Client Informed Consent for Treatment and Privacy Practices

Purpose of Services

At Mending Mental Health, our commitment is to create a truly patient-centered experience where your well-being is at the heart of everything we do. Our integrated approach combines compassionate clinical care, innovative treatment options, and responsive administrative support to ensure every client feels understood and supported.

We understand that each person’s path to wellness is unique, which is why we embrace a range of therapeutic approaches, including alternative and emerging modalities. Working collaboratively with you, we think outside the box to provide personalized care that not only addresses your immediate needs but fosters long-term resilience and self-assurance.

Our mission is to help you feel genuinely cared for as we work together to enhance your quality of life in meaningful, lasting ways. Our services require active participation, including following recommendations from your provider, and outcomes cannot be guaranteed.

Introduction
At Mending Mental Health, we prioritize your privacy and are committed to protecting your personal information. This Privacy Policy explains how we collect, use, and safeguard your data, ensuring compliance with HIPAA and relevant state laws.

Types of Information Collected
We collect personal and health-related information, including:

  • Name, date of birth, insurance, and contact details (phone, email, address).

  • Health history, treatment records, and payment information.

Method of Information Collection
Your information is collected through:

  • Intake forms and treatment records provided during appointments.

  • Secure communication channels (e.g., patient portals, phone calls, or emails).

  • Insurance claims and payment processing.

  • Data Sharing through AthenaHealth Secure Records imports.

Purpose of Data Collection
We collect and use your information to:

  • Provide personalized treatment and coordinate your care.

  • Process payments and manage insurance claims.

  • Maintain secure records and comply with legal obligations.

Data Security Measures
We implement robust security measures to protect your data, including:

  • Encrypted storage and secure data transfer protocols.

  • Controlled access to sensitive information, limited to authorized personnel.

Data Sharing
We do not share personal information with third parties except in the following cases:

  • Coordination with healthcare providers or business associates, such as billing services.

  • Compliance with legal requirements (e.g., court orders, audits).

  • Emergency situations requiring disclosure to protect health or safety.

We do not sell or share any SMS consent or personal information to third parties or affiliates for SMS marketing Purposes.

User Rights
You have rights regarding your personal information, including:

  • Accessing or requesting copies of your records.

  • Updating or correcting inaccurate information.

  • Requesting limitations on the use or disclosure of your data.

  • Opting out of optional communication, such as SMS marketing.

SMS Communication
We offer an optional SMS notification service. By opting in, you agree to receive up to two messages per month. Standard message and data rates may apply. To opt out, reply STOP at any time. For assistance, text HELP to 612-488-0040.

SMS communications are not shared with third parties or affiliates.

Opt-in consent for SMS messaging is optional and not required for form submission.

Contact Information
For privacy-related inquiries or concerns, please contact:

Director of Operations
Mending Mental Health
Leah Clausen

Email: lclausen@mendingmh.com

Ph: 612-488-0040

 

 

 

Confidentiality

Conversations with your provider are generally confidential; however, there are legal and ethical exceptions, including but not limited to the following situations:

  1. Suspected abuse or neglect of a child, elder, or vulnerable adult.

  2. Threats of self-harm or harm to others, or inability to self-care.

  3. Intent to harm a specific person or group, necessitating notification to law enforcement or potential victims.

  4. Receipt of a valid court order or subpoena.

  5. Insurance claims processing, audit responses, or case reviews.

  6. Emergency situations such as natural disasters that risk record loss.

  7. Regulatory requirements by licensing boards or compliance with the Patriot Act.

  8. Any other disclosures mandated by federal, state, or local law.

 

Observations and Consultations

For training and quality improvement, Mending Mental Health may engage peer or supervisory observation. Patients will be informed and obtained consent before any observation.

Notice of Privacy Practices

This notice outlines how Mending Mental Health uses and discloses your health information, in compliance with HIPAA regulations and Minnesota privacy laws. Our commitment is to protect your health information and keep it confidential.

We may use or disclose your health information:

  • For treatment purposes, such as consulting with a specialist involved in your care.

  • For payment of services, such as sharing progress updates with your insurance provider.

  • For healthcare operations, such as securely entering data into our system.

 

We may share your information with business associates, like Athena Support, who are also obligated to protect your privacy. We may contact you for appointment reminders or send information by your preferred contact method. If there’s an emergency, we may notify a family member or emergency contact.

Apart from these circumstances, we will not disclose your information without your prior written authorization. You may also request in writing to limit the use or disclosure of your information.

Your Privacy Rights

You have rights regarding your health information, including:

  • Requesting limits on certain uses or disclosures.

  • Choosing your preferred contact methods.

  • Transferring copies of your records to another provider.

  • Reviewing or receiving copies of your health information.

  • Requesting corrections to your information. If we do not agree to an amendment, we will document your request.

 

You may also request a copy of this notice at any time. Any updates to this notice will be provided in writing.

 

Complaints and Contact Information

If you believe your privacy rights have been violated, please contact our Director of Operations. Alternatively, you may file a complaint with the Department of Health and Human Services at 200 Independence Avenue, S.W., Room 509F, Washington DC, 20201.

Filing a Complaint

Our services are voluntary, and we encourage open communication. If you have concerns, please contact a supervisor at Mending Mental Health. Additionally, formal complaints can be filed with:

  • MN Dept. of Human Services

  • MN Dept. of Human Rights

Records and Information Release

Your records are confidential and will not be released without your written consent, except where required by law. Records requests must be accompanied by proper authorization. Note that email and text communications are not fully secure, so confidentiality cannot be guaranteed.

Audio and Video Recording

Mending Mental Health does not permit patients to record sessions without written consent. Violations of this policy may result in service termination. For training, students may listen to appointments, but they are not allowed to record appointments.

Emergency Services

Mending Mental Health does not provide emergency services outside of office hours (8:00 am – 6:00 pm, weekdays). In an emergency, call 911, visit your nearest hospital, or reach a crisis line. Minnesota crisis contacts include:

  • Minnesota Crisis Line: **CRISIS (**274747)

  • National Suicide & Crisis Lifeline: 988

 

Additional local crisis contacts are available upon request.

Client Rights and Consent for Services

Mending Mental Health respects your rights to non-discriminatory care. For details, please refer to the Minnesota Patients’ Bill of Rights.

I have read and understand these policies and give consent to Mending Mental Health to provide agreed-upon treatment. I understand that my participation is voluntary and that I may discontinue services at any time. My rights to confidentiality, as protected by state and federal laws, include limits for specific situations (e.g., abuse reporting or threats of harm). I am aware of my role in therapy and understand my responsibilities within this partnership.

Client’s Full Name: ____________ Client’s DOB: ____________

Client/Guardian Signature: _________________________ Date: ____________

 

Telehealth Consent

I consent to participate in telehealth services with Mending Mental Health. I understand that telehealth may include assessments, consultations, and therapy, delivered through audio, video, or other electronic means.

I understand my rights regarding telehealth services, including:

  1. I can withdraw consent at any time without impact on future care.

  2. Confidentiality laws apply, with required exceptions (e.g., abuse reporting).

  3. Potential risks of telehealth include technology disruptions or unauthorized access. Telehealth may not be as comprehensive as in-person therapy, and I may be referred for in-person care if needed.

  4. While telehealth may be beneficial, outcomes cannot be guaranteed. Platforms like Skype or FaceTime are not fully secure; I acknowledge potential confidentiality risks.

  5. I can access my records upon request.

  6. I understand that telehealth is not suitable for emergencies. In such cases, I will call 911 or use crisis contacts provided above.

Client’s Full Name: ____________ Client’s DOB: ____________

Client/Guardian Signature: _________________________