Informed Consent

Welcome to my practice. This document contains important information about my professional services and business policies. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. This document also represents an agreement between us, and that is made effective on the date of electronic acceptance, which is the date and time you schedule your first appointment. We can discuss any questions you have at any time.

Counseling is a relationship between a client and therapist that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. As your counselor, I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Goals of Counseling

There can be many goals for the counseling relationship. Some of these will be long-term goals such as improving the quality of your life, learning to live with mindfulness and self-actualization. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will be set by you. I may make suggestions on how to reach that goal, but you decide where you want to go.

Client

By starting therapy, you are the individual (“client”) who is receiving professional services. The agreement between us is that only you will receive services. Therefore, it is not acceptable to bring a sibling, spouse, friend, or anyone else into our meetings, and it is important to be in a location at the time of your session where you cannot be overheard by other people.

Risks/Benefits of Counseling

Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. Counseling can help you build awareness, make positive behavioral changes, reduce negative mental health symptoms, improve the quality of your life, learn to live in the present, and many other advantages. There are no guarantees that counseling will work for you, since every case is different – we’re all individuals. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly, or it may be erratic. Counseling requires a very active effort on your part. To be most successful, you will have to work on what we discuss outside of sessions.

Sessions

A session “hour” is 53 minutes in duration. There is no specific determination on how many sessions are needed or how often to attend, and it is important for you to make your own decisions regarding your needs. Because this is a voluntary service, you may withdraw from psychotherapy at any time.

I reserve the right to immediately and/or decline services for reasons such as, but not limited to, the following:

• Threats of harm, acts of harm, harassment or otherwise disrespectful behavior towards me or anyone associated with my practice.
• Showing up for sessions under the influence of drugs or alcohol, or the use of drugs or alcohol during sessions.
• Inappropriate sexuality including, but not limited to, removal of clothing, gestures, comments, advances, etc.
• Acts that would interfere with others’ utilization of services from my practice including, but not limited to, canceling appointments with less than 48 hours in advance or arriving more than 10 minutes late (“no showing”).
• Handling and/or use of weapons in session.
• Ethical considerations regarding wellness of fit and appropriate use of services.
• Suicidality or homicidality (see Confidentiality).

When you schedule an appointment, it is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 48 hours’ notice. If you miss a session without canceling, or cancel with less than 48-hour notice, you'd have to pay a rescheduling fee of $120 beforehaving another appointment. It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions; thus, you will be responsible for the fee. In addition, you are responsible for coming to your sessions on time; if you are late, your appointment will still end on time, and if you are more than 10 minutes late or leave early, I may consider your session as missed.

Confidentiality

I will make every effort to keep your personal information confidential. If you wish to have information released, you'd need to sign a consent form before such information will be released. In most situations I will encourage you to disclose your own information to whomever you choose rather than depend on me to do that for you. In addition, because my practice is online and I only work with adults, I do not travel to physical locations or contact others on your behalf.

There are some limitations to confidentiality to which you need to be aware. I may consult with another professional to give you the best service. Counselors are required by law to release information if a client poses a serious risk to others, and in cases of abuse to children or the elderly. If you feel you are in any kind of danger, you agree to contact the appropriate authorities for yourself. You understand my practice is not a crisis service. For that you need to call 911, a local crisis number, a national hotline (such as 1-800-273-TALK), go to a local hospital, or contact a supportive friend/family member depending on the severity and need of your situation.

Technology and Tools of Operation

My practice utilizes tools to operate as a business. I did not create, copyright, and do not own propriety rights to these tools. GoDaddy, which hosts my website, is often used to make initial contact and sign up for services. Psychology Today provides an online registry of therapists and allows me to be contacted through them. They also provide video services for virtual sessions. Google Services provide tools for contacts, calendar, email, and storage/backup. Square enables me to receive payment via credit/debit card and provide receipts. Acuity Scheduling provides appointment reminders and scheduling services. With these tools, the only way your information could be inappropriately seen in a way that was not intended is in the case of an unlawful theft, burglary, or hacking.

If you choose to interact with any social media provided by my practice, you are releasing/authorizing that information to the public since it can be seen by the general public. My practice is not responsible for a breach of confidentiality since you chose to voluntarily associate yourself with my practice by interacting via social media (blog, Twitter, Facebook, YouTube, etc.). Do not use a social media outlet to have communications with me to handle matters that would be more appropriately handled via another avenue. You’re under no obligation to interact with my social media and can, thereby, avoid all the privacy considerations discussed in this paragraph. On the other hand, HIPAA law is not your duty to keep and you are free to disclose and discuss our relationship in any manner you would like.

Record Keeping

I may keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your progress and continuity in service. They will not be shared except with respect to the limits to confidentially discussed in the Confidentiality section. Records will be kept for at least 7 years but may be kept for longer. Records will be kept electronically with Google Services.

Professional Fees

You are responsible for paying at the time of your session unless prior arrangements have been made. You can choose to utilize a third-party source, such as an insurance provider, but ultimately you are responsible for the full payment of your account balance. You must notify me immediately if your insurance information changes and provide your new insurance card at my next appointment.

Insurance

If you have elected so, I will submit insurance claims to your insurance company. If a claim is rejected or paid at a reduced amount, it is your responsibility to pay your account balance in full. Your account balance must be paid in full before you receive any service. Appointments will be canceled if you do not pay in full or if you have a remaining balance. There are no refunds for any service provided by my practice.

You should also be aware that most insurance companies require me to provide them with a clinical diagnosis. Sometimes I must provide additional clinical information which will become part of the insurance company files. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, contact your insurance provider for a list of in-network clinicians.

Contacting Me

I am often not immediately available by email or telephone messaging services. I check email and phone messages daily, but I do not respond when I am with clients or otherwise unavailable. It may take one to two business days for me to reply. To protect your privacy, I do not leave voice messages. If you feel you cannot wait for a reply from me or it is an emergency, go to your local hospital or call 911.