have voluntarily applied for admission to Aspire Wellness Center, Inc (“Aspire”). I understand that upon acceptance to Aspire, I consent to having evaluations, diagnostic studies and such non-invasive treatment given to me as deemed necessary.
Welcome to Aspire Wellness Center: Important Information You Need to Know: Aspire is an organization with a high level of commitment to the provision of essential services to children, adolescents, and adults, in an environment conducive to and supportive of their varied needs regardless of race, gender, or nationality. Aspire Wellness Center specializes in the treatment of mental health issues in an outpatient setting. Aspire offers care using person-centered, CBT, in addition to, other proven treatment modalities. Aspire may utilize alternative treatments such as mindfulness, relaxation, and breathing techniques, meditation, referrals to community based support groups such as AA/NA, journaling, and/or art therapy. Aspire’s mission is to “help people improve the quality of their lives by giving them the tools they need to succeed. We focus on partnering with our clients and staff to help them strengthen their emotional wellbeing, develop satisfying relationships, and resolve the challenges that keep them from achieving their goals. At Aspire, we strive to offer the highest quality care and a safe, trusting environment.” “We are committed to quality mental health care that is provided in a collaborative effort to meet the client’s treatment objectives. We are committed to the philosophy that we exist for our clients and one another.”
Frequency and Length of Counseling or Therapy: The frequency of treatment varies from several times weekly to monthly or bimonthly, according to acuity of illness and clinical need. Patients may be seen several times weekly, monthly, or bimonthly as indicated. The length of counseling varies greatly. Some stressors or symptoms can be alleviated in a few sessions while others may require longer treatment. The decision to end therapy remains between myself and my therapist, if therapy if ended prematurely or before maximum benefit has been reached, referrals for additional services will be provided to you. I understand that discharge from treatment should be a mutually agreed upon decision between myself, my therapist, and Aspire Wellness Center. If I withdraw from treatment and/or do not have regular contact with the psychiatrist/therapist, I may be discharged. Any significant violation of my patient responsibilities could also result in discharge.
Special Populations: Aspire therapists and psychiatry staff offer a person-centered approach to care and are experienced in working with children, adolescents, and adults. Aspire offers anger management groups for court-ordered individuals and can assist those struggling with substance use either through our services or by referral to an appropriate level of care.
Goal of Counseling and Medication Management: The goal of counseling and medication management is to reduce stressors and symptoms of mental distress or mental illnesses. For many individuals it leads to reduced feelings of stress or distress and increased positive interactions, insight, awareness, positive copings skills and problem resolution skills. Problems discussed in therapy can, for some individuals, cause an increase in in symptoms such as anxiety, depression, sleep disturbances, flashbacks, intrusive thoughts, suicidal ideation, and relationship problems. This is not an all-encompassing list. In some situations, hospitalization may be necessary. It is important you keep your therapist informed of any difficulties you may be experiencing during therapy.
Assessment: Psychiatry staff and counselors/therapists must complete both initial and ongoing assessments as it is imperative that all documents be fully completed, and all discussions include open and honest communication.
Consultation: Psychiatry staff and counselors/therapists may consult with supervisors and colleagues at Aspire to improve the services they provide and their skill set. If a therapist is being supervised, you will be informed of the name of the supervisor who will be reviewing and signing off on their documentation, when required. Statistics are compiled Aspire’s services, all identifying information is removed for these purposes.
Confidentiality: I have received and reviewed the HIPAA Notice of Privacy Practices. These rights generally include strict confidentiality of communication between Aspire and me unless I give specific written permission to release it. I understand that the following exceptions to total confidentiality apply: 1) if the court orders release of records; 2) if I present an immediate danger to myself or others; 3) if abuse of children or special populations is suspected; and 4) if health insurance requests information to authorize payment for services that I receive while at Aspire. These have been explained to me in such a way that I understand their contents. If you are required to attend treatment by a court order or other mandate, Aspire may be required to provide information such as attendance, notes, progress in treatment, and assessments/diagnostic information in response to a written request with a written authorization, court order, or legitimate subpoena. Aspire providers may be called to testify; however, it is at the discretion of the provider(s) whether recommendations for child custody cases or other legal issues are made. The parent or legal guardian of a minor has the right to access information regarding the minor’s care, excluding, for the most part, substance abuse or use information. Aspire may not release information to a parent or legal guardian, if the information may cause harm to the minor and it is found to be in the best interest of the child to not release the information. All treatment records will be kept for seven years as required by our overseeing boards (Maryland Board of Physicians, Social Work Examiners, and Professional Counselors and Therapists) and the Maryland Department of Mental Health and Hygiene. Following the seven years, records will be destroyed via shredding and disposal with a confidential recycling facility. I understand and acknowledge that Aspire uses video surveillance equipment to monitor its facilities, both inside and outside of the building. Video recording is restricted to common, public areas and is noticed by signs where surveillance is conducted. Private areas, including treatment rooms, are not monitored. The video surveillance activity and any corresponding electronic records are collected and maintained for the sole benefit of Aspire and will not be released to anyone without a court order. During accreditation or other audits or review, representatives from CARF International, DHMH, BHA, Beacon, or other payers may review client records for compliance with state or other standards and for accuracy. These reviews are held by the same confidentiality requirements as Aspire. Lastly, to ensure your confidentially and the professional relationship, Aspire providers will not accept invitation to our client’s personal or life events, accept gifts which are valued at $10 or more, and/or initiate conversation in any public settings.
Managing a Crisis/Emergencies: Aspire offers on-call services beyond the hours of operation on Friday through Monday morning and can be reached by calling 443-442-1568. On-call staff responds to client calls immediately and provide prompt service to address urgent matters and, if necessary, guide them through the steps to remain safe and seek emergency care. The on-call service is not for checking and/or changing appointments. During weeknights, feel free to leave a message on our voicemail system. You will be given a copy of Aspire’s Safety Contract at the time of intake, which is personalized and reviewed with you by the intake coordinator. If recommended, your counselor or therapist will complete a more in-depth crisis plan with you during your individual sessions. As part of the on-call procedure, Aspire staff will advise clients to follow this safety plan and provide clients with the support needed to manage crisis situations. Aspire staff instructs clients to call 9-1-1 or Mobile Crisis (410-931-2214) in times of emergency and may assist clients in doing so to ensure their personal safety.
Medical Concerns: I understand Aspire cannot diagnose or treat any medical conditions and it is my responsibility to inform my primary care provider and other medical providers of medications being prescribed to me while in treatment at Aspire. I also understand it is my responsibility to inform my providers at Aspire of any current medications I am being prescribed or taking, any past and/or current medical conditions, and any changes in my mental or physical health.
I understand I am responsible for respecting the privacy, rights, and property of staff and other clients at Aspire. I understand it is my responsibility to follow the treatment plan agreed upon and to refrain from making unreasonable demands on the staff of Aspire. Please see Aspire Orientation for further information on client behavioral expectations.
Fees: Our practice is committed to providing the best treatment to our clients. Our prices are representative of the usual and customary charges for our area.
Aspire thanks you for choosing us as your mental health care provider. Additional information regarding fees and payment can be found in your Aspire Orientation packet.
Effective discharge planning begins at the time of admission. You will be expected to participate in determining treatment goals, evaluating progress, and planning for your successful termination and/or discharge.
Baltimore County Core Service Agency6401 York Road, Baltimore, MD 21212Telephone: 410-887-2731Maryland Human Relations CommissionSuite 300, Metro Plaza, Baltimore, MD 21201410-333-1700 Civil Rights Compliance Office, Department of Health & Mental Hygiene201 W. Preston Street, Baltimore, MD 21201410-767-6592Van T. Mitchell, Secretary of Health and Mental Hygiene201 W. Preston Street, Baltimore, MD 21201410-767-6592
Client AcknowledgementThis informed consent contains information regarding our policies and procedures. By selecting the buttons and dating below, you acknowledge receipt of, understanding of, and agreement to the following:
Aspire Wellness Center 5022 Campbell Boulevard, Suite LNottingham, MD 21236