Peak Professional Group, PLLC’s Onboarding Forms

For each form, please read it and then fill out the corresponding signature portion. You can reference back to this page any time you would like to review it. We begin with the practice’s internal forms to be reviewed and signed. After that section, you will find links to our Payroll Forms along with a link to submit these signed PDF forms.

Electronic Health Record & Electronic Signature Policy

Peak Professional Group, PLLC adheres to a strict Electronic Signature Policy that includes the following information (per the Record Management and Documentation Manual (2009) located here:

If an electronic signature is used, the following standards shall be followed:

1. When an electronic signature is used, the provider shall be given an opportunity to review the entry for completeness and accuracy prior to electronically signing the entry.

2. Once an entry has been signed electronically, the computer system shall prevent the entry from being deleted or altered.

3. If errors are later found in the entry, or if information must be added, this shall be done by means of an addendum to the original entry. The addendum shall also be dated and signed electronically.

4. Passwords or other personal identifiers shall be controlled to ensure that only the authorized individual can apply a specific electronic signature. Passwords should be changed at specified intervals.

5. Any staff authorized to use electronic signatures shall be required to sign a statement that acknowledges their responsibility and accountability for the use of their electronic signature. The statement should explicitly state that the provider is the only one who has access to and use of this specific signature code/password.

6. An electronic signature shall be under the sole control of the person using it. A provider shall not delegate their electronic signature authorization to another person.

7. Policies and procedures shall be developed to:

a. Safeguard against unauthorized use of electronic signatures. The policy shall also address sanctions for improper or unauthorized use of electronic signatures.

b. Address procedures that staff should follow if the application is unavailable.

c. Close deficiencies created when a staff member is not available to electronically sign documents.

8. A list of staff who are authorized to use electronic signatures shall be maintained.

9. The governing body shall authorize the use of the electronic signature.

As part of your employment/contract with Peak Professional Group, PLLC you are hereby authorized to use an electronic signature with the current Electronic Health Records System.

Outpatient Therapist Job Description & Expectations

Position Description:

The outpatient therapist will provide culturally competent mental health services to individuals and families who are experiencing varying levels of difficulties due to life situations or mental health concerns. This job description is intended to convey information essential to understanding the scope of the job and the general nature and level of work performed by professionals within this position but is not intended to be an exhaustive list of qualifications, skills, efforts, duties, responsibilities or working conditions associated with the position.

Major Areas of Responsibility:

• Provide high quality, compassionate and ethical outpatient mental health therapy to clients as scheduled.

• Complete clinical documentation within 48 hours of date of service (recommended to be completed daily)

• Actively participate as a positive member of the clinical environment.

• Maintain good standing with the appropriate board and insurance entities.

• Complete all recommended continuing education requirements current with updated research and best practices.

• Be aware of community referral sources and refer when necessary.

• Secure client information per HIPAA standards.

• Maintain case files within electronic health record (EHR) that are up to date as described in the Job Expectations handout.

• Perform other duties as assigned (including but not limited to completion of Social Security/Disability forms, authorization and billing forms, phone calls, and participating in case consultation meetings).

• Review company Policies & Procedures on a regular basis 

Required Knowledge, Skills and Abilities:

• Knowledge of family systems and their impact on mental health within the family

• Skill in applying varied interventions with individuals/families in crisis

• Skill in working with a variety of cultures

• Skill in working independently and implementing time management strategies

• Ability to provide necessary self-care

• Ability to demonstrate positive team interactions with other clinic staff

• Awareness of personal strengths and appropriate timing for referrals

Education and Experience:

• Masters or doctoral degree in a mental health-related field

• Licensed within the State of North Carolina and credentialed with at least three insurance companies (once hired).

• Previous experience in home-based mental health, office-based counseling and/or school-based counseling protocol, and/or knowledge of EHR are desirable but not required­­­­­­­­­­­­­­­­­­­­­

Expectations & Timelines related to this position:

Comprehensive Clinical Assessment- 48-72 hours

The very first step in providing outpatient mental health treatment is the Comprehensive Clinical Assessment (CCA).  The purpose of a Comprehensive Clinical Assessment is to provide a face-to face evaluation of an individual's present and past mental health, developmental, and/or substance abuse conditions that results in the issuance of a written report known as a CCA.  This report is generated by filling out all of the areas in the template and is meant to serve as a guiding perspective on the client’s current presenting issues and diagnostic criteria.  All diagnosis must be identified and backed using the DSM-5 criteria for diagnosing (citing symptoms, duration and severity).  Assessments are due within 48-72 hours of the date of service.

Associate Licensed Clinicians-  All CCA’s done by an associate-level clinician (LPCA, LCSWA) must have it reviewed and “signed off” by a clinical supervisor at Peak Professional Group.  This is done by notifying your direct supervisor at the practice via email when the CCA is completed (not signed) and ready for review.  Please do not electronically sign the CCA until it has been endorsed by the supervisor in charge of reviewing your assessments (CCAs).  All corrections are due back within 48 hours of the request.

Treatment Plans-48-72 hours

Treatment plans provide the foundation for the on-going treatment must be completed during the initial session with the client.  A treatment plan must have the same initiation as the date of service of the initial assessment.  Clients are sent the Tx Plan Signature Page with the intake paperwork online. If the client/guardian has not signed this online form (school-based), a printed form can be signed and sent back to the support team via email.  Tx Plans are to be developed within 48-72 hours of the date of service.

Treatment plans should be individualized to the presenting issues of the client and measurable in nature.  It is important to include evidence-based interventions in the treatment plan.  Treatment Planners are available through the practice and you are encouraged to use them to assist in the documentation of the Treatment Plan. 

Treatment Plan Signature Pages must be turned into the office within 48-72 hours of completion for those who are not securing the forms online.

Progress Notes-24-48 hours

Progress notes have been streamlined through the implementation of our Electronic Health Record (EHR) Theranest.  Documentation should always be individualized in nature and should never be copied from another chart or different date of service.  Progress notes are to be completed and electronically signed within 24-48 hours of the date of service.

Other Important Expectations include:

• Confidentiality

All client information is considered protected and confidential in nature.  Each clinician’s licensing board sets out the rules and regulations of client confidentiality.  Please see your specific board’s Code of Ethics to ensure that you are following guidelines accordingly. 
Furthermore, all information that comes in and out of Ppg is considered private and confidential.  This information includes but is not limited to: forms, case consultation, supervision, invoicing, payroll and insurance rate reimbursements.  It is the explicit understanding that this information remain confidential within the context of the group practice.

• Client Scheduling of Appointments

Peak Professional Group, PLLC currently uses Theranest to schedule client appointments.  All client appointments should be entered into this system at least 72 hours before the scheduled appointment.  Failure to do this, will disrupt the overall flow of the office space and could have other significant effects on the workings of the company.  Clients have access to our online scheduler (in some cases) and some may choose to use this system to schedule appointments.  With this in mind, it is each clinician’s responsibility to maintain their office hours and keep these hours updated on a regular basis.  All newly scheduled appointments should be entered within 24 hours of making the appointment, so as to ensure that appointments are not made in a conflicting manner.

• Client Communications

Clients have many ways of communicating with clinicians at Ppg.  While Ppg does not set or enforce strict guidelines, it is assumed that general common sense will be used regarding how and when to communicate with client’s.  All official communication should be included in a non-billable note in our current EHR so as to protect all parties.  Clinicians are encouraged to decide and notify the clients that they offer counseling to of the best way to get in touch with their therapist.  Unsecure means of communication are discouraged.

• Ethical Issues

Any and all potential ethical issues including but not limited to: reporting, suicide/homicide risk potentials and other potential legal or ethical issues must be discussed with the practice owner and the clinical supervisor to ensure that all potentially involved persons are protected.  If needed, Ppg will seek outside consultation regarding any potential or identified risks. 

• Peak’s Policies & Procedures Manual

It is each clinician’s professional responsibility to review the Policies & Procedures Manual on a regular basis.  The Manual is meant to be a fluid document that is updated and changed as needed by administration.  Peak will maintain a Google document with general updates that will be shared with staff on a regular basis.

• Continued Education

All clinicians who are licensed through the State of North Carolina must meet minimum Continued Education requirements in order to maintain their license.  Ppg encourages and supports on-going continued education, understanding the very important role that education plays in the professional role.  Ppg will work with each clinician to ensure that they are given the support needed to make this happen.

• Crisis Coverage

Peak Professional Group, PLLC offers 24-hour crisis coverage for all people seeking outpatient mental health services through our office.  We have implemented a Policy (please see) that supports the 24 hour crisis coverage.  All clients are to be notified of this policy upon initiating counseling services.  It should be noted that clients are encouraged to first contact their therapist when experiencing a mental health concern due to clinical necessity.  If the therapist is not available, clients are encouraged to contact our after-hours line at 919-412-5685.

• Time away from Office

Self-care is an important part of remaining healthy in the counseling field.  With this in mind, taking time away from the office is important and encouraged.  Therapists are to first notify the practice owner and supervisor of any time off, with as much notice as possible so that case discussions can occur and clients’ clinical needs can also be addressed.  Please notify the practice owner of any time off of more than 3-4 days and notify clients of this if you unable to attend to general issues while you are “off”.  If you have any questions about this, let us know and we will discuss this further.

Confidentiality Agreement

RECITALS: WHEREAS, Covered Entity contracts with Independent Contractor/Employee to provide certain services to Covered Entity as described in the Independent Contractor Agreement. The parties acknowledge that Independent Contractor may incidentally or inadvertently encounter, view or access certain Confidential Information maintained by Covered Entity which may qualify as Protected Health Information (“PHI”) or electronic PHI within the meaning of the Health Insurance Portability and Accountability Act of 1996, as amended, and the privacy and security standards promulgated pursuant thereto (“HIPAA”). NOW,

THEREFORE, in consideration of the mutual promises contained herein, as well as other good and valuable consideration, the parties hereto agree as follows:
1. “Confidential Information” means any and all non-public, medical, financial and personal information in whatever form (written, oral, visual or electronic) possessed or obtained by either party. Confidential Information shall include all information which (i) either party has labeled in writing as confidential, (ii) is identified at the time of disclosure as confidential, (iii) is commonly regarded as confidential in the healthcare industry, or (iv) is Protected Health Information as defined by HIPAA.

2. Independent Contractor/Employee shall provide the services more fully described in Independent Contractor Agreement or Offer Letter.  For its services, Independent Contractor/Employee shall receive from Covered Entity compensation as agreed to in a separate contractual agreement and offer.

3. Independent Contractor/Employee is free to engage in any other employment of choice as long as that employment (contract or otherwise) does not directly or negatively impact Covered Entity.

4.  Independent Contractor/Employee agrees to maintain the confidentiality of any Confidential Information, including Protected Health Information that it may incidentally or inadvertent encounter, view or have access to while providing the services under the terms and conditions set forth in this Agreement.

5. Independent Contractor/Employee agrees not to further use or disclose any Confidential Information, including Protected Health Information that it incidentally or inadvertently views or obtains access to and further agrees to implement appropriate safeguards to prevent any further use or disclosure of any Confidential Information that is incidentally or inadvertently accessed.

6. Independent Contractor/Employee agrees to cooperate with Covered Entity and perform such activities as it may from time to time direct, in order to mitigate any harmful effects as a result of a wrongful use or disclosure of Confidential Information by Subcontractor.

7. Independent Contractor agrees to report to the Covered Entity any use or disclosure of Confidential Information in violation of this Agreement, HIPAA or any other federal, state or local law or regulation.

8. Independent Contractor/Employee agrees to comply with all applicable laws and regulations, including HIPAA and the HITECH Act, to the extent applicable, in meeting their obligations under this Agreement.

9. The obligations of confidentiality and non-use and non-disclosure under this Agreement will continue indefinitely from the effective date of this Agreement.

10. This Agreement may be modified or amended only with the written consent by both parties.

11. No waiver of any provision of this Agreement, including this paragraph, shall be effective unless the waiver is in writing and signed by the party making the waiver.

12. This Agreement shall be governed by and construed in accordance with the laws that govern the underlying contractual agreement between the parties.

24 Hour Crisis Coverage Policy

Paid Time Off Policy

At Peak Professional Group, PLLC, we understand the importance of taking time off to recharge and rejuvenate. We offer paid time off (PTO) to all eligible employees to ensure they can take time away from work for personal & professional reasons. Our PTO policy is as follows:

Eligibility:

All full-time employees are eligible to receive PTO after completing their probationary period. Part-time employees may also be eligible for PTO on a prorated basis.

Accrual:

Employees will accrue PTO at the rate of 1 hour for every 25 (60 minute) client sessions (includes the following CPT codes: 90791, 90837, 90846, 90847 and 44040.

Usage:

Employees may use their PTO for vacation, personal days, self-care, sick leave, or other personal reasons. To request PTO, employees must submit their request via our online

Provider Payroll Form.

Carryover:

Unused PTO (from January 1-December 31st) cannot be carried over to the next year. Any unused PTO at the end of the calendar year will be forfeited. Therefore, it is essential for employees to use their allotted PTO within the year it is accrued.  PTO accrued in the last pay period of the year (December 16th-31st) will carry over into the new year.

Exceptions:

There may be certain circumstances where exceptions to this policy are warranted, such as medical or family emergencies. In these cases, employees should speak with their supervisor and HR to discuss options. At Peak, we value our team's well-being and understand the importance of taking time off. We hope this policy encourages our team to take the time they need to rest and recharge, and we look forward to seeing everyone return to work refreshed and ready to tackle new challenges.

Unpaid Time Off

Peak Professional Group, PLLC affords each clinician a reasonable amount of unpaid time off. If you would like to take time off (paid or unpaid) of 1 week or more, please notify Sam (and/or immediate supervisor within the practice). Calina and admin team and clients are to be notified of who to contact in the event of a clinical emergency while you are away from the office.

This policy is subject to modification at any time as is with our other policies & procedures.

Peak Team Contact Sheet

Our Peak Team Contact Sheet includes your personal contact information and is not shared outside of the team. This sheet is to be updated any time there is a change in your personal contat information. Please click the link below “Peak Team Contact Sheet” and add your contact information for the team!

Bio & Headshot Form