CLIENT RIGHTS & RESPONSIBILITIES

CLIENT RIGHTS:

• You have the right to refuse services. However, participation in treatment is an expectation and it should be known that such refusal may be cause for RoxAnne Koenig, MS, LIMHP, LLC to discharge a client from outpatient services.

• You have the right to have treatment provided on a standard schedule. Treatment schedules are given at the time of intake. In emergency situations, the client is advised to dial 9-1-1 or proceed to the nearest emergency room.

• You have the right to be treated with dignity and respect.

• You have the right to a prompt response to reasonable requests for service.

• You have the right to a safe environment, free from sexual, physical and emotional abuse.

• You have the right to help in the development of your treatment plan and discharge plan.

• You have the right to be informed of the type of treatment you receive and to be told of alternative ways you can receive care and treatment.

• You have the right to be informed of your progress and to discuss any questions or problems.

• You have the right to a timely referral upon discharge or when further services are determined to be necessary.

• You will be informed of your therapist’s credentials, licensure, experience, professional associations, specialization and limitations.

• You have the right to be treated fairly without discrimination as to race, color, religion, natural origin, economic status, disability, marital status, sexual orientation, gender, military status or age.

• You have the right to be treated equitably and without prejudice or favoritism.

• You have the right to be informed of confidentiality laws. The laws of the State of Nebraska require that most issues discussed during the course of therapy with a psychotherapist are confidential. These laws permit you to waive the privilege of confidentiality by signing a release of information form. However, the release of confidential materials is required in situations of suspected child abuse, of potential harm to oneself or others, and in instances where the court may subpoena records or testimony. If you desire that information be communicated about you to someone, please ask for a release of information form. Both you and your parent/legal guardian will sign releases upon admission giving consent for staff to communicate to individuals specifically involved in your treatment.

• You have the right to know the cost of your care.

• The purpose of your clinical record is to document and evaluate your progress and treatment. Clinical records are the property of RoxAnne Koenig, MS, LIMHP, LLC. You have the right to examine your records and refute any information by inserting a counter-statement of clarification. All information is confidential and will not be released without a proper authorization as detailed by Federal Confidentiality Regulations. You have the right to request the transfer of a copy of your files to another therapist or agency.

• You have the right to receive services when they are needed. In emergency situations, the client is advised to dial 9-1-1 or proceed to the nearest emergency room.

• You and your legal guardian have the right to an Advance Directive. An Advance Directive is a written statement in which you state your choice for health care or name someone to make such choices for you, if you become unable to make your own decisions about medical care. The two most common forms are a Living Will and Power of Attorney.

• You have the right to terminate services against medical advice, to the extent permitted by law, with the understanding that you will be responsible for any harm to you or others a result.

• Upon your request, you have a right to receive a copy of any release that you sign authorizing the disclosure of confidential information.

• You have the right to offer feedback and suggestions regarding any client rights and responsibilities.

CLIENT RESPONSIBILITIES:

• Clients have the responsibility to participate actively and honestly in treatment. In many cases, particularly when the client is a child or adolescent, effective treatment requires active involvement and participation of parents or other family members.

• Clients have the responsibility to keep scheduled appointments or to give notice of cancellation if client will be unable to keep an appointment.

• Clients have the responsibility to treat their therapist with dignity and respect.

• Clients are responsible for asking questions about any policy, procedure, or treatment which they do not understand or with which they do not agree.

• Clients are responsible for carefully reading and understanding any papers they may be asked to sign in relation to treatment.

• Clients have the responsibility to honor their financial contract by paying for the services received at the agreed-upon times and/or terms. The client is also responsible for providing RoxAnne Koenig, MS, LIMHP, LLC with all information necessary for billing health insurance or other third party insurance.

I have read and accept the Client Rights and Responsibilities:

Client Signature Date