CareNet
Consent to Treat and Center Information

We are grateful that you have chosen CareNet to assist you in growth and wellness. We also appreciate the trust you place in us, and pledge to cooperatively work with you. During the course of your relationship with us, questions may arise about the center and our procedures. This document is to assist you in understanding some of the more important aspects of our relationship.

All CareNet, providers, including residents, and interns fall under the leadership of the division of Faith Health (Atrium Health Wake Forest Baptist). All staff members provide counseling in accordance with NC state laws pertaining to licensure of counselors and therapists. In addition, providers (excluding interns) are credentialed by their respective professional organizations and are clinically supervised.

Your counseling, including your record, is treated with the strictest confidentiality. We abide by HIPAA regulations to protect your confidentiality. Some limitations to confidentiality include: (1) imminent risk of harm to yourself or others become known to the provider, (2) child or elder abuse and / or neglect becomes known to the provider (3) need for professional consultation or supervision by your provider, (4) subpoena or court order for your record from the legal system (5) review of records by an accrediting agency or payor (6) involvement of a DSS worker or guardian ad litem. Please see the Atrium Health Notice of Privacy Practices for more information. Please feel free to discuss these important matters with your provider. We utilize a Patient Portal, through which you may access your record. You may also opt out of your record being made available on the Patient Portal. Please ask your provider about how to opt out of this service if you would like to do so.

When record requests are made, it is our general policy to release records directly to other professionals, which would require a written Consent to Release PHI to that professional. If you wish to receive a copy of records for yourself, the request should be made in writing, which will be reviewed by your provider, and completed in compliance with all applicable regulations.

To request a change or addition to your health record of information you believe is inaccurate or incomplete, please let your provider know. Your provider will give you the form to complete to make this request in writing, as well as information about the process.

If you are under 18 years of age, please be aware that the law may provide your parents or legally responsible person the right to examine or have a copy of your treatment records.

Our services are primarily supported by client fees. Your provider will inform you of the current cost per 30, 45 or 60-minute individual session and /or couple or group sessions at the outset of therapy. These rates are based on what is known as "the community standard" and are consistent across our statewide network. All fees, including applicable insurance co-pays and deductibles, are due at the time of appointment. Checks should be made payable to CareNet Counseling. We also accept Visa or MasterCard. In the event you are involved in a legal proceeding of some type and we are required to give testimony, or depositions, you agree to pay for the professional time required, even if we are compelled to testify by another party. Because of the complexity and difficulty of legal involvement, we charge our regular hourly rate for preparation and attendance at any legal proceeding (fee adjustment does not apply).

NSF Check Charge: Our office will charge a $35.00 fee for any checks returned as NSF.
We realize that in some cases, persons are unable to pay the full fee. No one will be denied initial consultation because of an inability to pay. There are some subsidy funds for these circumstances, although these funds are limited. If you are unable to pay the full fee, you and your provider can determine together a fee appropriate to your circumstances, or the number of sessions might be limited. Please note that insurance co-pays cannot be reduced for any reason.

If you plan to use insurance, please provide insurance information to CareNet prior to your first visit. This is to reduce your chances of having to pay full fee in the first session, as many insurance companies require prior authorization for services. You may be asked to communicate with your insurance company if issues arise, and your provider or billing office staff can assist you with this process. Should your insurance company decline to pay for any services rendered, you will be financially responsible for such charges. Insurance charges not paid within 60 days become the responsibility of the client. We do not file insurance for marital visits .You should also be aware that all insurance agreements require a formal diagnosis for reimbursement, and this becomes a part of your clinical record.

Questions or concerns about accounts (billing and insurance) may be directed to your provider or to the local Account Representative.

Return appointments are decided upon by you and your provider. If circumstances prevent you from keeping an appointment, please give 24-hour notice by calling your provider at the number provided, so that the time may be given to someone else. Please Note: More than 3 no-shows and/or late cancellations (less than 24-hour notice) in 1 (one) calendar year may result in termination of services and/or referral to another entity.

Your provider will advise you of our daily office hours.

•CareNet may contact you by telephone or text message at any number associated with your account, including wireless telephone numbers, to communicate about scheduling, treatment, or payment for services rendered. You may be contacted by e-mail using any e-mail address that you provide to CareNet. Methods of contact may include, but are not limited to, pre-recorded or artificial voice messages and the use of automatic dialing services.
•All providers will return phone calls in a 48 hour (business day) period. If you have called and have not received a return call within 48 hours please call back.
After Hours Emergencies
•If you are experiencing a life-threatening emergency, you should call 911 or go to your nearest hospital emergency department. As an established client of CareNet Counseling, your provider will provide you with instructions on how to contact our on-call service for after-hours and weekend/holiday urgent issues.

The therapy process can be fun and exciting. It can also, at times, be very challenging, difficult, and even painful. As with any significant process of change, there are both benefits and risks associated with the change. Risks may include, but are not limited to, experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger or frustration, or having difficulties with other people. If you experience such difficulties, please let your provider know.
•All providers will return phone calls in a 48 hour (business day) period. If you have called and have not received a return call within 48 hours please call back.
After Hours Emergencies
•If you are experiencing a life-threatening emergency, you should call 911 or go to your nearest hospital emergency department. As an established client of CareNet Counseling, your provider will provide you with instructions on how to contact our on-call service for after-hours and weekend/holiday urgent issues.

Client and provider may terminate counseling in any one of the following ways:
1. Client and provider mutually determine that counseling goals have been adequately met.
2. Client and/or provider determine that counseling is not progressing satisfactorily and the process should be discontinued. In this case, the provider can assist with referral to another provider.
3. Client has not seen provider for a session in 60 days and there has been no prior agreement to keep the case open and active.•All providers will return phone calls in a 48 hour (business day) period. If you have called and have not received a return call within 48 hours please call back.
After Hours Emergencies
•If you are experiencing a life-threatening emergency, you should call 911 or go to your nearest hospital emergency department. As an established client of CareNet Counseling, your provider will provide you with instructions on how to contact our on-call service for after-hours and weekend/holiday urgent issues.

If you are dissatisfied with any aspect of your counseling process, please let your provider know so that it can be resolved. If you think you have been treated unfairly or unethically by your provider and cannot resolve the problem, you may contact CareNet Inc. at 2000 W. 1st St., Winston Salem, NC 27104 for clarification of client's rights and/or to lodge a complaint. You may also contact the local CareNet Regional Director, or your provider’s licensing board. Office staff can provide you with the local Regional Director’s contact information.

If you have any other questions about our working relationship please feel free to ask.

My signature on this form:
1. Confirms that I have read/and or understand the information above.
2. Gives permission for CareNet staff to seek emergency medical care for me from a hospital or physician.

Consent to Treat/Center Information Form Original Effective Date: 3/1/15
Revised : 9/22/21
Revised: 11/29/21
Revised: 4/1/2023