How would you like us to contact you? (Please check)
Marital Status (Please select)
court Information
In Case of Emergency
Client Rights, Responsibilities and Rules of the Program
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My privacy for current and closed records is protected and assured, within the limits of confidentiality and my treatment plan.
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If family members of client(s) choose to be involved they agree to adhere to the rules, regulations and restrictions of Suncrest as outlined in this document.
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To receive treatment based on need without impartiality and without regard to race, color, sex, nationality or religion.
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To have my cultural, psychosocial, spiritual/religious, political and personal beliefs and preferences respected.
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To receive treatment in a caring and humane manner. To be free from mental, physical, sexual, financial, and verbal abuse, neglect and exploitation. To be recognized as an individual with inherent worth and value and to have that worth and value respected in the provision of treatment.
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To be treated in an environment that preserves dignity and contributes to a positive self-image.
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To participate in the planning and implementation of my individualized treatment plan. To request consultation and/or review of the treatment plan.
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To be informed of all costs and fees up front.
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To complete a request for review of grievance and/or to access advocacy services if I believe that any of my rights have been violated. All grievances go to the president of Suncrest. A grievance may be filed by phone, e-mail, or letter. Contact information is available upon request.
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Prior to involuntary termination clients will be verbally informed of any existing behavior(s) that would warrant such an action. It will be made clear to the client at the time of the warning that he/she has received a verbal warning. Verbal warnings will be documented in the client’s electronic file by the therapist/staff member who administered the warning. If a problematic behavior continues following the verbal warning the client will then receive a written warning that their actions will result in involuntary termination. In some cases, we may give you a warning, and in other cases you will automatically be terminated.
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To be provided with reasons should involuntary termination occur you must write a letter to the President of Suncrest.
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To be provided with criteria for re-admission to the program you must submit in writing a request to the President of Suncrest. The President will review your request and notify you by mail within 90 days of the receipt of your request.
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To be provided with treatment in a smoke free environment and afforded the right to smoke in accordance with the Utah Clean Air Act.
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To provide, to the best of my knowledge, accurate and complete information about present problems and past difficulties with other therapy institutions and other concerns related to my care.
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As a condition for Suncrest Counseling to provide you services, you agree not to record (e.g., audio and/or video) any part of your sessions with any Suncrest Counseling professional.
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If you would like a copy of the HIPAA regulations, please ask the front desk receptionist.
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I am responsible to come to my session sober. I will not arrive at Suncrest under the influence of any substance or alcohol that may hinder my ability to learn and grow in the process of counseling.
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I am responsible to notify Suncrest within 24 hours prior to my appointment if I will be cancelling. If outside this window I understand that I am responsible to pay a $50 fee.
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I am responsible and privilege for my actions and resulting consequences if I refuse to participate in the planning and implementation of my treatment plan.
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I have the responsibility to be considerate of the rights of other clients and SUNCREST staff.
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I am responsible for my belongings. I understand that I have the responsibility to notify SUNCREST staff of any lost or stolen personal belongings. I can expect SUNCREST to make any reasonable effort to locate these items.
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I have the responsibility and privilege to ask questions about any part of the treatment/program that I do not understand.
Health Information
List any health conditions :
Are you taking any current Medications?(Please select)
Cancellation Policy
Assessments : If you fail to appear at your scheduled assessment, or cancel the appointment within 24 hours, you will be required to pay an additional $50 for each time you reschedule. Three missed appointments will result in an immediate non-compliance with the court.
Individual Sessions : We require a 24-hour notice. If 24-hour notice is not given, you will be charged a $50 late cancel fee that is required at the time of service prior to any other services being rendered.
Late Policy
Weapon Policy
Informed Consent
Thank you for choosing Suncrest for your treatment needs and trusting us with personal information. Everything that is said in a session will be kept confidential among Suncrest therapists. The exceptions to confidentiality are as follows:
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State mandated report of abuse of children and/or vulnerable adults
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Intent to commit homicide or suicide.
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Information released as required by legal procedure
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Reimbursement from my insurance company that requires release of information to them (diagnosis, symptoms and type of treatment provided). This information may influence future costs and coverage.
While in treatment, you may experience changes in the following areas:
If you experience an emergency outside of treatment at Suncrest, you are advised to call 911, go to the nearest emergency room, or call the Valley Mental Health Crisis Line @ (801) 261-1442.
Payment is expected in full at the time of service unless other arrangements have been made.We accept cash,money orders or credit cards.
There may be times when you will be working with someone at Suncrest who is doing an internship here. These interns are supervised by a licensed Suncrest therapist.
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.
Why we are providing you with this notice:
We are required by a federal law known as the Health Insurance Portability and Accountability Act (HIPAA) to give you this notice. This notice will tell you about the ways we are to use and disclose health information about you, and will describe your rights and our obligations regarding the use and disclosure of that information.
Your health information:
This notice applies to the information and records we have about your health, health status, and the health care services you receive from Suncrest. This information relates primarily to counseling services you have received from Suncrest.
How we may use and disclose health information about you:
For treatment: We may use or disclose health information about you to facilitate counseling and other treatment within this company.
For payment: We may use and disclose health information about you so that we can be paid by you, an insurance company, or another party, for the services we provide to you. For example, we may need to give your health insurance company information about our services to you so the company will pay Suncrest for these services.
For professional operations: We may use and disclose health information about you in order to run this office and make sure that you and other clients receive quality care. For example, we may use your health information to evaluate our performance, or to contact you to remind you of your appointments, or to cancel an appointment.
Please notify us in writing if you do not want us to contact you to remind you of an appointment or where you prefer us to contact you to cancel an appointment.
Special situations: I may use or disclose your health information without your permission for several reasons. These reasons include:
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Disclosing your health information when we believe that disclosure is necessary to prevent a serious threat to your health and safety or the health and safety of another person.
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Disclosing your health information as required by federal, state, or local law.
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Disclosing your health information as required by law to prevent injury or suspected abuse or neglect.
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Disclosing your health information in response to a court order, subpoena, warrant, summons or similar process.
Other uses and disclosures of health information: Except where otherwise required or authorized by law, we will not use or disclose your health information for any purpose without your written authorization. If you authorize us to use or disclose health information about you, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization, but we cannot take back any uses or disclosures we have already made with your permission.
Notice of Privacy Practices Continued
Your rights regarding your health information: You have the following rights with regard to your health information:
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You may inspect and copy your health information, with certain exceptions.
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If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information.
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You may obtain an account of our disclosures of your health information. This is a list of all of our disclosures of your health information for purposes other than treatment, payment and health care operations.
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You have the right to request that we restrict or limit our use or disclosure of your health information to only treatment, payment or health care operations. We are not required to comply with your request.
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You may request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
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You have the right to receive a paper copy of this notice.
If you want to exercise any of these rights, please contact us, in writing at our office where you are receiving counseling.
Changes to this notice:We have the right to change this notice. If we do so, the new notice will apply to the health information we may already have about you and the health information that we receive in the future. We are required to abide by the most current notice that is in effect. We will post a summary of the most current notice in our office. You are entitled to receive a copy of the most current notice.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U. S. Department of Health and Human Services. To file a complaint with Suncrest, please contact us at (801) 255-1155.
This notice is effective as of July 2021.
Financial Agreement
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RATES
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Substance Abuse or Domestic Violence Assessment
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$100
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Prime for Life
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$275
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Anger Management
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$160
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Prime Solutions
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$40/ Class
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Individual Session
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$100
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Prime for Life 1st Offense AND under 21 years old
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$150
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Thinking Errors
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$160
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Domestic Violence
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$40/ Class
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Dual Assessment
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$200
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Principles of Recovery
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$160
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Level 2 Anger Management
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$280
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Mental Health Evaluation
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$495
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Parenting Class
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$160
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Level 2 Thinking Errors
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$280
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Release of Information
This release form gives Suncrest Counseling permission and consent to discuss your counseling sessions & treatment with the persons named in this form:
