Informed Consent & Patient Bill of Rights

Your Mental Health Therapist: Unless you are expressly advised otherwise, your therapist is an independent contractor providing services to you according to their agreement with New Mexico Crisis Counseling, LLC. Your therapist is an independently licensed mental health professional with one of the following active New Mexico licenses: LPCC, LCSW, LMFT, LP. Your therapist has no restrictions on his or her license and, as an independently licensed therapist, does not require supervision. Confidentiality: Discussions between a therapist and a client are generally confidential. No information will be released without the client’s written permission unless mandated or permitted by law or as outlined in this agreement. Possible exceptions to confidentiality include but are not limited to the following situations: abuse, neglect, or sexual exploitation of a child or vulnerable adult; situations where, in the therapist’s judgment, it is necessary to warn or protect individuals from harming themselves* or another person; court orders or subpoenas; or as required by health insurance companies, Medicaid, or others related to payment or authorization for health services; to employees or agents of New Mexico Crisis Counseling for operational, billing, or scheduling purposes; to regulatory authorities in connection with compliance responsibilities; for treatment consultations with other mental health professionals when deemed necessary; to your primary care provider or other mental health provider for the purposes of continuity of care; and fee disputes, licensing board complaints, or lawsuits between the client and the therapist or New Mexico Crisis Counseling. Also, if you see more than one New Mexico Crisis Counseling therapist, case worker, or community support worker or if you choose to switch from one New Mexico Crisis Counseling therapist to another therapist contracted with New Mexico Crisis Counseling, you consent that each treating therapist, case worker, or community support worker may have access to your client file without separate authorization. If you would like more information, please review the notice of privacy practices provided to you.

Disclosing thoughts of suicide and confidentiality: It is a common fear that if a person discloses suicidal thoughts emergency services will be contacted and they will be taken to a psychiatric hospital.  If you are at extremely high risk of acting on suicidal thoughts we may need to take steps to ensure your safety without your consent. There are very narrow circumstances that call for immediate hospitalization. Disclosing suicidal thoughts or plans alone does not constitute an extremely high risk. We are committed to your being fully informed about the limits of confidentiality when extreme risk for suicide exists. Please let us know if you have concerns about what you can share without us being required to intervene.

Payment Policy: If you are insured, you agree that New Mexico Crisis Counseling will bill the insurance company and will accept payment from your insurance company at their rates for the services. You agree that any insurance carrier with whom you have a policy shall direct to New Mexico Crisis Counseling any benefits and payments related to services rendered by New Mexico Crisis Counseling providers. You authorize and consent that New Mexico Crisis Counseling may provide your insurance company with all necessary information, including therapist notes, requested in connection with its review and consideration of the claim for payment of benefits. You are responsible for payment of all charges not covered by insurance, and any and all co-pays, coinsurance, deductibles, and any other payments are due at the time of service. If you have commercial insurance or pay out of pocket, you agree to have a credit card on file with New Mexico Crisis Counseling, which you agree to be charged for any payments due (including missed appointment charges). If insurance is terminated or benefits are reduced for any reason, you acknowledge that you are responsible for the entire cost of the session as well as any remaining balance on your account. Returned checks will require a bank fee of $37 in addition to the amount owed. Services may be terminated for non-payment of services if you have been made aware of the failure to pay and been allowed to make a payment arrangement (unless you are not in an acute crisis situation requiring temporary continuation of services).

Cancellation Policy: When sessions are canceled with less than 24-hours notice, your counselor will not be able to fill that time slot and will not be paid for their time. There is a cancellaton fee for appointments missed or canceled with less than 24 hours notice, or by Friday for Monday appointments (where such fees are permitted). The cancellation fee will be charged to your credit card on file, collected at the next appointment or you will pay upon receipt of an invoice. After two no-shows or late cancellations (except in cases of emergency), your regular scheduled spot will be removed, and you will be placed on a cancellation schedule (you will be offered open spots as they come up).

Text and Email Communication: There are inherent privacy and confidentiality risks with text and email communications. If you need to contact your therapist and choose text or email communication, email Do not share protected health information by email or text. Any therapy-related questions or issues will not be addressed in email but will be dealt with during your next therapy sessions. If you choose to communicate with New Mexico Crisis Counseling or your therapist via electronic means, you are fully aware of the risks and agree to hold New Mexico Crisis Counseling harmless for any resulting damages. Appointment Reminders: New Mexico Crisis Counseling sends out automated appointment reminders before your scheduled appointment as a courtesy to clients. With any electronic communication, there are risks involved.

Relationship with your Therapist: In order to have successful therapy, the relationship with your therapist is to be strictly professional and therapeutic. Personal/business relationships undermine the effectiveness of the therapeutic relationship. You agree not to attempt to contact your therapist outside the scope of therapy, give gifts, seek to spend time together socially, seek to connect via social media or create any other kind of dual relationship with your therapist. if your therapist encounters you in a public setting, in order to protect your health information, the therapist will not acknowledge you unless addressed by you first.

Involvement in Treatment Plan: You and your therapist will discuss the goals, purposes, and techniques of your therapy. You agree to communicate any questions or concerns you may have regarding the treatment recommended by your therapist and to communicate your input at the time the treatment plan is made and when it is revised from time to time. Audio or Video Recordings: You acknowledge, and by signing this form, agree that neither you nor the therapist will record (audio or video) any sessions without the prior mutual written consent of the therapist and client.

Litigation, Mandated, Reporting, or Court-Related Services: New Mexico Crisis Counseling does not provide therapy for the purposes of litigation or perform evaluations for custody, visitation, court-ordered therapy, or forensic matters. Therefore, it is understood and agreed that New Mexico Crisis Counseling cannot and will not provide any testimony or reports regarding litigation, custody issues, visitation or fitness of a parent in any legal matters or administrative proceedings. New Mexico Crisis Counseling is not an authorized organization to work with probation, pre-trial services, or CYFD. Because New Mexico Crisis Counseling does not provide therapeutic services in cooperation with or collaboration with NM CYFD, Probation and Parole, SSDI/SSI, Child custody evaluations, or for legal disputes, should the need arise for this type of collaboration or reporting, New Mexico Crisis Counseling will make recommendations to agencies or other providers able to help in this regard. If New Mexico Crisis Counseling is contacted by an attorney regarding your treatment or for any litigation (either at your behest or related to a legal matter you are involved in) you agree to and acknowledge the following: New Mexico Crisis Counseling charges a $500 retainer before any preparation or attendance of legal proceedings. New Mexico Crisis Counseling charges $100/hour to prepare for and/or attend any legal proceeding and for all court-related services. Charges for court-related services are not covered by insurance. Court-related services include: talking with attorneys, preparing documents, traveling to court, depositions and court appearances. If the court or attorneys do not pay our fee, you will be charged for the time your therapist spends responding to legal matters You will also be charged for any costs New Mexico Crisis Counseling incurs responding to attorneys in your case, including but not limited to fees New Mexico Crisis Counseling pays for legal consultation and representation by our attorneys.

Complaints and Appeals: If you carry insurance and you have an issue with your care, you have the right to file a complaint or appeal. Some examples of a complaint are: The care you receive from an New Mexico Crisis Counseling provider; The time it takes to be seen by a provider; Rude or inappropriate behavior by a provider or staff. An appeal can be filed when you do not agree with your insurance company’s decision on payment. New Mexico Crisis Counseling cannot take any negative action against you for filing a complaint or an appeal. If you need to file a complaint with New Mexico Crisis Counseling, you can contact Owner Gayle Porter at 505-225-2996 or director@nmcrisis.org

Patient Bill of Rights and Patient Responsibilities: If you are insured, you have rights and responsibilities with your insurance. You have the right to: Get the facts about your insurance and your insurance company’s services Be provided information about in-network providers Have privacy and be treated with dignity and respect of your individuality in a safe environment, free of threat and harm. Get the information you can understand about your diagnosis, and the risks, benefits, prognosis and choices of treatment. Participate in making decisions about your care and treatment. Refuse treatment to the extent permitted by law Receive a copy of your medical records, as allowed by law Request a change or correction to your medical records Voice any complaints or send in appeals about your insurance provider or the care you were given Use your member rights without fear of adverse results Receive the member rights and responsibilities each year and suggest changes Receive the healthcare you need regardless of your race, creed, age, color, beliefs, national origin, gender, gender identity, sexual orientation, religion, disability, marital status, or source of payment. Have qualified interpreter services available if you do not understand or speak English. Request assistance if you are vision and/or hearing impaired. Express your religious and cultural beliefs as long as the exercise of these beliefs does not harm others or interfere with the medical treatment or the rights of others. Sign an advanced directive so your providers know what care you want if you should be near death and unable to communicate your wishes. Decide who can make decisions about your care and treatment if you aren’t able to communicate your wishes. File a dispute or grievance for any issues like care or access that you haven’t been able to resolve with your provider.

You can file a grievance by calling: The NM Department of Health at 1-800-752-8649 or the Joint Commission at 1-800-994-6610. You may also contact the Department of Health by mail at:
New Mexico Department of Health, Division of Health Improvement,
Incident Management
P.O. Box 26110
Santa Fe, NM 87502-6110.

Get an explanation of your bill and the services provided to you. You have the responsibility to: Give all the facts that your insurance providers and your providers need to care for you, Know your health problems, and take part in the joint decisions about treatment planning. Keep appointments and be on time. If you will be late, call to let your provider know. Sign a consent for treatment, except in emergencies. Treat other patients, staff, and the property of others with respect. Ask questions or request more information when you do not understand information or instructions. Follow your treatment plan, or tell your healthcare team member why you cannot follow it. Tell your provider about any changes in your health. Cancel appointments you cannot keep. Meet your financial obligations.