Due to the consideration of the child's world being profoundly impacted by each parent, it is required that contact be made with each legal parent. Likewise, verbal consent at the minimum must be received in order for any child to be seen at Grand Rapids Therapy, PLLC. Any parents who are in a custody dispute or divorce proceedings must be aware that Jesilee Bonofiglio, LMSW, will not provide a custody evaluation, recommendation for parenting time, or testify against or for a parent. Please contact Jesilee Bonofiglio at 616-258-8454 if you have any questions.

I understand that:

I am requesting services from Grand Rapids Therapy, PLLC and authorize the therapist to provide treatment, recommendations and/or referrals considered necessary, helpful and appropriate.

I will participate in developing my treatment plan, which will define a vision for my future and my goals, roles, and responsibilities, as well as my wants and desires.

Treatment is voluntary and my consent to treatment may be withdrawn at any time.

I may feel better from treatment, however Grand Rapids Therapy, PLLC does not promise that this will happen or how long it will last. Following my treatment plan will help to give me the best chance to feel better.

Through implementation of the treatment plan, the therapist will assist me in understanding all procedures used, any possible risks or discomfort, the purpose of treatment, the reasonable expected benefits, and any alternatives to treatment, which may be helpful.

Therapy can lead to an increase in distress and symptoms and, if this occurs, it is my responsibility to notify my therapist of changes to ensure that services are meeting my needs and expectations.

I may be taken to an emergency room if the therapist thinks I need treatment right away that cannot be given to me at this clinic.

I have received and reviewed the Notice of Privacy Practices.

My treatment information is protected, confidential, and my therapist will respect my right to privacy.

My records and other personal data are only given out with my prior, written permission. This is done after the reason for giving out the information has been told to me unless it is for accrediting, licensing, payment, financial, therapist supervision, quality care review or to another healthcare provider, and/or if it is an emergency.

My treatment information may also be released, by law, to the proper authority / person if it is needed to keep others or myself from being harmed.

If I am a parent of a minor, I am expected to participate in my child’s treatment.

It is important that I express satisfaction and dissatisfaction with services and discuss my needs and preferences throughout my treatment to ensure that my services are meeting my needs and goals.

All information shared in this office is confidential unless a specific release of information is signed by you with the following exceptions:

You express your planned intention of harming yourself or your emotional/mental state is observed by the therapist to put you at risk.

You express that you intend to do bodily harm to another person. (In that event, I am obligated by law to take reasonable precautions to ensure others’ safety.)

You share that you have in the past and / or present emotionally, physically or sexually abused a minor.

You are a minor and you share that you are currently or have been physically or sexually abused, or your therapist determines that you are at significant risk.

Your insurance company requests information relative to payment of your claim or another process is required to collect unpaid fees, or any legal defense is required by your therapist.

Your therapist receives a signed court order by a judge to testify in court, or to provide records.

You complain of physical symptoms, or you develop any physical symptoms while receiving counseling / therapy. You will be requested to obtain a physical examination to rule out medical basis for symptoms, and allow your therapist to speak with your physician.

You are currently taking medication for a mental health condition, or if you need psychiatric care while receiving therapy, or if you have had previous Mental Health services. You will be requested to permit your therapist to speak with your prescribing physician, psychiatrist, or clinic.

In the above instances, your therapist will take appropriate action to ensure your safety. Otherwise, information cannot be revealed without your written permission. Grand Rapids Therapy, PLLC has no control over the confidentiality of any information once it is disclosed outside of this office. If you have any questions about who has access to your information, please contact others to whom you have authorized information to be released.

I am aware that my privacy is protected and that legally no information can be sent by text or email unless I waive this right. As a convenience to me, I hereby request that Grand Rapids Therapy PLLC communicate with me regarding my treatment by Grand Rapids Therapy, PLLC via electronic communications (e-mail or text message). I understand that this means Grand Rapids Therapy, PLLC and/or my treating providers will transmit my protected health information such as information about my appointments, diagnosis, medications, progress and other individually identifiable information about my treatment to me via electronic communications.

I understand there are risks inherent in the electronic transmission of information by e-mail, on the internet, via text message, or otherwise, and that such communications may be lost, delayed, intercepted, corrupted or otherwise altered, rendered incomplete or fail to be delivered. I further understand that any protected health information transmitted via electronic communications pursuant to this authorization will not be encrypted. As the electronic transmission of information cannot be guaranteed to be secure or error-free and its confidentiality may be vulnerable to access by unauthorized third parties, Grand Rapids Therapy, PLLC shall not have any responsibility or liability with respect to any error, omission, claim or loss arising from or in connection with the electronic communication of information by Grand Rapids Therapy, PLLC to me.

After being provided notice of the risks inherent in use of electronic communications, I hereby expressly authorize Grand Rapids Therapy, PLLC to communicate electronically with me, which will include the transmission of my protected health information. I understand that in the event I no longer wish to receive electronic communications from Grand Rapids Therapy, PLLC, I may revoke this authorization by providing written notice to Grand Rapids Therapy, PLLC at 3501 Lake Eastbrook Blvd SE Suite 280, Grand Rapids, MI 49546 or fax at 1-866-312-6172.
I agree that Grand Rapids Therapy, PLLC may communicate with me electronically unless and until I revoke this authorization by submitting notice in writing. This authorization does not allow for electronic transmission of my protected health information to third parties and I understand I must execute a separate authorization for my protected health information to be disclosed to third parties.

I hereby authorize the transmission of my protected health information electronically as described above.