PAULA S. GORDY LISW, LLC

NEW PATIENT INFORMATION

Patient Information

Emergency Contact Information

Insurance Information

Referral Information

PAULA S. GORDY LISW, LLC

Informed Consent for Mental Health Treatment

  1. I agree to obtain mental health treatment on a voluntary basis. I understand that I may end treatment at any time, but that my mental health provider may want to discuss this with me. I also understand that I also have the right to discuss any recommendations that are made regarding diagnosis and treatment.
  2. I will be given a description of the types of treatment recommended, such as individual/family therapy, group therapy, and other programs offered by this organization. The least restrictive level of care will be strongly considered. In addition, the frequency and length of each appointment will be determined by me and my mental health provider. I also understand that my mental health provider cannot promise certain results or outcomes from treatment.
  3. My mental health provider and I will discuss problems to be addressed, my strengths and needs/wants, and treatment interventions that may be used throughout the treatment process. We will also mutually agree upon and develop goals and objectives for continuing/discontinuing mental health treatment.
  4. I understand there may be some risks involved in participating in mental health treatment, such as being challenged on difficult or sensitive issues or addressing painful emotions related to past trauma or past losses. I am aware that I can discuss any risks with my mental health provider at any time.
  5. I understand that this Informed Consent for Mental Health Treatment is not intended to be absolute, but instead it is intended to provide helpful information before making a decision whether or not to be involved in mental health treatment. I am also aware that at any time, I have the opportunity to ask questions and have them answered satisfactorily.

501 N 12th Street, STE 1, Centerville, Iowa 52544
Phone: (641) 856-2688 Fax: (641) 856-2690

Individual / Provider Service Information

Rights and Responsibilities:

Paula S. Gordy LISW, LLC is responsible for providing qualified staff who receives ongoing education and training in established and accepted theories and techniques. Staff is responsible for acting in a respectful manner and performing their duties within their respective professional codes of ethics. Differences of opinions in the mental health process are valued. Paula S. Gordy LISW, LLC has an established "Problem Resolution Process" available to individuals in the event of a perceived ethical infraction, complaint or grievance. Mental health personnel are responsible for making appropriate referrals for psychiatric and psychopharmacological services as necessary. Mental health personnel will discuss the assessed need with you and will provide you with the information necessary to access this service.

Individuals receiving services are responsible for giving a 24-hour notice if needing to cancel an appointment. You are also responsible for being respectful in action and behavior. We are committed to creating a safe environment for those individuals receiving services. You have the right to be treated ethically in accordance with established codes. You have the right to receive care that does not discriminate on the basis of your age, race, color, religion, sex, sexual orientation, gender identity, gender expression, ethnicity, national origin, disability, marital status, etc.

Confidentiality:

What is said in mental health sessions is confidential with the following exceptions:

  • You are assessed to be a danger to yourself.
  • You are assessed to be a danger to others.
  • Child or dependent adult abuse is occurring.
  • Records or testimony is subpoenaed from the court.
Emergency Services:

Paula S. Gordy LISW, LLC does provide emergency, on-call service to individuals receiving Outpatient Mental Health Service. If you experience a mental health emergency after office hours, please utilize one or more of the following options:

  • 24/7 Suicide Prevention Lifeline 988 or 1-800-273-8255 or En Española 1-888-628-9454
  • Telephone 911 for access to emergency room services.
Telehealth / Telemedicine Policy

Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education.

Consent for Treatment

I hereby consent to evaluation and treatment by Paula S. Gordy LISW, LLC. I understand that I have the right to discontinue treatment at any time. I acknowledge that no guarantees have been made to me regarding the results of treatment.

Authorization for Third Party Billing and Assignment of Benefits

I authorize Paula S. Gordy LISW, LLC to furnish my third-party payer (e.g., insurance company, county of legal residence, etc.) all necessary information (per Iowa Code) that may be required in processing claims for service rendered. I hereby assign to Paula S. Gordy LISW, LLC all money to which I am entitled for expenses relating to services performed, not to exceed my indebtedness to Paula S. Gordy LISW, LLC. I understand that any money received from my third-party payer, over and above my indebtedness, will be refunded to me when my bill is paid in full. I also understand that any co-pays, co-insurance, deductible, or any other uncovered charges are my responsibility.

Photocopies of this authorization shall have the same force and effect as the original and may be attached to any claim form required by my third-party payer. This authorization shall be in effect until revoked by me in writing.

Payment for Services is expected at the time service is provided. Paula S. Gordy LISW, LLC will bill insurance companies and Iowa Medicaid or Iowa's Managed Care Organizations as appropriate when provided the necessary information from the individual or their guardian. Collection of co-pays, co-insurance or private payments will occur at the time of the scheduled session.

If the above paragraph is applicable to you, please sign below. If it is not applicable to you please initial on the following line:

I have received the Informed consent for mental health treatment, Notice of privacy practices, Grievance policy, Individual/Provider Service, and Informed Consent. I was given the opportunity to ask questions and receive a copy of this information upon request. By signing this, I indicate my understanding of this information.