Rally’s Counseling Program helps address unique psychological needs of entire families affected by a childhood cancer diagnosis. Rally families are eligible to receive up to ten (10) counseling sessions with licensed professionals at reduced cost.
Counseling Referral Form and Counseling Program Guidelines
Rally Foundation For Childhood Cancer Research, Inc. (“Rally”) appreciates the impact that a childhood cancer diagnosis has on the whole family. Rally’s multi-faceted approach to help address these unique experiences includes partnering with a network of trusted and licensed community based therapists willing to offer counseling sessions to Rally families (a “Provider” as defined below).
A Rally family’s circumstances must include one of the following life events to be considered eligible under Rally’s Counseling Program (the “Program”):
A child diagnosed with cancer, LCH, HLH, or aplastic anemia; A child who relapsed with cancer, LCH, HLH, or aplastic anemia; or A child who passed away from cancer, LCH, HLH, or aplastic anemia.
Rally determines in its sole discretion the Provider available under the Program, and a Rally family’s acceptance into the Program.
Upon acceptance into the Program, Rally will offer up to ten (10) counseling sessions with a Provider for eligible families and family members (a “Session Participant”) under the following reduced cost structure. A first session is free. For each subsequent session (sessions two (2)- ten (10)), the per session cost is $25.00. The per session cost is the sole responsibility of the Rally family, and payable directly to the Provider under payment arrangements determined by the Provider.
A Session Participant is any one or more family members chosen solely by the Rally family. The
Session Participant can change for any one or more of the counseling sessions to best support the Rally family’s needs. For example, a counseling session can include individual counseling, couples counseling, family counseling, etc. The ten (10) sessions are the maximum amount of sessions available to the Rally family under the Program. The Rally family may utilize less than the ten (10) under the Program, but once/if ten (10) counseling sessions are reached, the Program participation ends and does not renew.
Rally recognizes the unique circumstances of the life events affecting Rally families may entail more than ten (10) sessions, and Rally fully supports and encourages successful pairings of families/family members with counselors that warrant the much-needed therapies of continued sessions. Rally families that end Program participation may utilize the services of the same or different Providers beyond those sessions covered under the Program under any payment regime agreed to by the family and Provider. Rally has no involvement with session costs for sessions outside the Program.
Once you have signed and returned this form to Rally, Rally will determine Program eligibility as soon as reasonably possible, and upon acceptance into the Program, Rally will issue you an authorization code (Rally XXXXX) for use in the Program. Once you have received your authorization code you are solely responsible for contacting the Provider to schedule any session covered under the Program.
The Program provides one (1) free, and up to nine(9) additional sessions. The Program does not include scheduling such sessions, nor issues involved with cancelation either by the Provider or the Session Participant for any particular session. A paired Provider might require 24 hours advance cancellation to avoid being charged a cancellation fee equal to the co-pay. The arrangement(s) the Session Participant and the Provider have for such actions are solely within the personal relationship of Session Participant and Provider. While cancellation of, or a missed session, happen for a number of reasons, including as a direct result of a medical issue related to your child’s illness, various state and federal laws, including HIPAA limit Rally’s involvement in Session
Participant/Provider relationships, including whether or why a session might have been canceled.
Confidentiality
Grow Counseling and Art It Out, the center and/or therapist providing counseling services (individually, and collectively, sometimes the “Provider”) are committed to patient and family confidentiality, and comply with all applicable laws (e.g., HIPAA) and guidelines to maintain the privacy of healthcare information. Rally authorizes sessions for participants utilizing a limited release of protected health information. This does not authorize any Provider to disclose private information to Rally regarding patients or their families.
Disclaimer
Rally offers the Program solely to support patients with childhood cancer, LCH, HLH, or aplastic anemia, as well as the families of such patients. While Rally has chosen to partner with accredited centers with state-licensed Providers, Rally has no responsibility for, and makes no representations or warranties with respect to, a) the actions or inaction of Providers who render counseling and other services through this Program, including, but not limited to, any action taken by such Providers based on their perceived or actual legal or ethical obligations to report to legal authorities or other third-parties information obtained during the course of providing services as a part of the
Program; b) the information provided by the Providers in any form, whether printed or electronic;
c) the quality or outcome of services provided through this Program; or d) the ability of Providers to provide the contracted services, including any express, statutory, and implied warranties of treatment outcome. Rally reserves completely the right to alter the type and nature of the Program and/or services offered, with reasonable notice to the Rally family of such change(s). By participating in the Program, patients and their families agree to hold Rally harmless for any breach of professional liability, including that of any Provider’s breach of professional liability.
By submitting this executed form, I give Rally permission to provide my name, contact information, and limited health information regarding the child with cancer to the Providers agreeing to provide counseling services under the Program. By submitting this executed form, I am also confirming that I have read and understand the provisions of this Rally Foundation Counseling Program Agreement, and the Disclaimer provided above.