INFORMATION, AUTHORIZATION, & CONSENT TO TELEMENTAL HEALTH

Thank you for choosing Western Reserve Counseling, LLC (WRC This document is designed to inform you about what you can expect regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to TeleMental Health. TeleMental Health is defined as follows:

TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system, or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.

TeleMental Health is a relatively new concept despite the fact that many therapists have been using technology-assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. Practitioners with WRC have specialized training in TeleMental and have several policies and protective measures to assure your PHI remains confidential. These are discussed below.

Different Forms of Technology-Assisted Media Explained

It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and provided that phone number, we may contact you on this line typically regarding setting up appointments. If this is not an acceptable way to contact you, please let us know. Telephone conversations (other than just setting up appointments) are billed at the hourly rate.

In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. Therapists with WRC may also use a cell phone to contact you, typically only regarding setting up an appointment if needed. Telephone conversations (other than just setting up appointments) are billed at the hourly rate. Additionally, we may keep your phone number in our cell phone, but it is listed by your first name, last initial only. If this is a problem, please let us know, and we will discuss other options.

Text messaging is not a secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text because it is a quick way to convey information. Nonetheless, please know that it is our policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via text to prevent compromising your confidentiality. You also need to know that we may keep a copy or summary of all texts as part of your clinical record that addresses anything related to therapy.

Email is not a secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to email because it is a quick way to convey information. Nonetheless, please know that it is our policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that we are required to keep a copy or summary of all emails as part of your clinical record that addresses anything related to therapy.

We suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password-protected, not accessing the internet through a public wireless network, etc If you are in a crisis, please do not communicate this to me via email or text because we may not see it in a timely matter. Instead, please see below under "Emergency Procedures."

Social Media - Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc:

It is our policy not to accept "friend" or "connection" requests from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of our relationship.

However, if Western Reserve Counseling, LLC has a professional Facebook page and professional Twitter account, you are welcome to "follow" us on any of these professional pages where we post psychology information/therapeutic content. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to Western Reserve Counseling, LLC. Please refrain from making contact using social media messaging systems such as Facebook Messenger or Twitter. These methods have insufficient security, and we not monitor them closely.

We may post psychology information/counseling Information/therapeutic content on a professional blog. If you have an interest in following my blog, please feel free to do SO. However, please be mindful that the general public may see that you're following Western Reserve Counseling, LLC's blog. Once again, maintaining your confidentiality is a priority.

If you authorize a "Release of Information" form to send your medical records or any form of PHI to another entity for any reason, we may fax that information to the authorized entity. Fax machines may not be a secure form of transmitting the information. Additionally, information that has been faxed may also remain in the hard drive of a fax machine. However, the fax machine is kept behind two locks in the office. And, when my fax machine needs to be replaced, I 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 treatment, I may recommend that you visit certain websites for pertinent information or self-help. I 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/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 if you would like this information as an adjunct to your treatment or if you prefer that I do not make these recommendations. Please let me know by checking (or not checking) the appropriate box at the end of this document.

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI).

Electronic Transfer of PHI for Billing Purposes: If I am credentialed with and a provider for your insurance, please know that I utilize a billing service that has access to your PHI. Your PHI will be securely transferred electronically to Square. This billing company 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. Additionally, if your insurance provider is billed, you will generally receive correspondence from your insurance company, my billing company, or both.

Electronic Transfer of PHI for Certain Credit Card Transactions:

I utilize Square as the company that processes your credit card information. This company may send the credit card- holder a text or an email receipt indicating that you used that credit card for my services, the date you used it, and the amount that was charged. This notification is usually set up two different ways - either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit card holder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will also appear on your credit card bill. The name on the charge will appear as Western Reserve Counseling, LLC.

Your Responsibilities for Confidentiality & TeleMental Health:

Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any TeleMental Health sessions.

I'm required to make sure that you're aware that I'm located in the Southeast and I abide by Eastern Standard Time. My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper nor am I available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. I will return phone calls within 24 hours during business hours. However, I do not return calls, emails, or texts on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.

If you have a mental health emergency, I encourage you not to wait for communication back from me but do one or more of the following:

Cuyahoga County residents: The Mobile Crisis Unit at 216-623-6888. Lorain County residents: The Nord Center ESS at 1-800-888-6161

National Suicide Prevention Lifeline at 1-800-273-8255

Call 911 or go to your nearest emergency room.

Emergency Procedures Specific to TeleMental Health Services

There are additional procedures that we need to have in place specific to TeleMental Health services. These are for your safety in case of an emergency and are as follows:

You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental Health services are not appropriate. I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person's name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above. Please list your ECP here:

You agree to inform me of the address where you are at the beginning of every TeleMental Health session. You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a TeleMental Health session Please list this hospital and contact number here:

During a TeleMental Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and I have that phone number. If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. If the issue is due to my phone service, and we are not able to reconnect, I will not charge you for that

Structure and Cost of Sessions

I offer primarily face-to-face counseling. However, based on your ability to make in-person sessions, I may provide phone counseling on occasion if your treatment needs determine that TeleMental Health services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, TeleMental Health, or both. We will discuss what is best for you. Please remember that you insurance company may or may not cover therapy via phone.

The structure and cost of TeleMental Health sessions are exactly the same as face-to-face sessions described in my general "Health Insurance Verification/Fee Agreement" form. Texting and emails (other than just setting up appointments) are billed at my hourly rate for the time I spend reading and responding. I require a credit card ahead of time for TeleMental Health therapy for ease of billing. Please sign the Credit Card Payment Form, which was sent to you separately and indicates that I may charge your card without you being physically present. Your credit card will be charged at the conclusion of each TeleMental Health interaction. This includes any therapeutic interaction other than setting up appointments. Visa, MasterCard, Discover, or American Express are accepted for payment, and I will provide you with a receipt of payment and the services that I provided. The receipt of payment & services completed may also be used as a statement for insurance if applicable to you (see below Insurance have companies have many rules and requirements specific to certain benefit plans. At the present time, many do not cover TeleMental Health services. Unless otherwise negotiated, it is your responsibility to find out your insurance company's policies and to file for insurance reimbursement for TeleMental Health services. As stated above, I will be glad to provide you with a statement for your insurance company and to assist you with any questions you may have in this area. You are also responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, internet or phone charges, software, headset, etc.

In the event that you are unable to keep either a face-to-face appointment or a TeleMental Health appointment, you must notify me at least 24 hours in advance. If such advance notice is not received, you will be financially responsible for the $35.00 no-show/cancellation fee. Please note that insurance companies do not reimburse for missed sessions.

Limitations of TeleMental Health Therapy Services

TeleMental Health services should not be viewed as a complete substitute for therapy conducted in my office unless there are extreme circumstances that prevent you from attending therapy in person. It is an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding anotherone anotherwhencommunication lacks visual or auditory cues. For example, if video quality is lacking for some reason, I might not see a tear in your eye. Or, if audio quality is lacking, I might not hear the crack in your voice that I could easily pickup if you were in my office. There may also be a disruption to the service (e.g., phone gets cut off or video drops This can be frustrating and interrupt the normal flow of personal interaction. Please know that I havethe utmost respect and positive regard for you and your wellbeing. I would never do or say anything intentionally to hurt you in any way, and I strongly encourage you to let me know if something I've done or said has upset you. I invite you to keep our communication open at all times to reduce any possible harm.

Consent to TeleMental Health Services

Please check the TeleMental Health services you are authorizing me to utilize for your treatment or administrative purposes. Together, we will ultimately determine which modes of communication are best for you. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying me in writing. If you do not see an item discussed previously in this document listed for your authorization below, this is because it is built-in to my practice, and I will be utilizing that technology unless otherwise negotiated by you.

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

Please sign and date your name below indicating that you have read, understand, and discussed the contents of this form, you agree to these policies, and you are authorizing me to utilize the TeleMental Health methods discussed.