Clients Information

    How would you like us to contact you? (Please check)

    Marital Status (Please select)


    court Information


    In Case of Emergency

    Contact Person :

    Relationship :

    Phone Number :

    Email Address :


    Client Rights, Responsibilities and Rules of the Program

    • My privacy for current and closed records is protected and assured, within the limits of confidentiality and my treatment
      plan.

    • 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.

    • To receive treatment based on need without impartiality and without regard to race, color, sex, nationality or religion.

    • To have my cultural, psychosocial, spiritual/religious, political and personal beliefs and preferences respected.

    • 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.

    • To be treated in an environment that preserves dignity and contributes to a positive self-image.

    • To participate in the planning and implementation of my individualized treatment plan. To request consultation and/or
      review of the treatment plan.

    • To be informed of all costs and fees up front.

    • 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.

    • 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.

    • To be provided with reasons should involuntary termination occur you must write a letter to the President of Suncrest.

    • 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.

    • To be provided with treatment in a smoke free environment and afforded the right to smoke in accordance with the Utah
      Clean Air Act.

    • 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.

    • 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.

    • If you would like a copy of the HIPAA regulations, please ask the front desk receptionist.

    • 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.

    • 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.

    • 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.

    • I have the responsibility to be considerate of the rights of other clients and SUNCREST staff.

    • 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.

    • I have the responsibility and privilege to ask questions about any part of the treatment/program that I do not understand.



    Health Information

    Primary Physician :

    Phone Number :

    Physician:

    Phone Number :

    List any health conditions :

    Are you taking any current Medications?(Please select)

    Name :

    Dosage :

    Name :

    Dosage :

    Name :

    Dosage :


    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:

    • State mandated report of abuse of children and/or vulnerable adults

    • Intent to commit homicide or suicide.

    • Information released as required by legal procedure

    • 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:

    • Thinking, emotions, behaviors, and relationships


    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:

    • 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.

    • Disclosing your health information as required by federal, state, or local law.

    • Disclosing your health information as required by law to prevent injury or suspected abuse or neglect.

    • 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:

    • You may inspect and copy your health information, with certain exceptions.

    • If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the
      information.

    • 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.

    • 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.

    • 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.

    • 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

    RATES

    Substance Abuse or Domestic Violence Assessment

    $100

    Prime for Life

    $275

    Anger Management

    $160

    Prime Solutions

    $40/ Class

    Individual Session

    $100

    Thinking Errors

    $160

    Domestic Violence

    $40/ Class

    Dual Assessment

    $200

    Principles of Recovery

    $160

    Level 2 Anger Management

    $280

    Mental Health Evaluation

    $495

    Parenting Class

    $160

    Level 2 Thinking Errors

    $280



    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: