Informed Consent for Treatment Supported Rite of Passage
Please read the following, and ask questions as necessary. You will be asked to sign a document indicating that you understand and agree to the information below upon beginning the TSROP program, given that Treatment Supported Rite of Passage is a specific modality of Outpatient Mental Health Treatment provided in the State of Maryland.
I understand that TSROP is an Outpatient-only, mental health counseling service provided directly by Keely Owens, LCPC and consulting clinicians. I understand that I may receive ongoing outpatient therapy or I may receive a limited number of sessions specifically to support a particular goal (for example, preparation for and reintegration from a psychedelic or other transformative experience). The expectations for my treatment will be outlined in my Treatment Plan. I understand that Keely Owens, LCPC, is licensed to practice in the State of Maryland (West Virginia pending), and that services must be provided within that state unless State or Federal exceptions are granted by law of practice. I understand that Outpatient sessions will be conducted through a combination of Zoom telehealth and community settings, including outdoor settings.
I understand that TSROP does not provide psychiatric services and is not suitable for all clients. I understand that although referrals may be given, I am responsible for finding and working with a psychiatrist, including for any provision of ketamine for use during ketamine-assisted psychotherapy. Responsibility for my psychiatric care falls exclusively on on myself and my provider.
I understand that I will be assessed for my suitability for TSROP during my Intake. TSROP will not discriminate based on race, culture, religion, gender, sexual orientation, or socioeconomic status. My suitability for TSROP will be assessed based on clinical considerations including my developmental stage (TSROP is not suitable for children and early adolescents), my clinical diagnoses, and my level of crisis and support needs. I understand that if I am not suitable for TSROP, appropriate referrals will be given to Outpatient or Inpatient services.
I understand that if TSROP is not appropriate for me or is not meeting my needs, or if I am not able to complete the TSROP activities, my treatment under TSROP can be terminated at any time at either my or my counselor's discretion. If I am enrolled in TSROP as my sole ongoing therapy, and counselor-discharged from TSROP prior to July 31, I will have the option to continue weekly, maintenance-focused Outpatient treatment with Keely Owens, LCPC until July 31, 2022, or to receive a referral to another outpatient provider. After July 31, 2022, I will receive a referral to another outpatient provider. If I require Inpatient care, I will receive a referral to an inpatient provider.
I understand that billing for outpatient sessions will either be conducted through my insurance or through private pay.
Private Pay. The private pay rate is currently $150/session, unless I have specifically negotiated a Sliding Scale rate. Other rates apply for workshops, ketamine-assisted psychotherapy and outdoor retreats. I will be charged a $45 missed session fee if I miss a session without at least 24 hours notice. I am responsible for paying my bill monthly. If I do not pay my bill within two weeks of invoicing, services may be suspended until payment is provided.
Insurance. If I am expecting my insurance to cover my sessions, I am responsible for providing my insurance information to Keely Owens, LCPC, and having it approved prior to beginning sessions. I am also responsible for providing a valid credit card. I understand that my credit card will be billed for any copays, and that a $45 missed session fee will be billed if I cancel a scheduled session less than 24 hours before it is scheduled to begin. I understand that my insurance may not cover experiential activities. Private pay rates will be offered for all activities, and a sliding scale will be provided, with scholarships awarded based on financial need and available sponsorship.
Medicaid. If I have Medicaid, I understand that, at this time, TSROP is only able to accept my Medicaid if it is my only form of insurance, and if I enroll through Innovative Clinical Associates. I understand that as a Medicaid client I will also need to understand all of the rules and policies of Innovative Clinical Associates, which will be provided to me at Intake. I understand that as a Medicaid client, if I lose my insurance coverage during the course of my treatment (including adding a new insurance, because ICA is only able to cover Medicaid-only clients), that I will have these options: I may choose to switch to Private Pay status at the reduced rate of $45/session and continue my treatment (at a reduced frequency of sessions if need be), and I may apply for financial support if I have hardship, which I will receive if funds are available on a first-come first-serve basis; or I may choose to discharge to another provider, with a 2-month grace period where transitional Outpatient services will be received Pro Bono from Keely Owens, LCPC. I will still have the option to complete my Retreat, and to have it covered through my existing scholarship, and to receive reincorporation sessions and participate in Graduation activities, if I choose to discharge. I understand that Outpatient sessions cannot be billed unless I attend them, and that TSROP is providing significant financial support for its participants which relies on expected income. I commit to providing one week of notice if I need to cancel an Outpatient session, whenever possible. If I cancel Outpatient sessions with less than 24 hours of notice, or fail to show up for them, I am responsible for rescheduling them within the same calendar month and within the availability provided by Keely Owens, LCPC. If I am unable to attend the agreed-upon number of sessions in a given month, I have the option to pay a $45/session Missed Session fee. This Missed Session fee is optional. However, I understand that a maximum number of missed and unbilled sessions will be set at the outset of treatment, and if I exceed that maximum, I may be discharged from TSROP or from ICA at counselor's and agency's discretion. In the event of discharge, I will be provided relevant referrals.
Pro Bono. If I am enrolled Pro Bono via the Pro Bono Project, I am also responsible for understanding and adhering to all of the policies of the Pro Bono Project.
I understand that I will be discharged from TSROP, and from clinical care from Keely Owens, LCPC, regardless of my treatment status, at the end of the program on July 31, 2024. My options for re-intake into TSROP at the beginning of the next cycle will be discussed with me at that time. If I need ongoing Outpatient or Inpatient care upon discharge, I will be given relevant referrals beginning July 1, 2024, and all efforts will be made to secure my transition to another clinician. However, I understand that ultimately I am responsible for securing the treatment coverage that I need after July 31, 2024.
I understand that Keely Owens, LCPC, is a mandatory reporter in the State of Maryland, and that if I disclose actively occurring abuse of a minor child or vulnerable adult as defined by COMAR, the abuse will be reported to Child or Adult Protective Services, respectively. I also understand that if I disclose an intent to harm myself or others, Keely Owens, LCPC, in cooperation with Innovative Clinical Associates, will conduct a lethality assessment and may, at clinical discretion, take action including reporting to the police for a protection recommendation or wellness check, notifying a designated person, or in extreme cases petitioning for involuntary inpatient care. I will create a Crisis Plan at the outset of treatment, so that the specific actions will be known to me. I understand that in some cases, if I cease contact with Keely Owens, LCPC or Innovative Clinical Associates without disclosing intent to discharge, the police will be requested to conduct a wellness check to ensure my wellbeing. I understand that Keely Owens, LCPC, Innovative Clinical Associates, and Experience Learning do not provide real time crisis support in between sessions, with the exception of Reintegration Coverage which may be discussed with me separately, in conjunction with experiential activities. I understand that a crisis hotline will be provided, which I can access for support in the event of a psychiatric emergency that occurs between sessions.
I understand that Keely Owens, LCPC, follows all of the legal and ethical mandates of the American Counseling Association and the State of Maryland. Keely Owens, LCPC practices within her expertise and level of competence, discusses treatment options, does not engage in dual roles with clients, provides informed consent, follows ethical financial practices, keeps records accessible to me or those I designate at-will, and ensures confidentiality using the protocols established by HIPAA. All of my Protected Health Information will be held confidential by Keely Owens, LCPC and Innovative Clinical Associates with the following exceptions:
- Mandatory Reporting as discussed above
- Subpoena from a court of law: Subpoenas will be responded to within legal limits and with every effort to protect client wellbeing
- Professional Consultation: If I am a Medicaid client, I understand that my clinical records are managed by Innovative Clinical Associates, and ICA personnel will view them, as appropriate, for billing and for clinical support. If I am a non-Medicaid client, I understand that some of my information may be shared anonymously with an identified colleague (LCPC, LCSW, or Clinical Psychologist) for the purpose of clinical consultation to best provide me with services.
I understand that TSROP is an Outpatient-only, mental health counseling service provided directly by Keely Owens, LCPC and consulting clinicians. I understand that I may receive ongoing outpatient therapy or I may receive a limited number of sessions specifically to support a particular goal (for example, preparation for and reintegration from a psychedelic or other transformative experience). The expectations for my treatment will be outlined in my Treatment Plan. I understand that Keely Owens, LCPC, is licensed to practice in the State of Maryland (West Virginia pending), and that services must be provided within that state unless State or Federal exceptions are granted by law of practice. I understand that Outpatient sessions will be conducted through a combination of Zoom telehealth and community settings, including outdoor settings.
I understand that TSROP does not provide psychiatric services and is not suitable for all clients. I understand that although referrals may be given, I am responsible for finding and working with a psychiatrist, including for any provision of ketamine for use during ketamine-assisted psychotherapy. Responsibility for my psychiatric care falls exclusively on on myself and my provider.
I understand that I will be assessed for my suitability for TSROP during my Intake. TSROP will not discriminate based on race, culture, religion, gender, sexual orientation, or socioeconomic status. My suitability for TSROP will be assessed based on clinical considerations including my developmental stage (TSROP is not suitable for children and early adolescents), my clinical diagnoses, and my level of crisis and support needs. I understand that if I am not suitable for TSROP, appropriate referrals will be given to Outpatient or Inpatient services.
I understand that if TSROP is not appropriate for me or is not meeting my needs, or if I am not able to complete the TSROP activities, my treatment under TSROP can be terminated at any time at either my or my counselor's discretion. If I am enrolled in TSROP as my sole ongoing therapy, and counselor-discharged from TSROP prior to July 31, I will have the option to continue weekly, maintenance-focused Outpatient treatment with Keely Owens, LCPC until July 31, 2022, or to receive a referral to another outpatient provider. After July 31, 2022, I will receive a referral to another outpatient provider. If I require Inpatient care, I will receive a referral to an inpatient provider.
I understand that billing for outpatient sessions will either be conducted through my insurance or through private pay.
Private Pay. The private pay rate is currently $150/session, unless I have specifically negotiated a Sliding Scale rate. Other rates apply for workshops, ketamine-assisted psychotherapy and outdoor retreats. I will be charged a $45 missed session fee if I miss a session without at least 24 hours notice. I am responsible for paying my bill monthly. If I do not pay my bill within two weeks of invoicing, services may be suspended until payment is provided.
Insurance. If I am expecting my insurance to cover my sessions, I am responsible for providing my insurance information to Keely Owens, LCPC, and having it approved prior to beginning sessions. I am also responsible for providing a valid credit card. I understand that my credit card will be billed for any copays, and that a $45 missed session fee will be billed if I cancel a scheduled session less than 24 hours before it is scheduled to begin. I understand that my insurance may not cover experiential activities. Private pay rates will be offered for all activities, and a sliding scale will be provided, with scholarships awarded based on financial need and available sponsorship.
Medicaid. If I have Medicaid, I understand that, at this time, TSROP is only able to accept my Medicaid if it is my only form of insurance, and if I enroll through Innovative Clinical Associates. I understand that as a Medicaid client I will also need to understand all of the rules and policies of Innovative Clinical Associates, which will be provided to me at Intake. I understand that as a Medicaid client, if I lose my insurance coverage during the course of my treatment (including adding a new insurance, because ICA is only able to cover Medicaid-only clients), that I will have these options: I may choose to switch to Private Pay status at the reduced rate of $45/session and continue my treatment (at a reduced frequency of sessions if need be), and I may apply for financial support if I have hardship, which I will receive if funds are available on a first-come first-serve basis; or I may choose to discharge to another provider, with a 2-month grace period where transitional Outpatient services will be received Pro Bono from Keely Owens, LCPC. I will still have the option to complete my Retreat, and to have it covered through my existing scholarship, and to receive reincorporation sessions and participate in Graduation activities, if I choose to discharge. I understand that Outpatient sessions cannot be billed unless I attend them, and that TSROP is providing significant financial support for its participants which relies on expected income. I commit to providing one week of notice if I need to cancel an Outpatient session, whenever possible. If I cancel Outpatient sessions with less than 24 hours of notice, or fail to show up for them, I am responsible for rescheduling them within the same calendar month and within the availability provided by Keely Owens, LCPC. If I am unable to attend the agreed-upon number of sessions in a given month, I have the option to pay a $45/session Missed Session fee. This Missed Session fee is optional. However, I understand that a maximum number of missed and unbilled sessions will be set at the outset of treatment, and if I exceed that maximum, I may be discharged from TSROP or from ICA at counselor's and agency's discretion. In the event of discharge, I will be provided relevant referrals.
Pro Bono. If I am enrolled Pro Bono via the Pro Bono Project, I am also responsible for understanding and adhering to all of the policies of the Pro Bono Project.
I understand that I will be discharged from TSROP, and from clinical care from Keely Owens, LCPC, regardless of my treatment status, at the end of the program on July 31, 2024. My options for re-intake into TSROP at the beginning of the next cycle will be discussed with me at that time. If I need ongoing Outpatient or Inpatient care upon discharge, I will be given relevant referrals beginning July 1, 2024, and all efforts will be made to secure my transition to another clinician. However, I understand that ultimately I am responsible for securing the treatment coverage that I need after July 31, 2024.
I understand that Keely Owens, LCPC, is a mandatory reporter in the State of Maryland, and that if I disclose actively occurring abuse of a minor child or vulnerable adult as defined by COMAR, the abuse will be reported to Child or Adult Protective Services, respectively. I also understand that if I disclose an intent to harm myself or others, Keely Owens, LCPC, in cooperation with Innovative Clinical Associates, will conduct a lethality assessment and may, at clinical discretion, take action including reporting to the police for a protection recommendation or wellness check, notifying a designated person, or in extreme cases petitioning for involuntary inpatient care. I will create a Crisis Plan at the outset of treatment, so that the specific actions will be known to me. I understand that in some cases, if I cease contact with Keely Owens, LCPC or Innovative Clinical Associates without disclosing intent to discharge, the police will be requested to conduct a wellness check to ensure my wellbeing. I understand that Keely Owens, LCPC, Innovative Clinical Associates, and Experience Learning do not provide real time crisis support in between sessions, with the exception of Reintegration Coverage which may be discussed with me separately, in conjunction with experiential activities. I understand that a crisis hotline will be provided, which I can access for support in the event of a psychiatric emergency that occurs between sessions.
I understand that Keely Owens, LCPC, follows all of the legal and ethical mandates of the American Counseling Association and the State of Maryland. Keely Owens, LCPC practices within her expertise and level of competence, discusses treatment options, does not engage in dual roles with clients, provides informed consent, follows ethical financial practices, keeps records accessible to me or those I designate at-will, and ensures confidentiality using the protocols established by HIPAA. All of my Protected Health Information will be held confidential by Keely Owens, LCPC and Innovative Clinical Associates with the following exceptions:
- Mandatory Reporting as discussed above
- Subpoena from a court of law: Subpoenas will be responded to within legal limits and with every effort to protect client wellbeing
- Professional Consultation: If I am a Medicaid client, I understand that my clinical records are managed by Innovative Clinical Associates, and ICA personnel will view them, as appropriate, for billing and for clinical support. If I am a non-Medicaid client, I understand that some of my information may be shared anonymously with an identified colleague (LCPC, LCSW, or Clinical Psychologist) for the purpose of clinical consultation to best provide me with services.