You will be given copies of the following forms when you come to the Carruth Center for the first time. Please feel free to discuss any questions you may have about them with your counselor. She or he will also ask you to sign an Acknowledgement of Consent for Treatment indicating that you have received these forms and had the opportunity to read and discuss them.
Informed Consent for Psychotherapy or Other Services
Welcome to the Carruth Center for Counseling and Psychological Services. Thank you for trusting us to assist you with your personal concerns. Please take the time to read and understand this document and ask your therapist about any portions which may be unclear to you.
This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices. The accompanying Notice of Privacy Practices explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information before we provide any services. You may revoke this Agreement in writing at any time.
Services
The psychological services we provide include individual, couples, and group psychotherapy, as well as psychological testing. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy calls for an active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. On the other hand, psychotherapy has also been shown to have many benefits. 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.
In your first session your therapist will offer you some sense of what therapy will entail and how she or he will work with you to address your concerns. You should evaluate this information and whether you feel comfortable working with your therapist. If you have questions about our procedures, you should discuss them with your therapist whenever they arise. You have the right to ask for the rationale for any aspect of your treatment or to decline any part of your treatment. You also have the right to request another therapist. While we encourage you to discuss your concerns with your current therapist to explore why things may not be working out, you are under no obligation to do so.
If you are here for psychological testing, you have the right to an explanation of what the test or tests being administered are for, and you may decline participation at any time. You also have the right to a summary (which may be either verbal or written) of any test results.
Eligibility and Fees
Carruth Center services are available to all undergraduate and graduate students who provide proof of eligibility and have paid the appropriate fees. Students who are not enrolled for Summer I or II are eligible for services only if they were enrolled for the previous spring semester, have pre-registered for the fall semester, and have paid the “Summer Services Fee” through the Bursar’s office. A current WVU ID card or a receipt to show that these fees have been paid is required.
Individual counseling sessions are available at no additional cost at the Carruth Center. If you opt to obtain services at our satellite office at Health Sciences South, we are required by the Health Sciences Center to collect a $10-per-session co-pay at the time of services.
Testing services are available at additional cost, payable in advance. Please see our price list for testing services, obtainable from your therapist or the front desk staff.
Policies Regarding Appointments
Individual and couples therapy appointments are generally for 50 minutes and are typically scheduled once per week at a time you and your therapist agree on. That appointment time is a standing time each week, and will be reserved for you until you no longer want it or you have reached your 12 session limit for the year. If you cannot make a scheduled appointment, it is your responsibility to call 293-4431 to cancel. If you forget an appointment, call 293-4431 as soon as possible to reschedule. If you miss your appointment and do not call to reschedule, your standing appointment time will not be held for you, and there is no guarantee your therapist will have another available appointment time. If this occurs you may choose to be placed on the waitlist and reassigned, and you may use our Walk-in Counseling Clinic in the meantime.
Therapy groups usually meet once a week for 90 minutes. Before joining a group you must meet with one of the co-therapists to discuss your interest in the group and any questions or concerns you may have. Once you have joined a group, you are expected to attend all sessions. If you must miss, let the group know the week beforehand. If that is not possible, please call one of the group co-therapists to cancel.
Please note that email is not a secure form of communication and is not recommended as a means of contacting your therapist for any treatment-related concerns. Unless your therapist and you agree otherwise, please call to leave any messages, and talk with the front desk staff if you need to cancel or reschedule an appointment. Note that any communication you have with a therapist outside of a regular appointment session may be recorded in your file at the Carruth Center. Communication could be information shared face-to-face with your therapist, email messages, phone calls, etc.
In an Emergency
In some instances, you might need immediate help at a time when your therapist is not at the Carruth Center or cannot return your call. These emergencies may involve suicidal thoughts, thoughts of wanting to hurt someone else, or thoughts of committing dangerous acts. If you find yourself in any emergency situation between 9 AM and 4 PM, Monday through Friday, come to our Walk-in Counseling Clinic and ask to talk with any available counselor. At other times, call 293-4431 and ask to speak with the counselor on call. When our office is closed the WVU Department of Public Safety answers our phone. The officer who takes your call will immediately call the counselor on duty, who will return your call. If for whatever reason that option is not available to you, visit the nearest Emergency Room and ask for the mental health professional on call.
Below are some additional numbers which are answered on a 24-hour basis and may be helpful to you in case of an emergency:
- Valley Health Care System Emergency Hotline: 1-800-232-0020
- Rape and Domestic Violence Information Center: 292-5100
Limits of Confidentiality
The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written authorization form. There are other situations that require only that you provide written, advance consent. Your signature on the accompanying Acknowledgment of Informed Consent to Treatment form provides consent for those activities, as follows:
- We train advanced graduate students from the mental health professions, and also employ psychologists who are not yet licensed in West Virginia. Licensed psychologists on our staff supervise them, which includes reviewing treatment plans and progress, and signing off on all notes and other documents that go into your permanent file. You have the right to know the name of any supervisor and how to contact her or him; the staff member you meet with will provide this information at the outset.
- Because of our training mission, the staff member you meet with may ask your permission to record sessions for confidential supervisory and training purposes. Audiotapes and videotapes are kept in a locked cabinet and erased at the end of your treatment or at the end of each semester. Occasionally, tapes and other clinical materials (e.g. test results) may be presented in case conferences or other internal Carruth Center training seminars for our professional staff. In such instances, potentially identifying information about you will be altered to protect your anonymity.
- Your therapist may also occasionally find it helpful to consult with other Carruth Center professional staff members about a case. If you don’t object, your therapist will not tell you about these consultations unless he or she feels that it is important to your work together. Your therapist will note all consultations in your Clinical Record.
- Finally, we employ administrative staff and we need to share protected information with them for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside the Carruth Center without the permission of a professional staff member.
- If you are involved in a court proceeding and a request is made for information concerning your treatment, we cannot provide such information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information.
- If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
- If a client files a complaint or lawsuit against a therapist, we may disclose relevant information regarding that client in order to defend the therapist.
- If a client files a worker’s compensation claim, we must, upon appropriate request, provide a copy of the client’s record or a report of her/his treatment.
- If your therapist has reason to believe that a child or vulnerable adult is being neglected or abused, the law requires that the situation be reported to the appropriate state agency.
- If the therapist believes you present a clear and substantial danger of harm to yourself or another/others, he or she will take protective actions. These may include contacting family members, seeking hospitalization for you, notifying any potential victim(s), and notifying the police.
Professional Records
The laws and standards of our profession require that we keep Protected Health Information about you in your Clinical Record. Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem affects your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, results of clinical tests (including raw test data), any past treatment records that we receive from other providers, reports of any professional consultations, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of your Clinical Record, if you request it in writing, except in unusual circumstances that involve danger to yourself and/or others or when another individual (other than another health care provider) is referenced and we believe disclosing that information puts the other person at risk of substantial harm. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We therefore recommend that you initially review them in the presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we are allowed to charge a copying feel of $.10 per page. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.
In addition, your therapist may also keep a set of psychotherapy notes which are for his or her own use and designed to assist your therapist in providing you with the best treatment. These notes are kept separate from your Clinical Record. They are not routinely released to others with your Clinical Record, except under rare legal circumstances.
Minors
If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. Before giving parents any information we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss.
In Conclusion
Your signature on the accompanying Acknowledgement of Informed Consent to Treatment form indicates you have read the information in this document and agree to abide by its terms during our professional relationship.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed by the Carruth Center for Counseling and Psychological Services and how you can get access to this information. Please review this notice carefully.
Understanding Your Protected Health Information (PHI)
When you visit us, a record is made of your symptoms, assessments, test results, diagnoses, treatment plan, and other mental health or medical information. Your record is the physical property of the Carruth Center, the information within which belongs to you. Being aware of what is in your record will help you to make more informed decisions when authorizing disclosure to others. In using and disclosing your protected health information (PHI), it is our objective to follow the Privacy Standards of the Federal Health Insurance Portability and Accountability Act (HIPAA) and requirements of West Virginia law.
Your mental health and/or medical record serves as
- a basis for planning your care and treatment
- a means of communication among the health professionals who may contribute to your care
- a legal document describing the care you received
- a means by which you or a third-party payer can verify that services billed were actually provided
- a source of information for public health officials charged with improving the health of the nation
- a source of data for facility planning
- a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Responsibilities of the Carruth Center for Counseling and Psychological Services
We are required to:
-Maintain the privacy of your protected health information (PHI) as required by law and provide you with notice of our legal duties and privacy practices with respect to the protected health information that we collect and maintain about you.
-Abide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and to make the new provisions effective for all protected health information that we maintain, including that obtained prior to the change. Should our information practices change, we will post new changes in the reception room and provide you with a copy, upon request.
-Notify you if we are unable to agree to a requested restriction.
-Accommodate reasonable requests to communicate with you about protected health information by alternative means or at alternative locations, e.g. you may not want a family member to know that you are being seen at the Carruth Center. At your request, we will communicate with you, if needed, at a different location.
-Use or disclose your health information only with your authorization except as described in this notice.
Your Protected Health Information (PHI) Rights
You have the right to:
-review and obtain a paper copy of the notice of privacy practices upon request and of your health information, except that you are not entitled to access, or to obtain a copy of, psychotherapy notes and a few other exceptions may apply. Copy charges may apply.
-request and provide written authorization and permission to release information for purposes of outside treatment and health care operations. This authorization excludes psychotherapy notes and any audio/video tapes that may have been made with your permission by your mental health clinician.
-revoke your authorization in writing at any time to use, disclose, or restrict health information except to the extent that action has already been taken.
-request a restriction on certain uses and disclosures of protected health information, but we are not required to agree to the restriction request. You should address your restriction request in writing to the Carruth Center Director. We will notify you within 10 days if we cannot agree to the restriction.
-request that we amend your health information by submitting a written request with the reasons supporting the request to the Carruth Center Director. We are not required to agree to the requested amendment.
-obtain an accounting of disclosures of your health information for purposes other than treatment, payment, health care operations and certain other activities for the last six years but not before April 14, 2003.
-request confidential communications of your health information by alternative means or at alternative locations.
Disclosures for Treatment, Payment and Health Operations
I. The Carruth Center will use your PHI, with your consent, in the following circumstances:
Treatment: Information obtained by your psychologist/counselor or from a nurse, physician, dentist or other member of your health care team will be recorded in your record and used to determine the management and coordination of treatment that will be provided for you.
For payment, if applicable: We may send a bill for testing to the Division of Rehabilitation Services or WVU Athletics. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis to obtain reimbursement for your health care or to determine eligibility or coverage.
For health care operations. Members of the Carruth Center Administration may use information in your health record to assess the performance and operations of our services. This information will then be used in an effort to continually improve the quality and effectiveness of the mental health care and services we provide.
Disclosure to others outside of the Carruth Center: If you give us a written authorization, you may revoke it in writing at any time, but that revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your health information without your authorization, except as described below to report serious threat to health or safety or child and adult abuse or neglect.
II. The Carruth Center will use your PHI, without your consent or authorization, in the following circumstances:
Child Abuse: If we have reasonable cause to suspect that a child known to us in the course of professional duties has been abused or neglected, or have reason to believe that a child known to us in the course of our professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, we must report this to the relevant county department, child welfare agency, police, or sheriff’s department.For More Information or to report a problem
Adult and Domestic Abuse: If we believe that a vulnerable adult (ex. incapacitated or facility resident) is the victim of abuse, neglect or domestic violence or the possible victim of other crimes, we may report such information to the relevant county department or state official.
Serious Threat to Health or Safety: If we have reason to believe, exercising best judgment and our professional care and skill, that you may cause serious harm to yourself or another person, we may take steps, without your consent, to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition in order to protect you or another person from harm. This may include instituting commitment proceedings.
Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release the information without written authorization from you or your personal or legally-appointed representative, or a subpoena/court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered.
As required by law for national security and law enforcement: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information for law enforcement purposes as required by law or in response to a valid court order.
Law/Health Oversight: As required by law we may disclose your health information. For example, if the West Virginia Board of Examiners of Psychologists requests that we release records to them in order to investigate a complaint against a provider, we must comply with such a request.
Research: We may disclose health information to researchers when West Virginia University’s institutional review board has reviewed and approved the research proposal and established protocols to ensure the privacy of your health information. This data is generally de-identified, which means that no one could connect it back to you.
Worker’s Compensation: We may disclose health information to the extent authorized by you and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law; we may be required to testify.
As required by law for purposes of public health: e.g. as required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Business Associates: There are some services provided to the Carruth Center through contracts with business associates. Examples include computer support for our scheduling system and scoring of tests. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we’ve asked them to do. Business associates are required to safeguard your information.
If you have questions and would like additional information, please ask your clinician. He/she will provide you with additional information or put you in contact with the Director of the Carruth Center for Counseling and Psychological Services, Dr. Cathy Yura, at 293-4431.
If you are concerned that your privacy rights have been violated, or if you disagree with a decision we have made about access to your health information, or if you would like to make a request to amend or restrict the use or disclosure of your health information, you may contact:
Cathy Yura, Ed.D., Director, Carruth Center for Counseling and Psychological ServicesIf you believe that your privacy rights have been violated, you can also file a complaint with the Secretary of the U.S. Department of Health and Human Services:
Student Services Center, PO Box 6422
Morgantown, WV 26506-6422
Phone: (304) 293-4431 Fax: (304) 293-3705
Office for Civil RightsYou may also visit this web site for forms: http://www.hhs.gov/ocr/privacyhowtofile.htm
U.S. Department of Health & Human Services
150 S. Independence Mall West - Suite 372
Philadelphia, PA 19106-3499
(215) 861-4441; (215) 861-4440 (TDD) Fax: (215) 861-4431
The Carruth Center respects your right to the privacy of your health information. There will be no retaliation in any way for filing a complaint with us or the U.S. Department of Health and Human Services.
