Informed Consent
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    INFORMATION, AUTHORIZATION, & CONSENT TO TREATMENT

  • Welcome to Summit’s Edge Counseling. We are very pleased that you selected our facility for your therapy, and we are sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from your therapist or group leader, policies regarding confidentiality and emergencies, and several other details regarding your treatment at Summit’s Edge, LLC. Although providing this document is part of an ethical obligation to our profession, more importantly, it is part of our commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with your therapist or group leader is a collaborative one, and we encourage any questions, comments, or suggestions regarding your course of therapy at any time.

  • Inclusion Statement 

     

    Summit's Edge is an Anti-Racist, LGBTQ+ and Gender, Sexual, and Romantic Minorities-Affirming and Trans-Inclusive, practice. We are passionate about ensuring our organization is a safe space for our employees and our clients. As such, bigotry or any form of discrimination directed at our staff or other clients will not be tolerated and will result in immediate clinical termination.

    In Case of an Emergency

    Summit’s Edge, LLC is considered an outpatient facility and we are equipped to accommodate individuals who are reasonably safe and resourceful. We are not available at all times. If at any time this does not feel like sufficient support, please inform your therapist, and they can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. Generally, your therapist will return phone calls within 24-48 hours. If you are fearful that you may be a danger to yourself of another person or believe you are having a mental health emergency, we encourage you not to wait for a call back, but to do one or more of the following:

    • Call Behavioral Health Link/GCAL: (800) 715-4225 
    • Call Ridgeview Institute at 770-434-4567 
    • Call Peachford Hospital at 770-454-5589 
    • Call Lifeline at (800) 273-8255 (National Crisis Line)
    • Call 911
    • Go to the emergency room of your choice
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  • CANCELLATION & NO SHOW POLICY

     

    THE FEE FOR LAST MINUTE CANCELLATIONS AND NO SHOWS IS $100. 


    Summit’s Edge has an inflexible last minute cancellation and no show policy. In the event that an appointment is missed, canceled within 24 hours of the scheduled appointment time, or a client arrives more than 20 minutes after the scheduled appointment time, clients will be financially responsible for paying a $100 cancellation/no show fee. Please note, insurance companies do not reimburse for missed or canceled sessions. 


    To avoid the last minute cancellation fee, clients must notify our office at least 24 hours in advance of their scheduled session. Cancellations must be received via phone/voice mail at 888-551-5168 or by email to info@summitsedgecounseling.com. For calls/emails made outside of regular business hours, we will honor the timestamp of the voicemail or email. 


    EXCEPTIONS

    In cases where there is a real client emergency and when the client has made a documented effort to contact us to cancel, the fee will be waived. 


    REMINDER EMAILS

    As a courtesy, appointment reminder emails are sent 48 hours prior to the scheduled session. The email reminder portal is not monitored and is not an appropriate method of canceling an appointment. Clients are responsible for managing their scheduled appointments and not receiving the courtesy reminder email is not a valid reason for missed appointments. Clients are encouraged to check their spam folders for these emails. 


    HABITUAL NO-SHOWS

    Should a client “no-show” for two scheduled sessions without contacting the clinician or administrative staff, all future sessions will be canceled and the client will be subject to discharge and referrals will be provided.


    LATE ARRIVAL & FEES

    Please note, if clients arrive later than 20 minutes after their scheduled appointment time, the card on file will be charged the $100 cancellation and no show fee and services will not be rendered. Clients who come into the office after 20 minutes have passed will be asked to reschedule and they will be charged the $100 cancellation/no show fee for the missed appointment. 


    IMPORTANT NOTE FOR COUPLES

    In the event that one person as part of a couple is unable to attend their scheduled couples session, both parties will be contacted to determine the best course of action moving forward. Both parties must be in agreement in either conducting the session for one individual or rescheduling the couples session. Should the couple decide to reschedule, the $100 cancellation fee will be charged. 

     

    Please print, date, and sign your name below indicating that you have read and understand Summit’s Edge Counseling’s cancellation and no show policy and the associated fee.

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  • Confidentiality & Records


    Your communications with your therapist will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI).  Your PHI will be stored electronically with Therapy Notes, a secure storage company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of your  PHI in a HIPAA compatible secure format using point-to-point, Federally approved encryption. Your PHI may also be kept on our password protected computer system in an encrypted file format. In addition to having a signed BAA with all electronic platforms we use, all administrative staff have also signed a BAA.  In the case that our staff needs to contact you regarding your account, your treatment or on behalf of your clinician, administrative staff has access to your contact information and may call you when your clinician is not able to do so.


    Recording of any counseling session, whether in person or through technology of any kind, is prohibited unless the client is given prior authorization by the therapist.


    Your therapist will always keep everything you say to them completely confidential, with the following exceptions:  (1) You direct your therapist to tell someone else and you sign a “Release of Information” form; (2) Your therapist determines that you are a danger to yourself or to others; (3) You report information about the abuse of a child, an elderly person, or a disabled individual who may require protection please note that this includes and person or people who may have performed acts of abuse or neglect who still have access to children or the elderly; or (4) Your therapist is subpoenaed by a judge to disclose information.  In the latter case, your therapist’s license does provide them with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a counselor.  This state has a very good track record in respecting this legal right.  If for some unusual reason a judge orders the disclosure of your private information, this order can be appealed.  We cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what you say confidential.  


    Please note that in couples counseling, your therapist does not agree to keep secrets.  Information revealed in any context may be discussed with either partner. Should you decide to bring another person to therapy, we cannot protect you from what you say in their company and we will adhere to any stipulations made in the Release of Information. 


    Case Consultation or Contact by Staff


    We host confidential clinical consultations and case reviews to grow our clinician’s clinical expertise. Please bear in mind that in order to provide the best care for you and your family, your Clinician may work as part of a Care Team to support you through this consultative work. You may be asked to sign a Release of Information to place limitations or restrictions on what you would like shared between parties. In cases where Managers and Leadership must become involved to ensure that you are receiving the best possible care, one of our team members may contact you and/or may need to become familiar with your case in order to best serve those needs.


    In the event of client discrepancies or complaints pertaining to operational policies, clinical policies, or clinical treatment, someone within Summit’s Edge’s management and leadership may be designated to assist in mitigating and resolving the matter. In this case, the designated member of leadership or management may contact you and/or may need to become familiar with your case in order to best assist. 

     

    Background Information, Theoretical Views, & Client Participation

    This practice has partially and fully licensed therapists on staff. Information regarding your therapist's educational background and experience may be found on our website under their name. Please feel free to view that information at https://summitsedgecounseling.com

    It is our belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. As a client, you are in complete control, and you may end your relationship with your therapist/group leader at any time. Please note that if it is in your best interest, your therapist may also determine that a referral is necessary.

    In order for therapy to be most successful, it is important for you to take an active role. This means working on the things you and your therapist talk about both during and between sessions. This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return. Please note that you may not be able to continue therapy if you consistently attend therapy intoxicated. If you arrive for your appointment and appear under the influence of substances, your therapist reserves the right to end the session and call other resources to transport you safely home. The session and transportation will be at the expense of the client. Should the client become resistant to this recommendation, law enforcement will be called.

    Furthermore, it is our policy to only see clients who we believe have the capacity to resolve their own problems with our assistance. It is our intention to empower you in your growth process to the degree that you are capable of facing life’s challenges in the future without your therapist. We also don’t believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, your therapist will direct you to other resources that will be of assistance to you. Your personal development is our number one priority. We encourage you to let us know if you feel that transferring to another facility or another therapist is necessary at any time. Our goal is to facilitate healing and growth, and we are very committed to helping you in whatever way seems to produce maximum benefit. If at any point you are unable to keep your appointments or we don't hear from you after three months, we will need to close your chart. However, reopening your chart and resuming treatment at a future time may be an option.

     

    After Hours Appointments

    Our office hours are Monday - Thursday, 9am - 6pm, and Friday, 9am - 3pm. However, many clinicians see clients after hours. For appointments scheduled after hours, all payments will be collected prior to your session to ensure payment. If you would like to add a card or would like a different card charged for these appointments, please call our office during regular business hours to make your payment. If your card declines, our office staff will reach out to collect payment. If payment is not rendered prior to the close of business that day, your session time may be offered to another client.

    Education and Supervision

    Summit's Edge is an educational practice, providing opportunities for interns to shadow and co-facilitate therapy sessions, subject to client consent. Clients retain the right to opt out of this arrangement at any time. Additionally, Summit's Edge serves as a supervision site for pre-licensed therapists, meaning your therapist may receive clinical supervision from a fully licensed therapist. Weekly supervision meetings are held to uphold standards of proper treatment planning, ethical conduct, and ensure the provision of appropriate client care.

    Professional Relationship

    Psychotherapy is a professional service we will provide to you. Because of the nature of therapy, your relationship with your therapist has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and your therapist were to interact in any other ways, you would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can create conflicts between the therapist's interests and the client’s interests, in which case, the client’s (your) interests might not be put first. In order to offer all of our clients the best care, your therapist’s judgment needs to be unselfish and purely focused on your needs. This is why your relationship with your therapist must remain professional in nature.

    Seeking support in terms of mental health means acknowledging and addressing your emotional, psychological, and behavioral challenges with the support of trained professionals. It involves seeking assistance to navigate and overcome issues such as anxiety, depression, trauma, addiction, or relationship difficulties. This process typically includes:

    Recognition: Acknowledging that you are experiencing distress or difficulty in managing your thoughts, feelings, or behaviors.
    Acceptance: Embracing the idea that seeking help is a positive and courageous step towards improving your well-being.
    Engagement: Actively participating in therapy, counseling, or other mental health interventions to explore and understand your challenges.
    Collaboration: Working closely with mental health professionals to develop personalized treatment plans tailored to your needs and goals.
    Commitment: Making a commitment to attend therapy sessions regularly, practice therapeutic techniques, and implement positive changes in your life.
    Self-care: Incorporating self-care practices into your daily routine to support your mental and emotional well-being.
    Persistence: Understanding that progress in therapy may take time and effort, and staying committed to the process despite setbacks or challenges.
    Empowerment: Gaining insight, skills, and coping strategies to effectively manage your mental health and lead a fulfilling life.


    Emotional safety is a necessary component of the therapeutic rapport, alliance and progress. That being said, emotional safety is relative to their trauma narrative, identity, and self-awareness. Your therapist will make every effort as they are able in pursuit of your stated therapeutic goals to provide ethical safety through open discussion, pacing, compassion and curiosity.

    Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems and make better decisions in a thoughtful way. A therapist's responses to your situation are based on tested theories and methods of change.

    You should also know that therapists are required to keep the identity of their clients confidential. As much as your therapist would like to, for your confidentiality, they will not address you in public unless you speak to them first.  Your therapist also must decline any invitation to attend gatherings with your family or friends. They will also not research you at any time to learn more about you. They will assume that what you are telling them in therapy is true and that what you disclose in session is what you want them to know in order to best assist you. Lastly, when your therapy is completed, your therapist will not be able to be a friend to you like your other friends. In sum, it is the duty of your therapist to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

    Statement Regarding Ethics, Client Welfare & Safety


    Summit’s Edge, LLC assures you that our services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association and/or the American Counseling Association and/or the National Association of Social Workers and/or the American Association for Marriage and Family Therapy.  If at any time you feel that your therapist is not performing in an ethical or professional manner, we ask that you please let them know immediately.  If the two of you are unable to resolve your concern, please contact our office at 888-551-5168.

    Due to the very nature of psychotherapy, as much as we would like to guarantee specific results regarding your therapeutic goals, we are unable to do so.  However, your therapist, with your participation, will work to achieve the best possible results for you.  Please also be aware that changes made in therapy may affect other people in your life.  For example, an increase in your assertiveness may not always be welcomed by others.  It is our intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.  


    Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better.  This may occur as you begin discussing certain sensitive areas of your life.  However, a topic usually isn’t sensitive unless it needs attention.  Therefore, discovering the discomfort is actually a success.  Once you and your therapist are able to target your specific treatment needs and the particular modalities that work best for you, help is generally on the way.  


    In order to protect all staff members and clients, Summit’s Edge prohibits the possession or use of dangerous weapons on company property.  Please leave all weapons including; guns, concealed carry weapons, and knives in your car or at home.

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  • Termination Policy & Expectations

     

    Clients who have not been seen in our office for a period of 90 days or more will be terminated. Clients will receive written notice via email or by mail of this termination. Clients may decide to discontinue services at any time and can return once they have been terminated. You may need to complete the intake process again if services have not been rendered in the past six months.

    It is expected that clients arrive on time for their appointments. If a client demonstrates a pattern of canceling appointments with less than 24 hours notice or missing appointments, they will be terminated from Summit’s Edge Counseling. Clients will be notified of this termination via phone or email and will be given alternate referral sources.

    It is critical to understand what normal or natural reasons for termination may be when the client feels they have achieved their therapy goals and no longer require regular sessions, relocation, changes in work or family circumstances that may make ongoing therapy impractical or unnecessary. If a lack of progress is noted by you or your therapist or supplemental or alternative therapies are recommended, your therapist may suggest termination. Another reason might be when a client has reached a point where they feel stable and equipped to manage challenges independently. Your clinician may also suggest termination when progress is made and the frequency of sessions decreases over time to allow for continued growth outside of therapy.

    Just as important, as an informed participant in this process, we want you to be aware of reasons that may be more concerning for termination and in these cases we would like you to make us aware immediately by calling the main line so that we can take proper action, make a referral. Any behavior by the therapist that violates ethical guidelines or compromises the trust and safety of the therapeutic relationship, instances where the therapist crosses professional boundaries or clients cross boundaries for the clinical that one or both parties are unable repair, leading to potential harm or discomfort for the client. Nonmaleficence is a fundamental principle in counseling ethics, emphasizing the counselor's obligation to avoid causing harm to their clients. This includes both physical and psychological harm. It's important to understand that harm can occur unintentionally, even when the counselor has the best intentions. As an example, let's say a counselor challenges a client's beliefs or behaviors during a session. The counselor's intention might be to encourage growth and self-awareness. However, if the client feels invalidated or judged by the challenge, they may experience emotional distress or hurt. In this scenario, the counselor didn't intend to harm the client, but the client still experienced hurt. It is the client's choice of the client but the recommendation to effectively find resolve, to bring hurt to the therapist directly for discussion so that repair may be possible. There are many other reasons why a termination could occur. You are encouraged to ask and understand the rationale behind the termination with your therapist if you feel unclear. If for any reason, that’s not possible, please ask to speak with the Director.

    It's critical to the effectiveness of quality therapy to differentiate between causing harm and a client feeling hurt. While causing harm involves deliberate actions that result in negative consequences for the client, a client feeling hurt can occur even when the counselor is acting in alignment with therapeutic goals.

    This highlights the importance of empathy, communication, and sensitivity in the therapeutic relationship. By being aware of the potential impact of their words and actions, counselors can strive to uphold the principle of nonmaleficence while fostering a safe and supportive therapeutic environment. If you ever feel unsure or bothered by an interaction or intervention with your therapist, we encourage you to address it with your clinician, the clinicians assigned supervisor, the Clinical Director or a third-party clinician which can be requested by a Client Experience Coordinator.

    It's essential to differentiate between unethical behavior and not being a good therapeutic fit. Unethical behavior refers to actions that go against the established ethical standards of the therapy profession, such as breaches of confidentiality, dual relationships, or exploitation. On the other hand, not being a good therapeutic fit refers to a mismatch between the client's needs, preferences, and the therapist's approach or expertise. This can occur even when both parties have the best intentions but may hinder the progress of therapy. It's important to address these concerns openly and collaboratively to ensure the client receives the most effective and supportive care possible.

    Aggressive, hostile, and inappropriate behavior will not be tolerated and, if displayed, will result in immediate termination from Summit's Edge Counseling. Examples of this behavior include, but are not limited to: use of profanity, yelling, threats, throwing items or other physically or verbally aggressive gestures towards Summit’s Edge staff or other individuals on Summit’s Edge property. Should a client conduct themselves in any of the above mentioned manners, Summit’s Edge reserves the right to ask you to leave the property. Should the client resist this request, law enforcement will be called.

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  • DUE TO FEDERAL LAWS - PLEASE READ BELOW FOR THE DANGERS OF USING YOUR INSURANCE TO PAY FOR YOUR COUNSELING SESSIONS


    Risks of Using Your Insurance


    If you choose to bill your insurance company to pay for counseling services or for reimbursement of counseling services, your therapist is required to provide a clinical mental health diagnosis as determined by the Diagnostic and Statistical Manual of Mental Disorders.  Your mental health diagnosis will become a permanent part of your medical record. Your insurance company has the right to request copies of your client records. 

    • Certain mental health diagnoses may prevent you from purchasing a firearm, and may restrict you from being able to work for certain federal, state, or law enforcement agencies.
    • Mental health diagnoses may be considered a “pre-existing condition” which could prevent you from receiving health insurance benefits in the future. 
    • If you need security clearance for work, aim to join the military, or are applying for jobs that require a criminal background check, or are involved in a Workman’s Comp case, all your mental health information can be accessed.
    • If you are ever involved in a legal case, the opposing party can subpoena your medical and mental health records to build a case against you.


    When billing insurance companies, a mental health diagnosis is required and will become part of your permanent medical record.

     

    Primary and Secondary Insurance Coverage


    At the time of scheduling your intake or, if during the course of your treatment, you change or add additional insurance coverage, please notify our office immediately of all insurance policies you have. In order for claims to be properly submitted, processed, and paid, it is important we have any and all insurance policy information which you are covered by. If your provider is in network and you wish to utilize your insurance for your sessions, Summit’s Edge will submit claims to your primary insurance. If your provider is in network with your secondary insurance, we will also submit to your secondary insurance policy on your behalf. If your provider is not in network with your secondary insurance, you will be given a statement of charges which you may submit to your secondary insurance. 


    The Superbill Explained


    If your clinician is not in-network with your insurance provider, we are happy to provide you with a “Superbill” which is required to submit for “out of network” claim submission and possible reimbursement from your insurance company. Many clients will not receive any reimbursement and we cannot guarantee reimbursement by your insurance company for services provided. Reimbursement discrepancies should be handled between the client and insurance company. 


    Please bear in mind that in order to submit for out of network benefits, all insurance companies require a mental health diagnosis, which becomes a permanent part of your insurance and medical records. If you wish to use your out of network benefits, please request a Superbill from our Client Experience Coordinators.


    Insurance companies have many rules and requirements specific to certain plans. Unless otherwise negotiated, it is your responsibility to determine your insurance company’s policies and to file for out of network insurance reimbursement. 

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  • Structure and Cost of Sessions

    Your therapist agrees to provide psychotherapy at a rate determined when scheduling your intake. Session costs may vary based on clinician and session length or complexity and are subject to change periodically. Payment for sessions is due before the start of each session, unless otherwise negotiated with Summit’s Edge or your insurance carrier. Additionally, self-pay clients will receive a “good faith estimate” annually.

    Payment for services are due before the start of your session and are due by the client unless otherwise negotiated with Summit’s Edge or your insurance carrier. Psychotherapy services via telephone or video (telehealth) are available, although frequent need for communication between sessions may indicate a need for additional support or more frequent visits. In such cases, you and your therapist will discuss options such as adding sessions or exploring other resources.

    Cash, Visa, MasterCard, Discover, or American Express are acceptable forms of payment. Receipts are available upon request. Some services may not be covered by your insurance or, in certain circumstances, insurance companies may retroactively recoup payments previously made for your claims. In these cases, you will be financially responsible for the remaining cost of the session which will be charged to your card on file. Please keep in mind that if you do have a balance on your account, you may not be eligible to receive continued services until the balance is paid.

    The cost of your counseling services may be eligible for reimbursement or paid through your Health Spending Account (HSA), Flexible Spending Account or Out-of-Network Benefits. If you have a Health Spending Account or a Flexible Spending Account that can be accessed with a debit card (usually Visa or Mastercard), we can accept that as payment for your therapy sessions. Please bear in mind that should your primary card on file be an HSA card or Flexible Spending Account card, we require that an additional non-HSA/Flexible Spending Account card be kept on file as well.


    Offsite Services and Paperwork Fees


    Medical Forms,Clinical summaries, and all other document requests are subject to incur a charge paid by the Client as determined by the Practice’s standard hourly rates for clinical time. Fees are subject to change without notice. Requests for such documentation will require 5-7 business days to return. Please leave ample time for completion. Therapists may refuse paperwork completion if the client has not been seen for longer than 6 weeks. 


    In the event that a client requests services outside of our current practice locations, the client is responsible for any charges incurred. Offsite Services may include but are not limited to court proceedings and school visits. These services and fees are determined by the Practice’s standard hourly rates for clinical time, plus time for travel and mileage, and are subject to change without notice. 

     

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  • Technology Statement


    In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically.  It is of utmost importance to us that we maintain your confidentiality, respect your boundaries, and ascertain that your relationship with your therapist remains therapeutic and professional.  Therefore, we’ve developed the following policies:


    Cell phones:  It is important for you to know that cell phones may not be completely secure or confidential.  However, we realize that most people have and utilize a cell phone. Your therapist may also use a cell phone to contact you.  If this is a problem, please feel free to discuss this with your therapist.


    Text Messaging and Email:  Both text messaging and emailing are not secure means of communication and may compromise your confidentiality.  We realize that many people prefer to text and/or email because it is a quick way to convey information.  However, please know that it is our policy to utilize these means of communication strictly for appointment confirmations (nothing that could be inferred as therapy).  Please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality.  If you do, please know that your therapist will not respond. You also need to know that we are required to keep a summary or a copy of all emails and texts as part of your clinical record that address anything related to therapy.  


    Social Media:  It is our policy not to accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. Summit’s Edge, LLC  has a business Facebook page, Pinterest account, Twitter account and is on LinkedIn.  You are welcome to follow us on any of these pages.  However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to Summit’s Edge, LLC . Please refrain from making contact with us using social media messaging systems such as Facebook Messenger or Twitter Direct Message. These methods have insufficient security, and we do not watch them closely. We would not want to miss an important message from you. 

        

    Google:  It is our policy not to search for our clients on Google or any other search engine.  We respect your privacy and make it a policy to allow you to share information about yourself to your therapist as you feel appropriate.  If there is content on the Internet that you would like to share with your therapist for therapeutic reasons, please print this material and bring it to your session. 


    Blog: We may post individual therapeutic content on our blog.  If you have an interest in following our blog, you are welcome to. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to Summit’s Edge, LLC .


    Faxing Medical Records: If you authorize us (in writing) via a "Release of Information" form to send your medical records or any form of protected health information to another entity for any reason, we may need to fax that information to the authorized entity. It is our responsibility to let you know that fax machines may not be a secure form of transmitting information. Additionally, information that has been faxed may also remain in the hard drive of our fax machine. However, our fax machine is kept behind two locks in our office. And, when our fax machine needs to be replaced, we will destroy the hard drive in a manner that makes future access to information on that device inaccessible.


    Recommendations to Websites or Applications (Apps):  During the course of treatment, your therapist may recommend that you visit certain websites for pertinent information or self-help. They may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide and communicate to your therapist if you would like this information as adjunct to your treatment or if you prefer that your therapist does not make these recommendations.


    In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time.  Please feel free to ask questions, and know that we are open to any feelings or thoughts you have about these and other modalities of communication. 

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  • Tele-mental Health Informed Consent

    Due to state licensure regulations, telemental health services may only be used if the client is residing in the state that the clinician is licensed at the time of the session.  If clients are traveling out of state or temporarily reside out of state, telemental health services may not be used unless the clinician is also licensed in the state that client is in or the session is limited to crisis stabilization services.

    In this electronic era, clients must be aware that there are risks to confidentiality and privacy whether clinical services are provided in-home, in-office, via phone or while using a HIPAA-compliant virtual platform.


    Consultation, education, coaching and therapy may be delivered via email, telephone or video conferencing. There are risks and benefits associated with communicating via electronic media. While we make every effort to protect communications, it is important that you read this agreement carefully in order to provide informed consent for services. 


    This agreement outlines possible risks and benefits. By signing this form, you signify that you understand that the term “telecommunication” may include consultation, education or treatment that may consist of the transfer of medical and/or personal data about myself or a family member, emails, telephone conversations and education using interactive audio, video or electronic communications.


    I understand that telecommunication/coaching/consultation also may involve the communication of my medical/mental health information, both verbally and visually. I understand that I have the following rights with respect to telecommunication:

    1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
    2. The laws that protect the confidentiality of my medical information also may apply to telecommunication. As such, I understand that the information disclosed by me during the course of therapy is generally confidential. However, there are mandatory and permissive exceptions to confidentiality including but not limited to: reporting child or elder abuse, expressed threats of violence tos self or others and where my mental or emotional state may be in issue in a legal proceeding. 
    3. I understand that there are risks and consequences from telecommunication, including but not limited to the possibility, despite reasonable efforts on the part of my consultant, that:
      1. The transmission of my information could be disrupted or distorted by technical failures;
      2. The transmission of my information could be interrupted by unauthorized persons or electronic storage may be accessed by an unauthorized party.

    Please note that telecommunication services are billed at the same hourly rate as a regular office visit. Some insurance plans do not cover these services and you will need to render direct pay prior to the session. Please note that you will need to call our office to complete or approve payment and then transfer to your therapist at the scheduled time of the session. Please also be aware that the card on file will be charged for the session if you do not “show” to the appointment. After 20 minutes, we will not be able to proceed with the appointment you will be charged for the time. Finally, if you are driving or not in a place to conduct a session privately at the time that your therapist calls, you may be directed to reschedule, as this presents liability and safety issues. You will be charged for the appointment if it needs to be rescheduled due to these circumstances. If you have questions regarding office procedure and therapy options, please ask at any time.

    The informed consent is subject to change at any time and will be redistributed annually.

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    INFORMATION, AUTHORIZATION, & CONSENT TO TREATMENT

  • Our Agreement to Enter into a Therapeutic Relationship


    We are sincerely looking forward to facilitating you on your journey toward healing and growth.  If you have any questions about any part of this document, please ask your therapist.  


    Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of your relationship with your therapist/group leader, and you are authorizing your therapist/group leader to begin treatment with you.

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