I understand that most services provided by Blomquist Hale Solutions (BHS) are free to the participants. The cost is covered by the organization that is contracted with BHS. I understand that sessions generally last 50 minutes. When appropriate, my counselor may refer me to resources beyond the EAP. I understand that BHS does not pay for any services beyond direct EAP/life assistance counseling. I understand that BHS is not an insurance company and cannot verify coverage or guarantee payment of claims. I further understand that if I am referred to another provider, I am solely responsible for verifying benefits with my health plan. If BHS serves as my care coordination gateway, I consent to referrals being completed for care outside of BHS and agree to notify BHS if there is a change in provider or level of care. I understand that BHS is not obligated to provide court-ordered counseling. If I am unable to attend an appointment, I agree to cancel 24 hours in advance so that this costly resource is not wasted. I consent to treatment and agree to the practices described above.

I understand that my substance use disorder records are protected under federal law, including the federal regulations governing confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPPA") 45 C.F.R. Parts 160 and 164, and cannot be disclosed without any written consent unless otherwise provided for by the regulation.

CONFIDENTIALITY: Generally speaking, information provided by and to the participants during therapy sessions is legally confidential and cannot be released without a signed release-of-information.

Your confidentiality/privacy is protected EXCEPT in the following circumstances that require mandatory reporting:

1. If you make a serious threat to harm yourself or another person.
2. If information is shared that a child or a vulnerable adult has been or will be abused or neglected, or domestic violence occurs in the presence of a child.
3. If BHS receives a lawful order issued by a court.

If a client(s) elects to services via telehealth (i.e., phone or video) they are responsible for ensuring they are in a private area where they can speak confidentially. Blomquist Hale Solutions is not responsible for breaches of confidential information that occur because of location or other environmental factors on the client's end. If the primary client is a minor, a parent or guardian who has legal custody of the child is required to be present or immediately reachable for the therapy session, including virtual sessions.

For further information and to review our Privacy Policy click here. I acknowledge I have reviewed the Notice of Privacy Practices for Blomquist Hale Solutions.

By clicking below, you acknowledge that you understand and agree to the terms of the Informed Consent above.

Please review the intake information you provided Blomquist Hale while creating your appointment. If there are any errors in the details provided, please contact BH Staff at 801-262-9619 to make any changes. If you have received this message in error, please delete immediately and contact Blomquist Hale at 801-262-9619