Counselor / Client Agreement
Registering for my web portal has many advantages and it is highly secure due to its advanced security encryption protocols. The security/privacy protection methods exceed all Federal HIPAA compliance standards. Be assured, keeping your information safe and confidential is very important to me.

This agreement covers all forms of sessions and communications with you (in person, home, group, video, chat, telephone, email)

Welcome to my practice Positive Progress - Clinical Counseling & Coaching, a Florida Professional Limited Liability Company (PLLC). This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability Act (HIPAA), a federal law that provides privacy protections and patient rights and 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. When you sign this document, it will also represent a legal contract between us. We can discuss any questions you have when you sign them or at any time in the future.

Counseling and/or Coaching is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling/coaching, 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. I, as your counselor/coach, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Goals of Counseling/Coaching
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 according to what you wish to work on in counseling/coaching. As your clinician, I may make suggestions on how to reach a goal but you decide where you want to go.

Risks and Benefits of Counseling/ Coaching
Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.

Record Keeping
I will keep records of your counseling/coaching sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity of care. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept securely either electronically on a password encrypted HIPAA compliant server or in a paper file stored in a locked cabinet at the offices of Positive Progress - Clinical Counseling & Coaching, PLLC.

Professional Fees
You are responsible for paying at the beginning of your session unless prior arrangements have been made. Payment must be made by check or cash. Credit/debit card and PayPal payments can make securely through this portal. If you refuse to pay your services, I reserve the right to use an attorney or collection agency to secure payment. A $35 fee will be assessed in the event of a returned check for insufficient funds. A $35 fee will also apply to any declined credit/debit card payments. There will be no credited extension of services without payment.

Invoices not paid within 30 calendar days of the session date are subject to a $35 late fee. This fee will accrue with each additional 30 day period of non-payment. If you have a credit/debit card stored on the web portal, I reserve the right to charge this card for any delinquent payments.

Fees are non-negotiable. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. Fees are subject to change at my discretion.

If you fail to cancel a scheduled appointment (No show-No Call) and are paying under a discount rate, you will be charged my full competitive -publicized rates ( listed below) plus any additional fees.

Counseling Fee Schedule
Counseling diagnostic evaluation (Intake) $160

In Person
Amount Per
$90.00 60 Min Session or pre arranged sliding fee

Couples
Amount Per
$130.00 60 Min Session  (Iin person, Teletherapy)


In Person - Home
Amount Per Session Rule Rate Description
$130.00 60 Min Session or pre arranged sliding fee
$15 Any Session Travel fee 25 miles outside of Cape Coral

Online Video Individual
Amount Per Session Rule Rate Description
$90.00 60 Min Session Any

Online Chat
$.30 Per Minute

Phone Call
Free initial 5 minutes ($0.75 per each additional minute) *All calls pertaining to your care -collateral contacts will be billed*

Group Sessions
Amount Per Session Rule Rate Description
$25 90 Minutes Any

Sliding Scale Services Fee - See mutually agreed rates

Coaching Services ( Private Pay only)
60 min -$145

Insurance ( Individual/family Counseling Services Only)
If you have a health insurance policy, it will usually provide some coverage for mental health treatment ( it does not cover the cost of coaching services). With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage. You are responsible for knowing your coverage and for letting me know if/when your coverage changes.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information which will become part of the insurance company files. By signing this agreement, you authorize that I can provide requested information to your carrier (if you plan to pay with insurance). 

Insurance (Couples and Marriage Counseling) 

Most major insurance companies (Medicare, Blue Cross, United Healthcare, etc) will not cover the cost of marriage and couples counseling due to the fact that it is not deemed a "Medical Necessity". Insurance companies require that I diagnose one party with a mental health disorder (anxiety, depression, etc) in order to get reimbursed. I must provide a plan documenting I am treating this specific mental health disorder. If you have questions, contact your carrier and ask if they cover diagnosis code Z63.0 - Problems in relationship with spouse or partner. You must have written authorization from your carrier before I provide any couples/marriage counseling.

In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover counseling fees. If you did not obtain  prior authorization and it is required, you will be responsible for full payment of the fee. Many policies leave a percentage of the fee to be covered by the patient ( Co-pays). Either amount is to be paid at the time of the visit by credit card, check. or cash. In addition, some insurance plans also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. You are ultimately responsible for any cost of services deemed by your insurance carrier as "Non-Covered Services".

Note: You are responsible for the full cost of services (my regular session rate) if any claims are denied payment because you have not met your annual deductible or if the insurance provider refuses to pay for any reason at any time. There is also a $6.00 claims processing fee which will be assessed per claim which is denied for any reason. 


Use of PPO- Out of Network Benefits: 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 direct reimbursement to you. Please note that not all insurance companies reimburse for out-of-network providers. You must be under a PPO plan to be reimbursed by most carriers. If you prefer to use a participating provider, I will refer you to a colleague. I am not responsible for the assignment of benefits or any payments made to me by out of network insurance providers. If I receive a PPO reimbursement payment, I will mail the check payment to you. I am not responsible for lost or stolen payments for PPO payments. These reimbursements should be made directly to you by your insurance provider. Instruct your insurance carrier to "assign benefits to you".

Important: Credit Debit cards
For your convenience, I accept credit/debit cards. Please be aware that any transaction on your card could identify you as receiving mental health services to a third party (processor/bank). If you decide to dispute any charge, you agree to waive your right to client confidentially so I can respond to such disputes. I may be asked by the credit card processors to submit supporting documentation that shows you are or were receiving counseling /therapy services. Please keep this in mind when thinking about disputing a credit/debit card transaction. You will also be charged for any additional charges for refunding funds. If your credit/debit card is declined, you will be charged the standard session rates.

Ancillary Fees:
In rare cases, I am asked to perform ancillary or legal duties, please be advised there are fees for my professional time. Insurance will not cover these fees. Please note: You must submit a Written Request and sign a Release of Information at least 12 business days prior to due date of requested item listed below.

Copying and mailing/ faxing records requests - $0.31 per page under 100 pages
Preparing/submitting written case summaries ($25)   Written Assessments - $120 per hour
Writing and mailing professional letters - $40 per letter
Legal consultation with attorneys - $135/hr
Court depositions and attendance at legal proceedings (subpoenas, testifying) - $280 per hour
Client multidisciplinary team staffings with care providers - $115 per hour
Travel time: .35 per mile

Please Note: You must have been seen in person within 30 calendar days for any prepared professional recommendation letters (pets, testing accommodations, etc) or case summaries to be completed. This is because I must have current clinical information to complete the requested documentation. There will be no exceptions.

Conflicts - No Harm Clause
I will work hard to ensure that you have a positive experience with my services. However, if a conflict occurs, it is agreed that any dispute shall be negotiated directly between us. If these negotiations are not satisfactory, then we agree to mediate any differences with a third party mediator. If these are not satisfactory, then we shall move to arbitration, and then to binding arbitration, choosing a mutually agreeable arbitrator. Litigation shall be considered only if all of these methods of resolution are given a good faith effort and are unsatisfactory. Exception: As stated earlier under the Professional Fees section, in certain cases of non-payment, I reserve the right to retain services of a collection agency or attorney to secure outstanding debts. As a client, you have the right to end services anytime. I only request you provide me written notice.

Couples/ Marriage Counseling: It is understood that the sole purpose of any couples/marriage counseling is to identify issues within a relationship and to utilize treatment strategies & recommendations which will offer a resolution. The ultimate purpose is that both parties jointly agree to improve the overall health of their relationship. Further, it is understood that any counseling services will not be used in any potential legal action against the other participating party. It is agreed that this counselor will not be called to provide testimony/documentation, either verbal or in writing, against the other party in any civil/criminal legal proceedings involving divorce, child custody, or criminal activity. As your counselor, my only role is to be an objective third party who will assist you in improving the quality of your intimate relationship.


Contacting Me
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call and it is an emergency/crisis situation or if you are having thoughts of harming yourself or someone else, go to your local hospital or call 911. You may also contact Saluscare crisis unit in Fort Myers at 239-275-3222. or the 24/7 The National Suicide Prevention Lifeline 1-800-273-8255

Email
I may request client's email address. Client has the right to refuse to divulge email address. Counselor may use email addresses to periodically check in with clients who have ended therapy suddenly. I may also use email addresses to send newsletters with valuable therapeutic information such as tips for depression or relaxation techniques. Counselor also has a blog and if this is appropriate for the client, counselor may send information through email about subscribing to the blog or information related to mental health and wellness. By registering with this web portal, your are agreeing to receive electronic communications through chat, email, video.
If you would like to opt out of electronic communications, don't register with this portal. Contact me at 239-829-5480 to make other arrangements.

It is your responsibility to ensure all of your contact /billing information is up to date with my office. (email, phone numbers, payment information, credit & debit cards, etc) You can update information via your web portal account.

Consent to Counseling/Coaching Services
Your registration with this portal and electronic signature below indicates that you have read and understand this Agreement. I fully agree to its terms. Please print your electronically signed copy of this agreement.



______________________________________________________________
Signature of Staff Member Date
Rick Merillat, MSW, LCSW Florida License # SW7100
Positive Progress - Clinical Counseling & Coaching, PLLC

Appointments:

Please plan to arrive at your 10 minutes prior to your appointment time.

Appointments will ordinarily be 50-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment 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 will be required to pay for the total cost (listed below) of the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. If you cancel without 24 hours notice two (2) separate times during the course of treatment, I will require confirmation of any scheduled appointments and advanced payment for the session. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

If you miss an appointment without notifying (no show/call), you will be required to enter a valid debit or credit card payment method on the portal before another appointment is scheduled.

If you fail to cancel a scheduled appointment (no show/call) and are paying under an agreed discounted rate, you will be charged my full competitive -publicized rate which is currently $135.00/hr- Individual or $145/hr- Couples plus any additional fees.

Note: You must make contact with me directly when canceling. Voicemails, texts, and emails are not considered proper cancellation notice. I must talk with you. You will be charged for the session if I do not speak with you by the scheduled session time.

For your conveyance, the automated system will send out an appointment reminder 48 hours in advance to your preferred method of communication (call, text, email)

Most importantly, I ask that you be courteous and notify me if you can't attend your appointment so I may serve others who may benefit from the appointment time.

Note*** United HealthCare clients, Due to managed care contracts, the ABOVE POLICY MAY NOT apply to your payment provider/carrier***

Confidentiality

Maintaining your privacy is important to me. I will make every effort to keep your personal information confidential. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. I may consult with a supervisor or other professional counselor in order to give you the best service. In the event that I consult with another counselor, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If I receive a court order, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law. If you anticipate becoming involved in a court case, it is recommended that we discuss this fully before you waive your right to confidentiality. Per HIPAA Federal Privacy laws governing mental health treatment confidentiality, only a signed order by a Judge or Magistrate will be accepted for any disclosures.

Group Therapy
The nature of group counseling makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that I cannot guarantee that other group members will maintain your confidentiality. However, I will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. I also have the right to remove any group member from the group should I discover that a group member has violated the confidentiality rule.

Some clients may choose to use technology in their counseling or coaching sessions. This includes but is not limited to online counseling via this web portal, Skype, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. I will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. Should you have concerns about the safety of your email, I can arrange to encrypt email communication with you. By using this secured web portal, you are assured the highest level of confidentiality/security due to the advanced level of encryption and security protocols.

Texting- I strongly discourage the use of this form of communication due it's unreliable security. It should only be used in brief communications. ex. " I will be 10 minutes late"

Couples/Marriage Counseling - I understand and agree that certain information about me may be shared with my spouse/partner during the course of joint couples counseling/therapy. It is my responsibility to inform the counselor of any specific information which you wish to not be revealed during session.

Securing Payments From Third Parties- If you choose to use insurance benefits or credit/debit cards, your identifying health information may be required by third party vendors (insurance companies, credit card processing, etc) in order to process/collect payments.

By registering with this web portal and your electronic signature you have read, understand, and agree with the above privacy policies. You grant authorization to Positive Progress - Clinical Counseling & Coaching, PLLC Rick Merillat, LCSW to communicate with your insurance carrier for the purposes of verifying insurance coverage and submitting billing claims to your provider.


Print the full signed Federal HIPAA Privacy Practices document (next section)

Please print for you records

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.


Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child / Elder Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child/elder abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

Securing Payments From Third Parties- If you choose to use insurance benefits or credit/debit cards, your PHI may be required by third party vendors (insurance companies, credit card processing, etc) in order to process/collect payments.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at:
1222 SE 47th Street
Suite 217
Cape Coral, FL 33904

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any ques
Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself. Right to a Copy of this Notice. You have the right to a copy of this notice.


COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer (Rick Merillat, LCSW) at 1222 SE 47th Street, Suite 217 Cape Coral, FL 33904 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.


The effective date of this Notice is January 20th, 2020.(updated)
Rick Merillat, MSW, LCSW
dba
Positive Progress - Clinical Counseling & Coaching, PLLC

By signing electronically below, you are stating you have read, understand, and received a copy of this document. (Please print)

As a licensed therapist, there are certain legal and ethical guidelines which must be followed to protect both you and I. These guidelines ensure that professional boundaries are maintained and you receive the best care possible. Please read the below guidelines and sign stating you understand them.

1) Appointments- As stated under the appointment policies - I ask that you be courteous and notify me if you can't attend your appointment so I may serve others who may benefit from the appointment time. (48 -hour cancellation policy) Due to time constraints, if you do not show or contact me within 15-minutes of your appointment's scheduled start time, the appointment will be canceled and considered a No Show. 
 
2) Gifts - I am not permitted to accept any gifts from clients. (Cards are not considered gifts)

3) Touching - Only handshaking is permissible. Other forms of physical contact are not acceptable and could be misconstrued.

4) Dual Relationships - I am not permitted to enter into any other relationship with you while you are an active client (business, social, personal) My only role is to provide professional care to you within the scope of my license.

5) Privacy - As stated in the confidentiality policies section, maintaining your privacy is very important to me. You are responsible for safeguarding your portal username and password. Don't share this with anyone.

6) Communication - The only acceptable communications between us is either through the secure web portal, office phone or business email account. No personal communication is permitted. (including Facebook, Twitter, etc) I will not accept a friend request from you on these sites. This does not mean I don't care about you, it just ensures your privacy.
Additionally, I appreciate word of mouth referrals and online reviews, but be discrete as possible.

7) Payment- I ask that you be considerate and pay for all services at the time they are rendered to you. A credit/debit card will remain on the secure portal for payment purposes. If the card is declined, you will be charged the full standard rate of the session. You grant me permission to charge card on file for any cost of services, late fees, missed appointments. 

8) Keep In Touch - During the course of our work together, you may have other priorities, become discouraged, or just loose contact with me. It is your responsibly to maintain contact with me until you have been inactivated from my panel.

9) Fidelity - As your counselor /coach, I will be honest and fair about the services that I provide to you. We collaboratively work together as a team. I will always respect your right to self-determination.

10) If you're experiencing a life-threatening crisis. Please call 911 or National Suicide Prevention Lifeline 1-800-273-TALK 1-800-273-8255 prior to contacting my office.