Consent for Service, Limits and Terms of Use Agreement

Anyone registering, paying, and choosing to use Pacific Substance Abuse Assessment & Treatment Services agrees to the following Consent for Service, Limits and Terms of Use:

Pacific Substance Abuse Assessment & Treatment Services/ Client Reference Hereafter

• Pacific Substance Abuse Assessment & Treatment Services is hereafter referred to as "PSAATS". The term "PSAATS" refers to the corporate entity, Pacific Substance Abuse Assessment & Treatment Services. as well as its website (pacificesubstanceabuse.com), directors, officers, agents, employees, successors and assigns. Hereafter, registered users of the PSAATS shall be referred to as "you/your", "client" or "the client".

Adults/Minors Requesting Service

• You agree that you are 18 years old or older, and if you are not, you will have a parent or guardian establish the registration, payment and Consent for Service and Terms of Use Agreement on your behalf.

Solo Participation & False Identity

• You agree to answer questions and questionnaires without the presence or assistance of any third party and agree not to have any third party present at an in-person, telephone or video/webcam interview without first making a direct request to PSAATS and stating the reason that you wish for a third party to be present. PSAATS has the right to deny any such requests if they deem them inappropriate for any reason. You explicitly agree to not have another party stand in as your representative or falsely present themselves in an interview using your identity.

Online Service Limitations

• PSAATS provides online and phone services. You understand that use of online or phone services may not be an appropriate form of care for persons in an emotional or mental health crisis. We reserve the right to assess your situation and decline to offer you services if we believe it is not in your best interests to do so. If we are working with you and a mental health crisis develops we will refer you to your local emergency services and mental health providers where you can be seen in-person. Any fees paid to PSAATS prior to a mental health crisis will qualify for consideration of a partial or full refund, at the discretion of the PSAATS Director, and depending on the amount of services rendered before a referral to a local agency is made.

Consent for Treatment

• You understand and consent to treatment for professional services from PSAATS. PSAATS services are provided by certified and/or licensed substance abuse counselor or mental health practitioner and as such may render a substance abuse or mental health diagnosis where appropriate and indicate such diagnoses in your written records. You also consent to the release of information for therapeutic, billing, supervision and other purposes in connection with your treatment, between and among PSAATS therapists, staff and service contractors who perform supervisory work on behalf of PSAATS. General Information Security Practices
• PSAATS recognizes the absolute importance of keeping client records private and confidential. This section of the Agreement includes our general security practices to keep your information private:

All records are stored on SSL encrypted servers

• Account passwords are set to appropriate length and sufficient variation in characters to minimize chances of access by any third party.
• Sessions conducted via webcam/video are not recorded by PSAATS
• PSAATS does not share nor sell your email or other personal contact information to any parties.

Limits to Confidentiality and Privacy

• Privacy and confidentiality are not only important to have a trusted exchange of client/ clinician information, but they are also items subject to federal law. PSAATS complies with federal confidentiality guidelines under Federal Confidentiality regulations (42 CFR Part 2) and the Health Insurance Portability and Accountability Act (HIPAA 45 CFR). This protection of confidentiality also specifically (42/Part 2) protects the records of mental health, alcohol and drug abuse patients, including the prohibition of re-disclosure of information from client/patient records. HIPAA also requires that mental health and substance abuse professionals provide notice to all clients that information provided by PSAATS and voluntarily disclosed to third parties by you (to courts, probation officers, physicians, schools, etc.) may be re-disclosed by these third parties.
• Furthermore, in compliance with the aforementioned federal laws, PSAATS has the obligation to limit confidentiality and report specific information in the following circumstances:
• PSAATS is mandated to report suspected or known abuse of children and vulnerable adults to local law enforcement and/or local child/adult protective agencies.
• PSAATS is mandated to report specific information to local law enforcement in situations where a client is at significant risk for taking their own life or the life (or lives) of another (others). PSAATS will make a concerted effort to assist clients in accessing appropriate professional care in such circumstances.
• PSAATS is obligated to release your records for legal proceedings if ordered by a court to do so.
• PSAATS uses security encrypted (SSL) transmission for all professional assessment and counseling services completed online. If you choose a webcam/video/telephone service, including uploading, downloading, or faxing personal information to or from PSAATS, you should be aware that risk of interception of your information, though unlikely, is a possibility. PSAATS does not record or tape video/webcam sessions which may be used to provide your services. PSAATS client records are stored on encrypted secure servers.
• There is also no express or implied warranty for any client losses, damage or harm occurring from the use of electronic services, which would include: unauthorized data interception or data/records theft by a third party, unintended utility charges by a third party, computer/electronic viruses, accidental deletion of data or records, or any other claim of harm arising from your choice to engage PSAATS services using electronic means (telephone, fax, internet, wireless, email, video/webcam or any other electronic delivery services that might be used in the future).

Financial Responsibility & Fees

• You understand that payment for service is due before receiving services from PSAATS. Additionally, you understand that PSAATS has no contractual obligation with your insurance company or you that would guarantee your reimbursement for expenses you incur for any and all services from PSAATS.

Client Will Accurately Report Information

• As a client, you agree to provide accurate information about yourself and the circumstances surrounding your need for an evaluation or counseling to the best of your ability. This includes an agreement to not omit information relevant to your situation or present inaccurate information. If inaccurate information is provided or important information is purposely omitted, you will not be eligible for a refund if your assessment is not accepted.

PSAATS is not a Government Entity

• You understand that Pacific Substance Abuse & Treatment Services is not a State or federal organization. While our assessments and clinical reports are generally accepted by other professionals and government agencies you also understand that any clinical conclusions, diagnoses or professional recommendations provided by PSAATS may or may not be accepted or approved by courts, state or federal agencies.Furthermore, courts, state and federal agencies are not bound to agree with our assessments or clinical recommendations.

Refund Terms

• You understand and agree with our conditions and limits to grant a refund. Refunds are only given in circumstances where the requesting party (court, physician, probation department, etc.) will not accept the assessment we provided and the following procedures are followed:
• PSAATS will first attempt to contact any third party that does not accept your assessment to see if there is some additional information needed in order to gain acceptance of your report or service. In this circumstance you will need to first sign and return (fax or scan/email) a release of information form to allow your evaluator to speak with the third party.
• If we cannot make contact with the requesting party, you must provide written proof that your evaluation was not accepted by the requesting party. The document stating your assessment was not accepted must be on the letterhead of the requesting party and have an address, phone number and contact name included on it.

1. Refunds are not granted in situations where the client being evaluated:
2. omitted key information or;
3. provided inaccurate information or;
4. missed an assessment report deadline because:
   • PSAATS was not informed of the due date,
   • client did not meet with your evaluator at the originally scheduled time,
   • client did not provide PSAATS with the documents requested by your evaluator and outlined on the specific assessment (type) page on our website.
   • All refund requests must be applied for within 45 days of your original scheduled appointment.

• We cannot issue a refund if you have ordered an assessment with us and completed an interview, but have not sent in the documents required (e.g. police report, or other items listed for your assessment type) to complete your evaluation. Assessments are not considered complete without submission of relevant documents.
• Refunds are processed within 30-45 days. This allows time to verify that the requesting party has denied your assessment report.

Account Credits

• If you paid for service but decided not to use our service before conducting an interview with your evaluator, you need to make an account credit request via pacificsubstanceabuse.com within 72 hours. We will credit the same account you paid us from and send an email confirmation of the credit.

Limits of Electronic Connections and Liability

• You understand that there is a chance that internet or phone connection could be lost during your services. In the event your connection is lost, the counselor will attempt to contact you at the number you provided in your registration. If you have not heard from your counselor within five minutes, you agree to call our main number to reestablish connection and plan for continuance of your service. You also agree to hold PSAATS harmless with regard to any and all claims of damage from an electronic disconnection during services (also referred to in the Hold Harmless section of this agreement).

Respect of Copyrights

• All assessment, evaluation, educational and other material made available on our website and provided in our offices are copyrighted. You may use our materials for the purpose of PSAATS assessment, counseling or education services only. You agree not to use any aforementioned PSAATS materials in any other manner, including copying, reproducing, scanning, distributing, publishing, selling or otherwise conducting commercial activity with PSAATS materials. Efforts to engage in such activity are punishable by state and federal laws.

No Guarantees of Clinical Outcome

• You agree that you are using PSAATS services at your own risk and without guarantee of any specific clinical assessment, counseling, judicial or education outcomes; that there is no warranty for our services; that third parties are not bound by any contracts or laws to accept or agree with our evaluations.

Complaints

• To file a complaint with us, contact the Director of the practice at:

Pacific Substance Abuse Assessment & Treatment Services

2304 Marshwood Dr.

Jackson, MI. 49203

(517) 416.2010

• You will not be retaliated against for filing a complaint.

Acknowledgement of Receipt of Notice of Privacy Practices

• I acknowledge that I have been informed that I can access the Notice of Privacy Practices information link found below completing my assessment.

Disputes and Jurisdiction

• Any dispute arising from this Consent for Treatment and Terms of Use Agreement shall be governed by the laws and jurisdiction of the State of Michigan.

Notice of Changes

• PSAATS may notify clients of changes or additions to its services by publishing such notice on the PSAATS website. Clients may give notice to PSAATS at any time by any of the following:

Email: kiernan@pacificsubstanceabuse.com 

U.S. Mail: PSATTS 2304 Marshwood Dr. Jackson, MI. 49203

Modifications / Entire Agreement

• This Agreement constitutes the entire agreement between you, the client, and PSAATS. The content represented herein supersedes all previous written or verbal terms of use agreements. PSAATS may amend, modify, clarify, or remove any part of this agreement with notice through the pacificsubstanceabuse.com website. Any use of PSAATS services by you after any amendments, modifications, clarifications, or deletions shall be deemed to constitute acceptance by you of the updated terms of the agreement. You understand that if a court deems any part of this agreement to be illegal or a violation of Michigan statutes, the remaining parts of the agreement shall be considered valid and enforceable until proven otherwise in a Michigan court of law.
• By signing in person or clicking on the "agree" toggle in the purchasing button above, this Consent for Service, Limits and Terms of Use Agreement shall be construed and controlled by the applicable laws of the state of Michigan and the United States of America.