providing hope while improving the health of our community, one patient at a time.”

Office Hours: All sessions are by appointment and are usually 55 minutes in length. Treatment may last up to six (6) to eight (8) weeks. During final session re-evaluation of goals will occur to determine continued course of treatment. Treatment will end when goals have been sufficiently achieved; or alternate services are identified as more appropriate.

Client Rights & Responsibilities:

Basic Rights: Therapy services shall not be denied or discriminated against to any individual or family on the basis

of race, color, creed, sex, sexual orientation, handicap, age, national origin or length of residence. You will be treated with respect and dignity. You will receive courteous and timely service in an environment that offers reasonable safety and

privacy. You will receive services from a therapist who has met at least the minimal qualifications of training

and experience required by state law. You have the right to be free from seclusion, restraint, abuse or neglect. You may report any incident of abuse or neglect, as well as other concerns, without retaliation.

Access and Information Rights:

You can receive services in a manner and language consistent with your culture, including access to an interpreter if needed.

You will be asked to give written informed consent prior to the start of services. You will be informed of the cost of services and any financial obligations you may have. You may receive services without parent or guardian consent when lawfully married, emancipated,

or age 14 or older for outpatient services. You have the right to receive care for behavioral health emergencies 24 hours per day, 7 days a

week either via telephone or in person by connecting with the Crisis Hotline. You and your therapist may define together what constitutes a mental health emergency. It is your responsibility to inform your therapist if a crisis was treated outside of MVMC.

Your Treatment Rights:

You will receive quality, trauma-sensitive care. You will receive information from your therapist about their credentials (including a Professional

Disclosure Statement, depending upon licensure). You will be an active participant in developing your goals for treatment and ensuring that the

services received are consistent with your goals. You may receive a written copy of the treatment plan identifying goals and services. You have the right to ask about risks and benefits of treatment and other treatment options

available.

You may, upon written request, receive a copy of any behavioral health documents originating from MVMC. There will be a fee to account for the copy costs.

You must give written permission before information about you or your treatment can be shared with anyone outside of MVMC. Your information and the services provided to you will be kept confidential per state and federal laws unless it falls under the following exceptions:

o Reporting suspected child abuse, elder abuse, neglect or domestic violence in the presence of children, whether past or present

o Reporting imminent danger to client or others o Reporting information required by your insurance company for reimbursement o Reporting to other relevant agencies as required by mandate. For instance, an agreement

has been created between the OHP system and local doctors that allows for exchange of protected health information to provide for more comprehensive client care.

o Responding to a court order o Defending claims brought against a therapist to their governing licensing board

You have a right to refuse treatment at any time, treatment if voluntary. You have the right to file a written or oral complaint relating to treatment or providers and receive

assistance in filing the complaint. You will receive prior notice of service conclusion or transfer, if services will be reduced or

terminated.

Your Responsibilities: You will treat others with courtesy and respect. You will provide information needed in order to provide care. You will participate, as much as possible, in developing mutually-agreed upon treatment goals. You will follow the treatment plans you have agreed to. You will inform providers of any dissatisfaction with services. You will arrive on time for scheduled appointments. If you are more than 10 minutes late

your appointment will be considered a failed appointment. You will call 12 hours or more ahead if you are unable to attend your scheduled appointment.

No-shows or late cancellations will be assessed a fee of $50. Three (3) or more late cancellations or no-shows may result in either termination of counseling service or completion of attendance contract with therapist.

You will inform MVMC of any changes in address, telephone numbers, and other personal information relating to treatment.

You will bring insurance information and cards to appointments and inform MVMC of any changes in coverage.

You will seek help for any addiction or behavioral health issue that may interfere with treatment. You will protect the confidentiality and safety of other individuals. You will not make threats of harm to other individuals, staff or providers, nor destroy property. The

consequences of such behavior may result in immediate termination of services to protect the safety of others.

You will use a respectful volume when speaking, being mindful that yelling may limit your privacy and trigger other individuals receiving services.

You will pay for any services received as described in the “Patient’s Responsibility for Payment” agreement signed at time of establishing care with MVMC.

You will please provide your therapist with a current copy of any divorce decree or parenting time agreement in order to assess who has the legal right to authorize treatment for your minor child(ren). Please keep in mind that any communications you send may be able to be accessed by the non-custodial parent.

Professional Credentials:

All behavioral health specialists at Mountain View Medical Center are licensed professionals. All therapy is regularly reviewed with supervision.

Philosophy of Therapy:

Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your or your child/youth’s life, you or your child/youth may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

At MVMC, we deliver trauma-informed services in order to have the least impact on client and client’s family. It is our goal to build professional relationships with our patients in order to provide a safe space to express their emotions and to tell their stories. We take a holistic view and believe in meeting the patients where they are to support where they may want to go.

The Therapy Process and Role of the Therapist: The therapist’s role is to assist you in determining the best course of treatment and to provide you with information regarding risks of treatment as well as treatment methods. During the first session (Behavioral Health Assessment) you and your therapist will make a decision whether to initiate therapy based on symptoms and diagnosis. At this time, you may be referred to a more suitable resource. If you continue therapy, you will partner with your therapist to develop a treatment plan based on your goals, objectives, and the interventions by which you are treated. This includes collaboration with your Primary Care Physician. It may include collaboration with your Psychiatrist, natural support(s), or anyone else you may wish to include with a signed authorization form. You always have the right to refuse these services and are encouraged to ask any questions about your treatment of programs policies.

Legal Issues and Proceedings: We aim to help children, adolescents, parents/caregivers and adults improve their behavioral health and overall wellness; we do not provide them with evaluation or testimony in the judicial system. Behavioral Health patients, and/or guardians of patients, who consent to treatment with MVMC Behavioral Health agree not to involve our therapists in their legal proceedings. If you need a forensic assessment or a therapist who will testify in court, we will attempt to assist you in finding a provider who offers those services.

I am acknowledging that I have read through my rights and responsibilities as a client at MVMC. Furthermore, I agree that I will abide by the responsibilities identified above and that any support persons that accompany me to my appointments will also be expected to adhere to these responsibilities.

Client: DOB: Signature (if 14 or older)

Client: Date: Printed Name

Parent/Guardian: Date: Signature

Parent/Guardian: Printed Name

Therapist: Date: Signature

Therapist: Printed Name


Mountain View Medical Center (MVMC)

Behavioral Health New Patient Form

PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS (This information is confidential

and will not be shared outside of this clinic). If you are a parent, guardian, or caregiver completing

this form for a child, please answer the questions from the child’s perspective.

Today’s Date: ______________

Legal Full Name: ________________________________ Preferred Name: _______________

Date of Birth: ___________________ Age: ______ Gender: ____Male ____Female ____Other

Pronouns used (he/his/him, she/her/hers, they/them/their, etc.):__________________________

What has led you to seek services through us today?

____________________________________________________________________________

Please check any of the following that you or your child is currently experiencing: Distractibility Sadness/depression Irritability/anger Hyperactivity Lack of motivation Aggression/fights Impulsivity Withdrawal from people Difficulty making friends Difficulty completing tasks Hopelessness Difficulty parenting Difficulty organizing Loneliness Obsessive thoughts Often loses important items Suicidal thoughts/attempts Compulsive behaviors Poor memory/confusion Self-harm School problems Anxiety/worry Change in appetite Substance abuse Fear about being away from home or caregiver

Loss of interest in things that used to be enjoyed

Visual or auditory hallucinations

Panic attacks Eating problems Homicidal thoughts Sleep problems Social anxiety Flashbacks Nightmares/terrors Low self-worth Racing thoughts Suspicious/paranoid Guilt/shame Foster care/DHS History of fire setting Mean to animals Poor boundaries Sexual activity Exposure to pornography Difficulties with attachment

Is this the first time the client is seeking counseling? ____Yes ____No

If No, where and when were counseling services last received?

___________________________________________________________________________

If services are for a child, do you have the legal authority to consent to this child’s treatment?

____Yes ____No

If the individual seeking counseling is a child, or is an adult or child under the supervision of a

guardian or caregiver, please provide documentation that you can legally consent to treatment

(court documents, power of attorney, etc.) and complete the following:

Parent/Legal Guardian Name, Address, Phone Number: _______________________________

Do you feel you are going to hurt yourself, someone else, an animal, or is someone hurting

you? ____Yes ____No

Are you required by court (or any other program; DHS/Child welfare, etc.) to be here? ____Yes

____ No

MVMC Behavioral Health

Disclosure of Health Information Agreement

D

The following specifies your rights about this authorization under the Health Insurance

Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”).

1. Tell your therapist if you don’t understand this authorization, and the therapist will

explain it to you.

2. You have the right to revoke or cancel this authorization at any time, except: (a) to the

extent information has already been shared based on this authorization; or (b) this

authorization was obtained as a condition of obtaining insurance coverage. To revoke or

cancel this authorization, you must submit your request in writing to business office at

the following address: 1909 Mountain View Ln., Ste 200, Forest Grove, OR 97116

3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability

to obtain treatment or payment or your eligibility for benefits.

4. Once the information about you leaves this office according to the terms of this

authorization, this office has no control over how it will be used by the recipient. You

need to be aware that at that point your information may no longer be protected by

HIPAA.

5. If this office initiated this authorization, you must receive a copy of the signed

authorization.

6. For information about HIV/AIDS, mental health, genetic testing, or alcohol/drug abuse

treatment, the authorization must clearly identify the specific information that may be

disclosed and the purpose.

7. If you are a minor, you may authorize the disclosure of mental health or substance

abuse information if you are the age 14 or older; for the disclosure of any information

about sexually transmitted diseases or birth control regardless of your age; for the

disclosure of general medical information if you are age 15 or older.

8. If the person signing this form is a personal representative, such as a guardian, a copy

of the legal documents that verify the representative’s authority to sign the authorization

must be attached to this form. Similarly, if an agency has custody and their

representative signs, their custody authority must be attached to this form.

Continued on next page

AUTHORIZATION FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

Patient’s Full Name (Please Print) Date of Birth

I authorize the Mountain View Medical Center – Behavioral Health to use and disclose

specific health information described and selected below. I understand and agree that

information will be disclosed if initialed by me.

To be disclosed to:

For the purpose of:

If the information to be disclosed contains any of the types of records or information listed

below, additional laws relating to the use and disclosure of the information may apply.

Entire Behavioral Health Chart

Behavioral Health treatment information (progress notes, treatment plan, discharge summary, etc.)

Drug/alcohol diagnosis, treatment, or referral information

Other: ______________________________________________________

I understand that the information used or disclosed pursuant to this authorization may be

subject to redisclosure and no longer be protected under federal law. However, I also

understand that federal or state law may restrict redisclosure of HIV/AIDs information,

behavioral health information, genetic testing information and drug/alcohol diagnosis, treatment

or referral information.

Authorization and Signature: I authorize the release of my confidential protected health

information, as described in my directions above. I understand that this authorization is

voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to

be made to conform to my directions. The information that is used and/or disclosed pursuant to

this authorization may be re-disclosed by the recipient unless the recipient is covered by state

laws that limit the use and/or disclosure of my confidential protected health information.

Client: Date:

Signature (if 14 or older)

Parent/Guardian: Date:

Signature

Parent/Guardian:

Printed Name

*This consent is subject to revocation and will apply from the date revocation is placed forward. Any information shared prior

will be deemed within permission given. If not previously revoked, this consent will terminate upon (specific date, even or

condition): ____________________________________________________________________



Limits of Confidentiality

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows: Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the behavioral health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the behavioral health professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. Abuse of Children and Vulnerable Adults If a client states or suggests that he/she is being or has been abused, the behavioral health professional is required to report this information to the appropriate social service and/or legal authorities. If a client states or suggests that he/she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the behavioral health professional is required to report this information to the appropriate social service and/or legal authorities. Prenatal Exposure to Controlled Substances Behavioral Health professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. (Under Oregon Law, both custodial parents and non-custodial parents have the right to access clients’ records.) The Behavioral Health professional will make an attempt to inform both parents of child’s therapy if there are no legal documents stating otherwise, and/or it has been determined that there will be no harm to child/adolescent. Consultation Your Behavioral Health professional may consult another Behavioral Health professional, and with medical staff, from MVMC from which you or your family receive services. All MVMC staff are obligated to keep your information confidential and expected to share your information within the program only on a need-to-know basis. Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

Continued on next page

Payments If you become delinquent in your payments, MVMC has the right to provide your name, address, and amount due to a collection agency so that the collection agency can attempt to secure payment from you. Legal A court may order a release of information or subpoena a MVMC Behavioral Health professional. Likewise, records will be released if you bring a lawsuit against a MVMC Behavioral Health professional. (In both cases, the BH professional will make it known to the courts that disclosure of any confidential behavioral health information is only shared after being ordered by the presiding judge; unless client has signed an authorization form.) Emergency Situations If you need emergency medical care but cannot give consent because of your condition, or parents or legal guardian cannot be contacted in a timely manner, MVMC must release information necessary to obtain medical care. In an urgent situation, MVMC will honor your verbal release (as documented in the clinical record) for verbal and/or written information sharing to facilitate coordination of care. Audits Program, State, or Federal audits (client files are reviewed by professionals). Appointment Reminders MVMC may call or text to remind or confirm client of their appointment date and time.

I agree to the above limits of confidentiality and understand their meanings and ramifications.

Client: DOB: Signature (if 14 or older)

Client: Date: Printed Name

Parent/Guardian: Date: Signature

Parent/Guardian: Printed Name



Informed Consent

I understand that as a condition to my receiving treatment from Mountain View Medical Center (MVMC),

the clinic may use or disclose my personal identified health information to obtain payment for the

treatment provided, and as necessary for the operation of MVMC. These uses and disclosures are more

fully explained in the Privacy Notice that was provided to me at the time of establishing care.

**I understand that the privacy practices described in the Privacy Notice may change over time and that

I have the right to obtain any revised Privacy Notice by contacting the medical office at 503-359-4773.

COMMUNICATION:

I understand and give permission for MVMC to call and leave a voicemail and/or text message at the

number provided at the time of intake. These types of communications are a courtesy and will serve as

appointment reminders only. MVMC is committed to protecting your Protected Health Information

(PHI) while providing you with ease of communication. There are some risks associated with the use of

*standard email, standard text, and standard voice mail. If you would like us to use standard text

messages or standard voice mail to communicate with you, we need to inform you of the risks

associated with standard electronic communications, get your permission, and let you know that MVMC

is not responsible for any unauthorized access that may occur as a result of standard electronic

communications we send with your permission. *Standard or unencrypted implies that there are no

security measures put in place and that it is NOT HIPAA compliant.

The primary use of any electronic forms of communication is solely for appointment-making, cancelling,

and/or rescheduling. It is not intended for therapeutic practice.

Risks Associated with Standard Email, Text, or Voice Mails

Standard messages are inherently insecure.

Messages may not reach the intended recipient as messages can be lost in transmission, delayed

or intercepted by an unintended party.

Appointment reminders and other communications could identify you as a client of MVMC.

There is risk of theft or loss of device.

Backup copies may remain even if deleted from device.

Your mobile carrier may impose additional charges for texting which MVMC will not be

responsible for.

Your Behavioral Health specialist is not often immediately available by telephone. Their office hours are

between 8am and 5pm, however during this time any calls made will be answered by a MVMC staff

member. You may leave a message for you Behavioral Health specialist and they will do their best to

return the call within 2 business days (if you are difficult to reach, please advise of times when you will

be available for the specialist to return your call). If you are experiencing a mental health emergency

please contact your local crisis line or go to your nearest emergency department.

Washington County 24 Hour Crisis Hotline: 503-291-9111 or text 741741

Yamhill County 24 Hour Crisis Line: 844-842-8200

If your Behavioral Health specialist will be unavailable for an extended period of time a member of the

MVMC Behavioral Health team may assist in the interim.

Professional Records

Law and standards pertaining to Behavioral Health require that your Behavioral Health specialist keep

treatment records. You are entitled to receive a copy or summary of your records; however, because

they are profession records they can be misinterpreted and/or upsetting to untrained readers. If you

wish to see your records it is recommended that you do so in the presence of you Behavioral Health

specialist to discuss the content. Requests for medical records will incur a fee for copy expenses.

Minors and Custody

MVMC Behavioral Health specialists will not conduct custody evaluation, determine whether a parent is

"fit", recommend one parent over another, nor focus on reunification of a child and parent. The

therapist will not testify in court about custody issues, unless compelled by a court. For children with

divorced parents, the therapist expects the parents to communicate with each other about services,

decide who will schedule appointments, who will bring the child to treatment, etc. The therapist and

the child cannot be messengers between parents. Both parents will have access to a child's record,

regardless of custody, unless parental rights have been restricted or revoked. The therapist keeps

records about your child's treatment, records will also include child-focused information supplied by

each parent. Please recognize that any information you disclose to the therapist will be included in

your child's treatment record.

Children benefit from an expectation of some privacy while receiving treatment, the therapist not

generally share details of what a child says or does in treatment. They will share with you your child’s

progress or lack of progress in treatment, as well as notify parents/guardians of any risks of harm to self

or others. Parents are included in treated for the benefit of the child.

**For those under the age of 18, please be aware that the law may provide your parents the right to

examine your treatment records.

I agree that Mountain View Medical Center Medical Providers and MVMC Behavioral Health Team may exchange my/my child’s personal health information for the purpose of, and when necessary for: evaluation; treatment; care coordination; and/or continuing care. (Initial line for consent).

Payment/No Show/Cancellation Policy

All MVMC policies pertaining to payment, no show, and cancellation that were signed at the time of

establishing care at MVMC remain in effect and will continue to be enforced regardless of treatment

being sought, e.g. medical or behavioral health treatment.

If you would like to see these policies again please ask reception or contact the business office by calling

503-359-4773.

TERMINATION

You have the right to terminate treatment at any time. If problems arise in therapy, we ask that you

discuss your concerns with your Behavioral Health specialist prior to terminating treatment. A lapse in

treatment for thirty (30) days or more, without prior notification, will result in a closure of behavioral

health treatment and inability to provide any further behavioral health services until you contact the

clinic.

My termination will be effective on the date I request, except to the extent that MVMC has taken action

in reliance on my consent for use or disclosure of my health information (billing, release of information,

etc). Provisions of future treatment may be withdrawn if I withdraw my consent.

My initials indicate I was offered a copy of the following documents and understand the terms and

conditions set forth:

Rights and Responsibilities of Clients

Limits of Confidentiality

Informed Consent Form

I consent to therapy at Mountain View Medical Center for myself and/or my child listed below. I

understand that my participation is voluntary.

Client: DOB:

Signature (if 14 or older)

Client: Date:

Printed Name

Parent/Guardian: Date:

Signature

Parent/Guardian:

Printed Name

mountain view medical center (mvmc) behavioral health

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