The purpose of this Informed Consent is to inform you, the client, about my professional services, business policies, the process of counseling services, the counselor and the potential risks and benefits of these services. When you sign this document, it will represent an agreement between us. 

PSYCHOLOGICAL SERVICES

Psychotherapy (also referred to as counseling and therapy) is not easily described in general statements.  It varies depending on the personalities of the counselor and client, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Counseling is not like a medical doctor visit.  Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Counseling can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.  On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Counseling can lead to better relationships, solutions to specific problems, and possibly even reductions in feelings of distress. But, there are no guarantees as to what you will experience.

Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select.  If you have questions about my procedures and methods, we should discuss them whenever they arise. If either of us deem that I am not the right counselor for you, I will provide you with referrals to other therapeutic practitioners with whom you can contact.

FEE FOR SERVICE

Payment is due at the time of your scheduled appointment.

My hourly fee (defined as a 50 minute session) is $150.  If we meet more than the usual time, I will charge accordingly. I charge this same hourly rate for other professional services you may need and/or request such as report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me.  If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party.  I charge $500 per hour for professional services I am asked or required to perform in relation to your legal matter.  I also charge a copying fee of $1.00 per page for records requests.

CANCELLATION POLICY

Since scheduling of an appointment involves the reservation of time, specifically for you, a minimum of 24-hour notice is required for re-scheduling or canceling of an appointment. As a result, the full fee will be charged for sessions missed without such notification.

INSURANCE REIMBURSEMENT

I do not accept insurance. I am considered an out of network provider with most insurance companies. You may decide to seek reimbursement on your own accord and will have access to your session invoices through counsol.com that can be submitted by you to your insurance company. The amount of reimbursement co-payments and deductibles depends on the requirements of your insurance plan. You should note that you are ultimately responsible for verifying and understanding the limits of your insurance plan and for obtaining information on how to obtain reimbursement. Payment of my services is your responsibility regardless of insurance coverage and reimbursement. Furthermore, I also cannot guarantee whether your insurance will provide payment for the services provided to you.

You should be aware that most insurance companies require that I provide them with a clinical diagnosis. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once obtained. In some cases, they may share information with a national medical information databank. As a result, it is imperative that you understand that if you submit your session invoices to your insurance for reimbursement you authorize me to release information about you and your treatment to your insurance company.

CONTACTING ME

Due to the nature of my practice, I am rarely immediately available to communicate. However, I will make every effort to return calls within 24 hours, with the exception of weekends and holidays.

Please note: my practice does not operate as a crisis facility. If you are in need of immediate mental health services, you should dial 911 or call the Knoxville area Mobile Crisis Hotline at (865) 539-2409.

ELECTRONIC COMMUNICATION

You may choose to utilize home phones, landlines, cell phones, computers, online video sessions, SMS/MMS/online chat and phone sessions to communicate and to augment counseling with me. It is important for you to know that these methods can pose risks. These risks include but are not limited to the following:

- The possibility of technology failure resulting in messages / information not being received.

- The possibility of misunderstandings is increased with text-based modalities such as email or chat due to the absence of nonverbal/visual cues. 

- Use of email may result in various servers creating permanent records of these transactions.

- Many employers and government agencies review email archives on a routine basis, record letters typed on a keyboard, and / or engage in data           mining programs to identify transmissions containing specified content.

- My email and the online web portal may not be checked daily and may result in a possible lag in turnaround / response.

- Confidentiality may be breached at many points when using electronic communication including unauthorized monitoring / interception of   transmissions from your computer and my own; it may also be breached as the information passes through the servers along the route to each other. This means that it is possible that third parties may access your records / communication when you are using an unsecured service (such as gmail, hotmail, SMS, MMS, online chat, etc.)

- What is said online may be viewed by others.

- Assessment / diagnosis often becomes more difficult without the benefit of face-to-face contact.

While convenient, most forms of SMS, MMS and online messaging are not HIPAA compliant or a secure and confidential way to communicate. These forms of communication come with many inherent risks, including, but not limited to those listed above. The most secure way to communicate with me (outside of face-to-face interaction in session) is by messaging me through counsol.com, which uses encryption.

You, the client, are responsible for creating and using additional safeguards when using a computer to communicate and when augmenting services. Safeguards include, but are not limited to, creating passwords to use the computer, keeping passwords and IDs secret, and maintaining security of wireless internet access points (where applicable). I encourage you to only communicate through a computer and/or device that you know confidentiality can be ensured. Moreover, you should be aware of privacy issues and the possibility of others identifying your participation in therapy if you have GPS tracking or a passive LBS app enabled on your mobile phone. By understanding the inherent risks of devices and communication tools, you can make an informed choice about when / where / how to use aforementioned tools.

RECORDS

I maintain records of counseling services. These records are confidential and will be maintained as required by applicable legal and ethical standards.

CONFIDENTIALITY

Maintaining client confidentiality is extremely important. I will take care and consideration to prevent unnecessary disclosure. Information about you, the client, will only be released with your permission, with the following exceptions:

- If I suspect abuse or neglect of a minor and/or an incapacitated adult.

- If I believe that a client is threatening serious bodily harm to another person.

- If a client has a suicide plan and cannot and/or will not agree to be safe.

- If I am court ordered to release information.

Both parties acknowledge that the goal of psychotherapy, either individual or marital or couples counseling, is for the sole purpose of the amelioration of psychological distress and that the process of psychotherapy depends on trust and openness during the therapy sessions.

Therefore it is understood by both parties that if they request my services as a psychotherapist, they are expected not to use information given to me during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit. 

AGREEMENT SIGNATURE(S)

I, the client(s)/guardian(s), have read, or have had read to me, and fully understand my rights and responsibilities detailed in this document. My signature below indicates that I have discussed those points I did not understand and have had my questions, if any, fully answered.

I hereby agree to the counseling terms and understand the associated risks detailed and listed above in the Informed Consent. I understand that no specific promises have been made to me by this therapist about the results of treatment and the effectiveness of the procedures used by this therapist. 

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. 

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.  The Notice, explains HIPAA and its application to your PHI in greater detail. 

The law requires that I obtain your signature acknowledging that I have provided you with this.  If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless I have taken action in reliance on it. 

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist.  In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary.  Reasons I may have to release your information without authorization:

1.     If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.

2.     If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.

3.     If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

4.     If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

5.     I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:

1.     If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Tennessee Abuse Hotline.  Once such a report is filed, I may be required to provide additional information.

2.     If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Tennessee Abuse Hotline.  Once such a report is filed, I may be required to provide additional information.

3.     If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

●      For Treatment - I use and disclose your health information internally in the course of your treatment.  If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

●      For Payment - I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.

●      For Operations - I may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights:

●      Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category. 

●      Right to Confidentiality - You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer.  I will agree to such unless a law requires us to share that information.

●      Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request.

●      Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

●      Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee charge of $1.00 per page.  Please make your request well in advanced and allow 2 weeks to receive the copies.  If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.

●      Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days. 

●      Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.

●      Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, I will discuss with you the details of the accounting process.

●      Right to Choose Someone to Act for You - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action. 

●      Right to Choose - You have the right to decide not to receive services with me.  If you wish, I will provide you with names of other qualified professionals. 

●      Right to Terminate - You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued.  I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.

●      Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate.  Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.

Therapist's Duties:

●      I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.  I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.  If I revise my policies and procedures, I will provide you with a revised notice in office during our session.

COMPLAINTS

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Tennessee Department of Health, or the Secretary of the U.S. Department of Health and Human Services.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.