Salesmanship Club Youth and Family Centers is committed to maintaining the confidentiality, integrity, and security of personal information entrusted to us by our donors.

SCYFC does not sell or rent donor names or information, however acquired, to any firm or nonprofit organization. SCYFC does not share your information with any other firm or nonprofit organization for their fundraising purposes.

Information that you provide to us by filling out online forms is located on a secure server. We have put into effect appropriate procedures to safeguard and secure the information we collect online. Once you provide us with personal or professional information, that data remains confidential.

NOTICE OF OUR PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will change this Notice and make a new Notice available upon request.

USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
  • Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or other practitioner.
    • Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
    • Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within Salesmanship Club Youth and Family Centers, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of Salesmanship Club Youth and Family Centers, such as releasing, transferring, or providing access to information about you to other parties.

USES AND DISCLOSURES REQUIRING AUTHORIZATION

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission that is above and beyond the general consent that permits only specific disclosures. In those instances, when we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION

We may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If we have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, we must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency.
• Adult and Domestic Abuse: If we have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, we must immediately report such to the Texas Department of Protective and Regulatory Services.
• Health Oversight: If a complaint is filed against us with the State Board of Examiners, the board has the authority to subpoena confidential mental health information from us relevant to that complaint.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety: If we determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, we may disclose relevant confidential mental health information to medical or law enforcement personnel.
• Worker’s Compensation: If you file a worker's compensation claim, we may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.

PATIENT RIGHTS

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.
• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
• Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described previously). On your request, we will discuss with you the details of the accounting process.

QUESTIONS OR COMPLAINTS

If you want more information about our privacy policy or have questions or concerns, please contact us. If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may complain to us using the contact information listed at the end of this Notice. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

Jim Jackson
Contact Officer
Telephone: 214-915-4751
Email: jjackson@salesmanshipclub.org
Address: 106 E. Tenth St., Dallas, TX, 75203

MENTAL HEALTH SERVICES INFORMED CONSENT

Welcome to Salesmanship Club Youth and Family Centers. It is important to us that you know what to expect from the services you receive at our office. For this reason, we ask that you read and understand the information provided here, as it explains several aspects of how we work. Please ask us if there is anything unclear to you. We will be glad to explain it in more detail.

Salesmanship Club Youth and Family Centers, Inc., is a private, nonprofit agency that provides mental health services at our Family Therapy Center, our Family Works Center and in the community. Licensed mental health professionals, educational specialists, parent educators, trainees, and other staff provide assessment, training, and treatment services.
The services include:

• Family Life Education – Provides parent-child training for families of young children (birth through age 6) with emerging emotional, behavioral, and social concerns. The program focuses on educational groups for parents to help them work with their young child.
• Family Therapy – Provides therapy to children and adolescents having emotional and behavioral problems and their families.
• Infant-Child Comprehensive Assessment Program – Provides families of children ages birth through 6 with comprehensive, team-based evaluations of the child’s developmental, cognitive, emotional, and behavioral needs. In order to best help the child, the program is family focused to provide identification and recommendations of needs for the entire family.
• Therapeutic After School Program – Provides intensive therapy to youth (ages 12 through 15) experiencing emotional and behavioral trouble, while helping keep them in their own schools and homes. The program is family and strengths based.

ABOUT THE SERVICES AND/OR TREATMENT YOU’LL RECEIVE:

Family Life Education (FLE) – FLE conducts parent-child training groups on topics of concern for parents of young children. The groups may range from one session to a series of 10 or more sessions that focuses on a specific topic (e.g., social skills training for the anxious child). The primary focus is for parents, although concurrent children’s group may also be a part of the training experience.

Family Therapy (FT) –During the first few sessions, your therapist will be working toward developing an understanding of your needs. Early in these meetings, your therapist will be able to offer you some first impressions regarding what your work together will include. Since counseling/therapy involves a commitment of your time and energy, you should evaluate the information your therapist shares, along with your own opinions, to be sure you are comfortable working with your therapist. If your therapist finds that she/he is unable to assist you, she/he will provide you with a referral to another therapist or agency if you so desire.

Infant-Child Comprehensive Assessment Program (ICCAP) – ICCAP is a team-based approach to assessment where the family is an integral part of the team. Parents participate in all aspects of the assessment, ranging from completing testing on the child’s and family’s functioning to being a part of the feedback and recommendation session. All assessments begin with an in-home visit followed by an intensive four to five hour assessment session at our facility. In the following week a feedback session is held where all team members – including parents – develop recommendations and plans for follow-up.

Therapeutic After School Program (TASP) – TASP is an intensive after school treatment program for youth, ages 12 through 15, and their families. Youth who need intensive therapy but are able to stay at home and in school attend TASP during after school hours. The program focuses on building on the youth’s strengths and includes significant family involvement, including participation in parenting and multifamily groups and family meals together at our facility twice a week.

Please keep in mind that our assessment, group, and counseling/therapy services are not like a medical doctor visit. Instead, they call for a very active effort on your part. For your work with your therapist or group leader to be most successful, you’ll have to work on the things you both discuss – not only during group or individual sessions, but also at home. At any time, you may ask your therapist or group leader why she/he is gathering information or using a particular approach. Your therapist or group leader will be happy to explain what she/he is doing and the thinking behind her/his actions.

Your relationship with Salesmanship Club Youth and Family Centers staff is a professional relationship. In order to preserve this relationship, staff cannot have other types of business or personal relationships with you. We will do all we can to treat you professionally with dignity and respect.

RISKS AND BENEFITS OF ASSESSMENT OR COUNSELING/THERAPY. The assessment and counseling/therapy process can have both benefits and risks. It may not by itself resolve your problem or concern. There may be discomfort associated with the discussion of difficult issues and with change. On the other hand, these services have been shown to have many benefits. They often lead to a better understanding of problems and to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Of course, there are no guarantees as to what your experience will be.

CONFIDENTIALITY. The law protects the privacy of communications between you and our staff. In most cases, our staff can only release information about your treatment to others when you sign an Authorization for Use and Disclosure of Protected Health Information. There are other situations that only require your written, advance consent. These activities are defined as treatment, payment and health care operations, and are explained in more detail in the attached Notice of Privacy Practices. By signing the Mental Heath Services Informed Consent, you are providing consent for these activities.

If you participate in marital or joint therapy sessions with mental health staff, you consent for Salesmanship Club Youth and Family Centers to maintain a single case file for all joint sessions and to release all information contained in the file for joint sessions to any adult participant in the joint session upon request by a participant.

There are a limited number of situations when your rights to confidentiality do not apply, including but not limited to the following situations: a) child abuse; b) elder abuse; c) sexual exploitation; d) situations where we have a duty to disclose, or where, in our judgment, it is necessary to warn, notify, or disclose. These situations are also outlined in the attached Notice of Privacy Practices. We urge you to carefully read the Notice and share with us any concerns you might have regarding the confidentiality of your information.

CUSTODY DISPUTES. Our mental health team supports a cooperative parenting approach in working with divorcing, divorced or conflicted parents. Therefore we will not do evaluations to determine fitness for parental custody nor will we take a position about who should be awarded custody. By signing the Mental Health Informed Consent, you are agreeing not to call any of our staff to court in a custody dispute.

APPOINTMENTS. We ask that you do your very best to honor your commitment to us by arriving on time for appointments. If you will not be able to keep your appointment, please notify your therapist or the receptionist at least 24 hours in advance.

TERMINATION OF SERVICES. You may choose to leave assessments, groups, or counseling/therapy at any time, but this is best accomplished in consultation with your therapist or group leader. If you are dissatisfied with the course of services, we encourage you to talk with your therapist, group leader, or her/his supervisor. Your services here may be terminated by us either verbally or in writing for any of the following reasons: (a) Missing two consecutive appointments without prior notification; (b) threatening or abusive remarks/behavior to any of our staff members; (c) failure to follow important recommendations (i.e., medical referrals, suicide interventions, safety contracts).

OBSERVATION, SUPERVISION AND VIDEOTAPING. Observation, supervision, and videotaping can be useful in your treatment and allow for instruction and input that ensure the highest quality service possible. These practices will be used during assessments and may be used by your therapist or group leader to clarify her/his understanding and to help formulate new ideas to address your concerns. At no time will these practices be used without your full knowledge. Your therapist or group leader will explain these practices further and address any concerns you might have should she/he decide they would be helpful in her/his work with you.

PHONE CALLS AND EMERGENCIES. Our phone is answered in person or by voicemail 24 hours a day. Due to appointment schedules, it may be several hours before your therapist or group leader can return your call. Calls received late in the day may not be returned until the following day. Weekend calls are generally not returned until the following Monday. In an emergency in which you cannot contact your therapist or group leader, you may wish to call 911 or CONTACT at (972) 233-2233, or the Suicide and Crisis Center at (214) 828-1000. You may also go to the nearest hospital or emergency room.

FEES. Since Salesmanship Club Youth and Family Centers is a nonprofit agency committed to serving children and families, we are able to provide quality services at affordable rates. The fees for each program vary and will be discussed with you at the time of service. For families in need of assistance, we provide grants to help cover the cost of service. On the Financial Arrangements page of this packet, a fee will be assessed based on your family income.

Thank you for taking the time to read over this important information. It matters a great deal to us that you feel respected and informed in this process. With your signature on the attached Mental Health Services Informed Consent signature page, you are stating that you understand all policies and agree to abide by all conditions stated in this form.
We appreciate the opportunity to work together and hope that you will always feel free to discuss with us any concerns you have about our practices.