Note: This form must be completed by a legal guardian for the intended adolescent patient. The exception is if the patient is the legal age to consent to their treatment and is seeking services on their own. Physical custody will not suffice for completing his form. By signing as the "Parent/Guardian" you attest that you have current legal guardianship over the intended patient.

Note: The email provided here will be used to send login information to the TherapyPortal for any virtual sessions.

NOTE: If a custody order exists for the patient, please email that to administrative@myspectrumcc.com to be added to the chart along with the insurance card images.

Note: If your child is able, please have them answer the questions below until you reach the Billing Information section. If your child is not capable of answering the questions below, please answer in their place to the best of your ability as you perceive their symptoms and emotions.

Please give as accurate account as you can and if you have any questions or concerns, we invite you to discuss them with your Therapist. Checkmark or place an "X" on your child's responses.

Please sign and date this form as an acknowledgement of completion to the best of your ability:

You only need to let us know the name of your EAP in this intake packet. Once you are scheduled, we ask that you reach out to our administrative team to provide your reference number and EAP approval letter so that we can submit claims to your EAP. Most EAP reference numbers are therapist specific, so you will want to inform your EAP of the therapist you were scheduled with to make sure claims process correctly. Claims are submitted under an individual name, so we cannot accommodate multiple EAPs under different names to pay for sessions. Please include your primary insurance information below so we can explore coverage after your EAP sessions are completed. Thanks!

I (we), the undersigned, authorize and request MySpectrum Counseling & Coaching to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by MySpectrum Counseling & Coaching This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60-day notification to MySpectrum Counseling & Coaching in writing and the account must be in good standing.

a. I acknowledge that as a courtesy, MySpectrum Counseling & Coaching may bill my insurance or EAP company for services provided to me.

b. I consent to MySpectrum using insurance or EAP policy information provided either in this intake packet or by an insurance or EAP provider to cover the cost of services provided.

c. I agree to pay for services that are not covered, or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductibles, or charges not covered by insurance or EAP. I also understand that there is a $15 charge for not making a copay at the time of my appointment and that a 1.5 percent charge will be added to my bill for each month a statement is mailed.

d. I understand that there is a $50 fee for returned checks.

e. I understand that if I do not show up for an appointment without calling or if I cancel on the same day of my appointment, my credit card or account will incur a $65 fee. Appointments must be canceled 24 hours in advance to avoid a charge. Charging the fee is at the discretion of the clinician and may be waived in some circumstances.

f. If I arrive 15 minutes late for my appointment, I understand that my therapist will not be able to see me, I will be charged a No Show fee of $65, and I will have to reschedule my appointment. Charging the fee is at the discretion of the clinician and may be waived in some circumstances.

e. If I arrive 15 minutes late for my appointment, I understand that my therapist will notbe able to see me, I will be charged a No Show fee of $65, and I will have to reschedulemy appointment.

e. I acknowledge that MySpectrum Counseling & Coaching may utilize the services of a third-party business associate or affiliated entity as an extended business office (EBO Service) for I acknowledge that MySpectrum Counseling & Coaching may utilize the services of a third medical billing and servicing.

f. I hereby assign to, MySpectrum Counseling & Coaching any insurance or other third-party benefits available for health care services, provided to me. I understand, MySpectrum Counseling & Coaching has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to MySpectrum Coaching & Coaching, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.

g. I certify that any information I provide, if any, in applying for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to MySpectrum Counseling & Coaching, by the Medicare and Medicaid programs.

h. I agree that, in order for, MySpectrum Counseling & Coaching, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that, MySpectrum Counseling & Coaching or EBO Servicers and collection agents may contact me by telephone at any telephone number, without limitation to wireless, I have provided or, MySpectrum Counseling & Coaching or EBO Servicers and collection agents have obtained or at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recording/artifical voice messages and/or use of an automatic dialing service, as applicable.

MySpectrum Fee Schedule / Self-Pay Rates

Initial Intake Assessment (60 minutes) - $115

Therapy Session (45-50 minutes) - $75

Therapy Session (60 Minutes) - $90

Family Therapy (w/client) - $90

Family Session (w/o client) - $90

Interactive Complexity Add-On - $25

Group Therapy - $40 per group

Life Coaching - Telehealth - $120 (50 to 60 minutes)

Life Coaching - In-Person - $175 (50 to 60 Minutes)

Mental Health Evaluation for Court, Lawyers (does not include fee for writing a report) - $250

Outside Office Work (Inpatient visits, Collaborative Services, Court appearances, etc.) - $100 per hour

Written Report (Court, Supervisors) - $100 per hour

Consultation - $100 for non client, $75 for current client

No Show/Late Cancellation Fee (less than 24 hour notice) - $65

Returned Check Fee (per check) - $50

The purpose of meeting with a counselor or Therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or Therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or Therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling.

As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. I have listed some of these situations below.

Confidentiality cannot be maintained when:

>You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.

> You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform your parent or guardian, and I must inform the person who you intend to harm.

>You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

>You tell me you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, I am required by law to report the abuse to the Virginia Department of Social Services.

>You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Communicating with your parent(s) or guardian(s):

Except for situations such as those mentioned above, I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian.

Example: If you tell me that you have tried alcohol at a few parties, I would keep this  information confidential. If you tell me that you are drinking and driving or that you are a passenger in a car with a driver who is drunk, I would not keep this information confidential from your parent/guardian. If you tell me, or if I believe based on things you’ve told me, that you are addicted to alcohol, I would not keep this information confidential.

Example: If you tell me that you are having protected sex with a boyfriend or girlfriend, I would keep this information confidential. If you tell me that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations, I will not keep this information confidential. You can always ask me questions about the types of information I would disclose. You can ask in the form of “hypothetical situations,” in other words: “If someone told you that they were doing, would you tell their parents?”

Even if I have agreed to keep information confidential – to not tell your parent or guardian – I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you. My goal is to help you, along with your family or close others, so involving your parents or caretakers can be a very important part of the therapeutic process.

[You should also know that, by law in Virginia, your parent/guardian has the right to see any written records I keep about our sessions.]

Communicating with other adults:

School: I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counselor or Therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress with therapy, you can ask your Therapist at any time.

Check boxes and sign below indicating your agreement to respect your adolescent’s privacy:

This Informed Consent for Teletherapy contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

Teletherapy refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of teletherapy is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Teletherapy, however, requires technical competence on both our parts to be helpful. Although there are benefits of teletherapy, there are some differences between in-person psychotherapy and teletherapy, as well as some risks. For example:

Risks to confidentiality. Because teletherapy sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

Issues related to technology. There are many ways that technology issues might impact teletherapy. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

Crisis management and intervention. Usually, I will not engage in teletherapy with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in teletherapy, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our teletherapy work.

Efficacy. Most research shows that teletherapy is about as effective as inperson psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

We will decide together which kind of teletherapy service to use. You may have to have certain computer or cell phone systems to use teletherapy services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in teletherapy. For communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to administrative matters, and should be directed to the administrative team. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not discuss any clinical information by email or text and prefer that you do not either. Also, I do not regularly check my email or texts, nor do I respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary.

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our teletherapy. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for teletherapy sessions and having passwords to protect the device you use for teletherapy

The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent still apply in teletherapy. Please let me know if you have any questions about exceptions to confidentiality.

I will let you know if I decide that teletherapy is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in teletherapy services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the teletherapy platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you.

The same fee rates will apply for teletherapy as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in teletherapy sessions in order to determine whether these sessions will be covered.

The teletherapy sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies.

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions.

707 N Courthouse Rd. N Chesterfield, VA 23236 804-924-2236

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. THIS DOCUMENT ALSO COVERS INFORMED CONSENT. *PLEASE REVIEW CAREFULLY.*

I. Confidentiality

MySpectrum Counseling & Coaching is legally required to protect the privacy of your Protected Health Information (PHI), which includes information that can be used to identify you that is created or received by MySpectrum Counseling & Coaching or their therapist about your past, present or future health or condition, the provision of healthcare to you, or the payment for this health care. MySpectrum Counseling & Coaching must provide to you with this Notice about our privacy practices, and such Notice must explain how, when, and why MySpectrum Counseling & Coaching will “use” and “disclose” your PHI. A “use” of PHI occurs when MySpectrum Counseling & Coaching shares, examines, utilizes, applies, or analyzes such information within our practice. PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of our practice. With some exceptions, MySpectrum Counseling & Coaching may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, MySpectrum Counseling & Coaching is legally required to follow the privacy practices described in this notice.

II. Operational and Billing Use

MySpectrum Counseling & Coaching can use and disclose your PHI to bill and collect payment for the treatment and services provided to you. PHI may also be used or disclosed to business associates, such as billing companies, claims processing companies, and others that process claims on behalf of MySpectrum Counseling & Coaching. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Out of Pocket Payments: If you paid out of pocket (in other words, you have requested that MySpectrum Counseling & Coaching not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and MySpectrum Counseling & Coaching will honor that. This request must be received in writing with specific details as to which service this applies.

III. “Limits of Confidentiality” & INFORMED CONSENT TO TREATMENT

Possible Uses and Disclosures of Mental Health Records without Consent or Authorization

There are some important exceptions to this rule of confidentiality - some exceptions are due to the policies of MySpectrum Counseling & Coaching and some are required by law. If you wish to receive mental health services from MySpectrum Counseling & Coaching you must sign the attached form indicating your accept and understand these policies about confidentiality and its limits. Please feel free to discuss any questions or concerns with your therapist.

MySpectrum Counseling & Coaching may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required by law:

• Emergency - If you are involved in a life-threatening emergency and MySpectrum Counseling & Coaching cannot ask your permission, MySpectrum Counseling & Coaching will share information if MySpectrum Counseling & Coaching believes you would have wanted us to do so, or if MySpectrum Coaching & Counseling believes it will be helpful to you.
• Child Abuse Reporting: If MySpectrum Counseling & Coaching has reason to suspect that a child is abused or neglected, MySpectrum Counseling & Coaching is required by law to report the matter immediately to the Virginia Department of Social Services.
• Adult Abuse Reporting: If MySpectrum Counseling & Coaching has reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, MySpectrum Counseling & Coaching is required by law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
• Health Oversight: Virginia law requires that Licensed Clinical Social Workers and Counselors report misconduct by a health care provider of their own profession. By policy, MySpectrum Counseling & Coaching also reserves the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider or any profession, MySpectrum Counseling & Coaching is required to explain to you how to make such a report. If you are yourself a health care provider, MySpectrum Counseling & Coaching is required by law to report to your licensing board that you are in treatment with MySpectrum Counseling & Coaching if we believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
• Court Proceedings: If you are involved in a court proceeding and a request is made for information regarding your diagnosis and treatment and the records thereof, such information is privileged under the state law and MySpectrum Counseling & Coaching will not release information unless you provide written authorization or a judge issues a court order. If MySpectrum Counseling & Coaching receives a subpoena for records or testimony, we will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, MySpectrum Counseling & Coaching is required to place said records in a sealed envelope and provide to the Clerk of the Court. In Virginia civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice”. In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if MySpectrum Counseling & Coaching does an evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety: Under Virginia law, if MySpectrum Counseling & Coaching is engaged in professional duties and you communicate to us a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and MySpectrum Counseling & Coaching believes you have the intent and ability to carry out that threat immediately or imminently, MySpectrum Counseling & Coaching is legally required to take steps to protect third parties or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. MySpectrum Counseling & Coaching policy also states that we may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, MySpectrum Counseling & Coaching can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or a law enforcement officer, whether you are a minor or an adult.
• Workers Compensation; If you file a worker’s compensation claim, MySpectrum Counseling & Coaching is required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
• Records of Minors: Virginia has a number of laws that limit the confidentiality of the records of minors. For example, parents regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and MySpectrum Counseling & Coaching will discuss these in detail if we provide services to minors.

Other uses and disclosures of information not covered by this notice or the laws that apply to MySpectrum Counseling & Coaching will be made only with your written permission.

IV. Patient’s Right and Provider Duties

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information MySpectrum Counseling & Coaching discloses about you to someone who is involved in your care or the payment of your care. If you ask MySpectrum Counseling & Coaching to disclose information to another party, your may request that MySpectrum Counseling & Coaching limit the information that is disclosed. However, MySpectrum Counseling & Coaching is not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell MySpectrum Counseling & Coaching 1) what information you want to limit, 2) whether you want to limit MySpectrum Counseling & Coaching’s use, disclosure or both; and 3) to whom the limits apply. 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. (For example, you may not want a family member to know that you are being seen at MySpectrum Counseling & Coaching. Upon your request, MySpectrum Coaching & Counseling will send your bills to another address. You may also request that MySpectrum Counseling & Coaching contact you only at work, or that MySpectrum Counseling & Coaching do not leave a voicemail message To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
• Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice On your written request, MySpectrum Counseling & Coaching will discuss with you the details of the accounting process.
• Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, MySpectrum Counseling & Coaching may charge a fee for the costs of copying and mailing. MySpectrum Counseling & Coaching may deny your request to inspect and copy in some circumstances. MySpectrum Counseling & Coaching may refuse to provide you access to certain psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.
• Right to Amend: If you feel that protected health information MySpectrum Counseling & Coaching has about you is incorrect or incomplete, you may ask your therapist to amend the information. To request an amendment, your request must be made in writing, and submitted to MySpectrum Counseling & Coaching. In addition, you must provide a reason that supports your request. MySpectrum Counseling & Coaching may deny your request if you ask for information to be amended that 1) was not created by MySpectrum Counseling & Coaching however MySpectrum Counseling & Coaching will add the request to the record; 2) is not part of the medical information kept by MySpectrum Counseling & Coaching; 3) is not part of the information which your would be permitted to inspect and copy; and 4) is accurate and complete.
• Right to a copy of this notice: You have the right to a paper copy of this notice. You may ask MySpectrum Counseling & Coaching staff to give you a copy of this notice at any time. Changes to this notice: MySpectrum Counseling & Coaching reserves the right to change its policies and/or change this notice, and to make the changed notice effective for medical information already received by MySpectrum Counseling & Coaching about you as well as any information MySpectrum Counseling & Coaching receives in the future. The notice will contain an effective date. A new copy will be given to you or posted in the reception area. MySpectrum Counseling & Coaching will have copies of the current notice available upon request. You may also request to receive this notice by email.
• Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured PHI.

Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request to MySpectrum Counseling & Coaching in writing. You may also send a written complaint to the Virginia or U.S. Department of Health and Human Services at:

Virginia Secretary of Health & Human Services 202 North 9th Street, Suite 622 Richmond, Virginia 23219 804-786-7765

Secretary of Health & Human Services Hubert Humphrey Building 2000 Independence Avenue, S.W. Washington D.C. 20201 20-690-70000

707 N Courthouse Rd N Chesterfield, VA 23236 804-924-2236

By signing this form, you acknowledge receipt of the Notice of Privacy Policies that MySpectrum Counseling & Coaching gave to you. The Notice of Privacy Policies provides information about how MySpectrum Counseling & Coaching may use and disclose your Protected Health Information (PHI You acknowledge that you have read it in full.

MySpectrum Counseling & Coaching reserves the right to change the Notice of Privacy Policies. The most recent will always be available at MySpectrum Counseling & Coaching or you may request to receive it by email.

If you have any questions about the Notice of Privacy Policies, please contact your therapist or a MySpectrum Counseling & Coaching staff member at the address or phone number listed above.

I acknowledge receipt of the Notice of Privacy Policies of MySpectrum Counseling & Coaching.

MySpectrum values everyone’s time. In order to ensure that we are able to help as many people as possible, we have the following guidelines in place for appointment cancellations:

• We allow only two missed intake appointments for new clients. If someone tries to schedule an intake appointment for a 3rd time, they will be informed that they are not eligible for services at MySpectrum for a one-year period.
• For current clients, a $65 Late Cancellation/Missed Appointment Fee will be charged if the appointment was not cancelled more than 24 hours in advance. This applies to no shows as well (not calling and letting us know ahead of time). 
• If a client is able to continue services and then misses 3 consecutive appointments in a 60-day period, the Therapist will be alerted and a $100 reinstatement fee will be applied to the client’s account. 
• Services at MySpectrum Counseling & Coaching will generally proceed at the clinical and practical discretion of the Therapist.  As such, a Therapist may consider discharge of a client whenever session attendance is not reliable and/or consistent.  Usually, this means a session attendance rate of 50% or less over time is created, or that 2 or more sessions are missed consecutively. 

Note: Services are intended to be rendered to the benefit of the client.  Clinical discretion refers to the ability of the Therapist to judge whether or not services are in fact benefitting the client, and to discontinue services based on a judgement that they are not, as well as to suggest referral to other services or providers (possibly within the practice) if necessary.

By signing this form, I acknowledge that I have received and reviewed this policy:

There may be a time during your treatment at MySpectrum that your Therapist may be subpoenaed to court for the purpose of litigation, or that you request your Therapist’s involvement in your court case. Please be aware that your Therapist can only testify and provide information to the facts of the case and to his/her professional opinion. This does not guarantee that testimony will be solely in your favor. The same is true for records requests for the purpose of litigation. Furthermore, when your Therapist must go to court, all clients that are normally seen that day must be rescheduled, so the fees below take this into account. None of these fees are billable to your insurance and are the sole responsibility of the client or requestor and/or legal guardian for a minor being treated by MySpectrum.

If the Therapist is to receive a subpoena, then the attorney or office staff must contact MySpectrum to set up a time within business hours to serve the subpoena. A minimum of 72 hours will be requested in order to accommodate schedule changes. Any requests with less than 72 hours will be assessed a rush fee of $100.

There may be times when your Therapist is not subpoenaed to court, but you may wish to ask their presence, or request that they provide written documentation on your behalf to the court. There may also be times when you request that your Therapist speak to someone involved in your, or your child’s, case, such as a Guardian Ad Litem, Court Appointed Special Advocate, Attorney, or another person. Fees for such instances are included below, in addition to any time a Therapist is acting in response to a subpoena.

Fees for the purpose of court related matters are as follows:

• $100 per hour for written documentation such as a general summary of involvement in Therapy
• $100 per hour for consultation with another person involved in the case via phone or in person
• $250 flat fee for a mental health evaluation, plus $100 per hour for the time necessary to complete writing the report
• $800 per day if the Therapist is subpoenaed or requested to appear in court. Your Therapist will need to clear his/her schedule for that day to be available to the Court, given the fluctuations of Court scheduling that may occur. If the Therapist is not called to testify, $800 is still charged.
• $150 flat fee for filing any documentation with the court
• $100 rush fee if notice for any documentation or appearance in court is less than 72 hours. This fee is charged in addition to the other fees listed above.

A $500 retainer will be due 72 hours before any requested court appearance. The remainder will be billed to the client and is due within 30 days of receipt of invoice. There may be times that your provider will be out of town, and therefore unable to accommodate requests for court appearances.

I understand that the purpose of this disclosure is for CLIENT TREATMENT COLLABORATION.

I understand that I am giving permission to disclose, release and/or obtain protected health information. Any eligibility for benefits, treatment, payment, or enrollment is not affected by this release of information. Such information may be subject to re-disclosure by the recipient and will thus no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations and may not be protected by state law.

I further understand that I may decline to sign this form. I also understand that I may revoke this consent to disclose information at any time. If I choose to revoke this consent, I must do so in writing. The authorization will remain in effect for one (1) year.

Note: This information may be protected by federal regulations concerning alcohol and drug abuse patient records. (42 CFR, Subchapter A, Part 2), which prohibit a recipient from making any further disclosure of alcohol or substance abuse treatment information unless expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by such regulations. These regulations also restrict any use of information to criminally investigate or prosecute authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug patient.

This document contains important information about our decision (your Therapist and you) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let your Therapist know if you have any questions. When you sign this document, it will be an official agreement between you, your Therapist, and MySpectrum Counseling & Coaching.

*Herein, “we” refers to your Therapist and you; “I” refers to your Therapist

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.

When you arrive at the office for in-person services, you are required to follow these steps before entering the building:

• You will wait in your car or outside [or in a designated safer waiting area] until you receive a text message from our Admin Team to enter the building.
• You will escort the adolescent patient directly to their therapist.
• No one will enter the building with you unless they are also involved in the Therapy session.

If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.

You understand that by coming to the office, you are assuming the risk of exposure to illness for you and your child. This risk may increase if you travel by public transportation, cab, or ridesharing service.

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, MySpectrum team members, and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. Initial each to indicate that you understand and agree to these actions:

• You will only keep your in-person appointment if you are symptom-free of any contagious illness
• You will adhere to safe distancing precautions by not waiting in the waiting room, or standing around.
• You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
• If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
• You will take steps between appointments to minimize your exposure to illness
• If a resident of your home tests positive for or exhibits any symptoms of a contagious illness, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My practice has taken steps to reduce the risk of spreading illness within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.

You understand that I am committed to keeping you, me, MySpectrum, and all of our families safe from the spread of illness. If you show up for an appointment and I [or office staff] believe that you have a fever or other symptoms, or believe you have been exposed to a contagious illness, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

If I [or staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

If you have tested positive for a contagious illness like the coronavirus, I may be required to notify local health authorities that you have been in the office depending on current local, state or federal orders or guidelines. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.