Step 4:
​Client Informed Consent for Assessment and Services

    Informed Consent 

    ​Thank you for choosing LeBlanc Consulting for you and your child’s services. We realize that starting consultation services is a major decision and you may have many questions. The information herein is in addition to the information contained in the Notice of Privacy Practices is for both our and your protection. LeBlanc Consulting is legally and ethically responsible provide you with informed consent. If you have other questions or concerns, please ask, and we will try our best to give you all the information you need.
     
    Services:
    Prior to beginning consultation services, it is important for you to understand our approach. One of the things we offer is Consultation and Counseling for children ages 3 and adults. For children: Play is the language of children and children to play out their fears, worries, and conflicts. For adult we use a variety of methods depending on the individual. Some of the methods used include but are not limited to Solution Focus, Cognitive Behavioral Therapy and Gestalt Therapy.
     
    It is our policy to provide you with general information about services and treatment status. We will also meet with you on a regular basis to consult about changes as well as to find out how you or your child is managing both at home, work, and school and in the community. If we feel it is necessary to refer you or your child to another professional with more specialized skills, we will share that information with you and have you sign a release of confidentiality. Ultimately, you have the right to refuse services at any time. And we will honor that decision. However, closing consultation sessions with you or your child to appropriately end services is the right way to go as a result there may be some forms that you will need to fill out before ending services.
     
    Goals:
    Goals for consultation may be specific or change depending on you and you’re your family. Goals may also be general (less anxiety, better self the complexity and severity of problems). For children we encourage parent participation in all phases. Moreover, as the parent, it is important for you to support your child's work with me, making sure that appointments are kept and offering encouragement as needed. For adults in a relationship, we may ask that you bring your partner in to counseling or consultation to work on issues together if needed. Your partner has the right to decline, however, it may interfere with the work that you are doing to progress your personal and parenting skills.
     
    Benefits and Risks of Consultation Services:
    Consultation can be beneficial to you and your child in a variety of ways. You and your child will support, will learn to understand feelings and problems, and will be encouraged to try out new solutions to old problems. While Consultation may provide significant benefits, it may also pose risks. Occasionally, a disagreement among parents and Consultants regarding the best interests of the child may occur. Disagreements or agree to disagree, so long as this enables your child’s to continue to develop and process. Consultation may also elicit uncomfortable thoughts, feelings or memories. These feeling are normal for development and growth. Your Consultant will guide you through these emotions and will be by your side through these times.
     
    Confidentiality:
    Consultation is most effective when a trusting relationship exists between the Consultant and the Client Learner. Privacy is important in securing and maintaining that trust. Specific details of the information you or your children share with us in consultation sessions is not shared with parents (unless you or your child gives us his/her consent) so as to encourage children to be honest and forth coming and to maintain an emotionally safe environment for them. As part of the process we encourage you and your children to share information only with those you trust. However, there are specific exceptions to this confidentiality which include the following:
     
    • When there is risk of imminent danger to you or your child or another person, we are required to take necessary steps to prevent such danger.
    • When there is suspicion that you or your child is being sexually or physically abused or is at risk of abuse, we are mandated to take steps to protect your child, and to inform the proper authorities.
    • When a valid court order is issued for health records, we are bound by law to comply with such requests otherwise it is our policy not to testify in custody battles. We do not allow records to be read or reviewed by any person other than staff and Regional Center.
     
    Photographs and Videos:
    We will be photographing, you, your children, sand scenes and art work and may use these photographs in a professional article, book or at a professional training. There will be no identifying information except for the age and gender of your child.
     
    Photograph and Video Release:
    I hear by grant Le Blanc Consulting permission to the rights of my image, likeness and sound of my voice as recorded on audio video tape without payment or any other consideration. I understand that my image may be edited, copied o, exhibited, published or distributed and waive the right to inspect or approve the finish produced wherein my likeness appears. Additionally, I waive my right to royalties or other compensation arising or relative to the use of my image or recording. I also understand that this material may be used in diverse educational settings within unrestricted geographic area.

    Photographic or video recordings may be used for the following purposes:
    • Conference presentations
    • Educational presentation or courses
    • Informational presentations
    • Advertisement both print and online
    • On-line educational courses
    • Educational videos

    Parenting Consultation Agreement
    Parenting Consultation is in person and rarely by phone. We want you to get great value from your time with your consultant together. In order to gain the best from your time with your consultant there are some things that you must agree to do. In order to prepare for your parenting consultation sessions you must agree to:

    1. I agree to be by myself or with my child or children only.
    2. I agree that will have no pets or other distractions that will prevent me from learning and paying attention.
    3. I agree that I will not answer my phone while I am in consultation unless it is an emergency.
    4. I agree that I will have paper and pen ready to take notes if needed.
    5. I agree that I will ask my consultant for my homework if he or she has not given it to me and that I will keep up with my weekly assignments so I can benefit from the lessons.
    6. I agree to complete my homework assignments before my next consultation
    7. I agree that if I need to cancel my appointments I will do so within 24 hours of my appointment for consultation. I know that it is up to my consultant as to if he or she wants to schedule within the same week.
    8. I agree that if I have a question about my services I will go through the process of grievances with the company before complaining to my case manager. First I will contact my consultant’s supervisor and if I am not satisfied I will contact management.
    9. I agree that there will be professional secrecy & confidentiality from both myself and my consultant.
    10. I agree to meet with my consultant on the day and time scheduled. I will be dressed and ready to consultation services.
    11. I agree that I will give Consultation Services a try for at least 12 months (a full year) before discontinuing services so that I may fully reap the benefits of the program.
    12. I agree that my services are FREE, however, if I discontinue services before my service agreement is up, I may be held responsible and charged the remaining balance owed to LeBlanc Consulting for a breach of contract.  
    13. I agree to the above and acknowledge that I know that violation of the above is grounds for termination of services and dismissal from the program.
    ​Notice of Privacy Practices
     
    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
     
    The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal law that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronic, on paper, or orally, are kept properly confidential. HIPAA gives you, the client, and significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. Each time you meet with your psychotherapist, or service provider a record is made which may contain your symptoms, diagnoses, treatment, a plan for future treatment, and billing-related information. Usually, less information is recorded if you are not using insurance to pay for treatment. This notice applies to all of the records of your care generated by LeBlanc Consulting.
     
    Psychotherapist Responsibilities
     
    LeBlanc Consulting is required by law to maintain the privacy of your health information and to provide you with a description of her legal duties and privacy practices regarding your health information. LeBlanc Consulting is required to abide by the terms of this notice and notify you if LeBlanc Consultants makes changes to this notice, which may be at any time.
     
    How LeBlanc Consulting May Use and Disclose Medical Information about You
     
    Consultation: LeBlanc Consultants may use and disclose medical information about you to provide, coordinate, and manage your consultation services. LeBlanc Consultants may disclose your personal health information to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, LeBlanc Consultants may disclose your personal health information in order to coordinate your care. For example, if a referral is made to another health care provider, LeBlanc Consultants may provide oral information and copies of various reports that should assist her or him in treating you.
     
    Payment LeBlanc Consultants may use and disclose medical information about you in order to obtain reimbursement for services, to confirm insurance coverage, for billing or collection activities, and for utilization review. An example of this would be sending a bill for your sessions to your insurance company, regional center or other state agencies.Health Care Operations: LeBlanc Consultants may use and disclose, as needed, your health information in order to support business activities, including quality assessment, licensing, legal advice, and customer service. For example, LeBlanc Consultants may call you by name in the waiting area when she is ready to see you.
     
    Other Uses and Disclosures
     
    LeBlanc Consultants may use and disclose your health information in an emergency situation to prevent harm to yourself or others. An example would be mandated reporting of abuse to children, the elderly, a dependent person, or when a judge orders the release of information. Only the minimum amount of information relevant to your health care will be disclosed. LeBlanc Consultants may create and distribute de-identified health information by removing all references to individually identifiable details. LeBlanc Consultants may contact you to provide appointment reminders, or to offer information about consultation alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and LeBlanc Consulting is required to honor and abide by that written request, except to the extent that LeBlanc Consultants has already taken actions relying on your authorization.
     
    Know your Rights
    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to LeBlanc Consulting:

    • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, close personal friends, or any other person identified by you. LeBlanc Consulting is, however, not required to agree to a requested restriction. If LeBlanc Consulting does agree to a restriction, LeBlanc Consulting must abide by it unless you agree in writing to remove it.
    • The right to receive confidential communications of protected health information. For example, you can request bills be sent to certain addresses or to limit phone calls to retain privacy.
    • The right to inspect and copy your protected health information (as long as this is deemed by LeBlanc Consulting to be in your (or, in the case of treatment of a minor, the minor client’s) best interest.
    • The right to amend your protected health information.
    • The right to receive an accounting of disclosures of protected health information.
    • The right to obtain a paper copy of this notice from us upon request.
     
    You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with LeBlanc Consulting office, or with the federal government at the address below, about violations of the provisions of this notice or the policies and procedures of our office. LeBlanc Consulting will not retaliate against you for filing a complaint.
     
    Department of Health & Human Services,
    Office of Civil Rights
    200 Independence Avenue S.W.
    Washington, D.C. 20201.
    1-877-696-6775
     
    If you have any questions about this notice, please contact:
     
    LeBlanc Consulting, Inc.
    2415 San Pablo Dam Road #106-152
    San Pablo, CA. 94806 
    (510) 275-3679

    Electronic Signature 

    Consent for Consultation, and Photo Release of yourself and your child: 

    Please sign this document stating that you have read, been read to and/or received a copy of our Notice of Privacy Practices.
    ​
    ​    I understand the information received will be used for evaluation to determine my eligibility to receive services and/or to provide services to me.  This authorization for release of information will become invalid one year from signature date.
     
    The question of privacy between myself and LeBlanc Consulting, the company, institution, agency, school, the attending physician or physicians is hereby waived.  I agree that I am aware that I may furnish copies of all or any desired parts of any record you maintain.
     
    You are hereby released from all legal liability that may arise from the release of information requested.  I understand that I may receive a copy of this authorization. A photocopy is as valid as an original.

    I authorize LeBlanc Consulting to use my signature below as my Electronic Signature as proof for meeting The LeBlanc Consulting Instructor, Counselor or Employee for one to one services. These services are a part of my Purchase of Service (POS) agreement between myself, LeBlanc Consulting and the third party such as the Regional Center. I am aware that I no longer have to provide a signature each time I see my instructor, consultant, program manager or anyone with LeBlanc Consulting as long as my POS is active, I give LeBlanc Consulting permission to use this signature below as proof of services. 

    I/We consent that my child may participate in the assessment and Consultation offered LeBlanc Consulting. I also give Le Blanc Consulting permission to use photos of me or my children as stated above. Lastly, I agree to the above regarding my services. I/We have read and understand the above.  I/We agree not to subpoena or ask for copies of my records, my child’s records, or testimony/evaluations from LeBlanc Consulting. I agree to the above and do not hold LeBlanc Consulting, its owners, consultants or insurance companies liable for anything including but not limited to the services they provide.  

    ​By signing this release I understand this permission signifies that photographic or video recordings of me maybe placed on the internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on the document only. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
    Client Documents Upload. 
    Please upload the necessary documents to the client's file. 
    Max file size: 20MB
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    • Health Documents 
    • Psychological Evaluation 
    • School Documents 
    • Court or Legal Documents 
    • Driver's license
    • Birth certificate (for ALL children)
    • Hospital certificate of birth
    • State issued non-drivers' ID card
    • Marriage certificate with date of birth
    • US passport
    • Immigration or Naturalization certificate
    • Medicaid card
    • Proof of US Citizenship or Legal Residence for each person in household who wants services
    • Social Security card or number
    • Immunizations or shot records for all children
    • School information for all children
    • Most recent IEP from the school
    • Most recent Psychological and Behavioral Assessment
    • ​Court Documents if you have a pending or open CPS case