Liberated Counseling

Relationship Therapy Intake Packet

 

 

These first questions will ask for demographics details for Partner 1. Whichever person fills for Partner 1, please have them fill for those same fields throughout the intake packet.

 

Partner 2 will have an option to fill out demographics below.

PARTNER 1

Email, text messaging, and other electronic communications are not secure mediums and therefore, confidentiality cannot be assured. Please use discretion when sending information that is sensitive in nature.

PARTNER 2

Email, text messaging, and other electronic communications are not secure mediums and therefore, confidentiality cannot be assured. Please use discretion when sending information that is sensitive in nature.

EMERGENCY CONTACT(S)

CONSENT TO TREATMENT

It is the policy of Liberated Counseling LLC that clients have the right to say whether they wish to receive Outpatient services. Each client has impartial access to treatment, regardless of race, religion, gender identity, ethnicity, age, sexual preference or disability, within the range and diagnostic criteria for which Liberated Counseling LLC provides treatment.

The undersigned acknowledges that Liberated Counseling LLC makes no guarantees to the undersigned or the client as to the results or likelihood of success of Liberated Counseling LLC services.

The undersigned acknowledges that if a client becomes dangerous to him/herself or to others, the staff will exercise the necessary precautions to protect the client or others.

The undersigned acknowledges receiving a copy of information about Liberated Counseling including policies and procedures, Informed Consent, HIPPA compliance protocols, and Notice of Privacy Practices.

The undersigned releases Liberated Counseling LLC staff from any liability for the loss or damage of personal property and/or money while receiving services at Liberated Counseling LLC or at the client's home.

Our signatures below attests to the fact that we have read this form, understand its content and agree to the stipulations herein. 

CONSENT TO POLICIES

Thank you for choosing Liberated Counseling as your therapy provider. Please review carefully the consent to disclosure to insurance companies (if applicable) and receipt of notice of privacy practices below. If you agree to each item, please have both people initial next to each statement indicating your agreement and sign at the bottom.

RECEIPT OF NOTICE OF PRIVACY PRACTICES

We acknowledge that we have been provided a Notice of Privacy Practices that fully explains the uses and disclosures that Liberated Counseling will make with respect to our individually identifiable health information. We understand that we have the right to review said notice before signing this consent. Additional copies of this notice are posted on the website www.liberatedcounseling.com and also in the office lobby. We also understand that Liberated Counseling reserves the right to change its notice and the practices detailed therein prospectively and will notify us of any changes.

 

 

RECEIPT AND CONSENT TO INFORMED CONSENT AND ADDITIONAL POLICIES

We acknowledge that we have been provided and reviewed a copy of Informed Consent, additional privacy policies and cancellation and no-show policy. We understand these policies and agree to abide by the boundaries and stipulations therein.

 

 

We understand the limits of confidentiality in communication by electronic means. I will use discretion when electronically communicating information to this therapist.

CONSENT TO CANCELLATION POLICY

We understand that if we are unable to attend our scheduled therapy appointment, we must notify Liberated Counseling by email or at 505-504-5449 by text or voicemail 24 hours in advance of our appointment.

 

We understand that If we do not call to cancel or reschedule our appointment, this will be considered a no-show. Additionally, arriving later than 20 minutes for our scheduled therapy appointment time constitutes a no-show. No-shows to appointments will result in a subsequent fee of $25.

 

 

We understand that reoccurring no-shows / same day cancellations (2 instances in 12 months) may result in the termination of services. We understand that if we miss our scheduled appointment, it is our responsibility to call to set up another appointment. We understand that if we don't respond to contact attempts from Liberated Counseling, this will be interpreted as communication that we no longer wish to receive services.

 

 

We understand that if extenuating circumstances arise and we cancel in advance of our appointment but not with 24 hours' notice, Liberated Counseling may choose to waive this fee on a case-by-case basis.

 

 

We understand that if we miss our scheduled appointment, it is our responsibility to call to set up subsequent appointments. Failure to cancel with 24-hour prior notice may result in our losing our preferred time slot. If we are failing to maintain contact, Liberated Counseling may take this as communication that we are terminating services.

 

We affirm that we have read, fully understand, and agree with these policies for relationship counseling.

Please review carefully the boundaries and expectations outlined below. Please have both people initial next to each statement indicating your agreement and sign at the bottom. These are considered a necessary condition for treatment.

GENERAL PAYMENT POLICIES

We understand that all fees are due at the time or service. We understand that unless other arrangements are made in advance, we will be expected to pay the noted fee for these services at each appointment. Any payments may be made via cash, check, or credit card.

 

We understand that the full-scale fees for services are as follows: Intake Assessment $200, After hours Therapy $200 per 55 minutes, Counseling / Therapy Appointments $175 per 55 minutes, Relationship Therapy Appointments $175 per 55 minutes, and a one-time $45 fee for the Gottman Relationship Checkup Assessment Measures for relationship therapy clients.

 

We understand that any balances not paid within 30 calendar days may be turned over to collections with an additional 2% late fee added. We understand that if our bill must be turned over to collections due to not paying our balance after 30 calendar days, we are responsible for the collection's fees (typically 40% of the total bill).

We understand that if payment for the services I receive is not made, the therapist may stop my treatment.

 

We understand that if we pay by check or with credit card and the payment is later recouped (ex. the check bounces), a fee of $50 per incident will be incurred. We understand that this balance must be paid by alternative means in 5 days.

 

 

ADDITIONAL SERVICES

We understand that any out of session communication (telephone call or other medium) lasting more than 5 minutes will result in a fee of $25 per 15 minutes. There will be no fee for contacts lasting less than 5 minutes.

 

 

We understand that other services such as record preparation, report writing, and other documentation are charged at the rate of $25 per 15 minutes.

 

We understand that if we choose to subpoena Stephen Ratcliff, all legal services including preparation time, testimony time, transportation time, and commute time will incur a fee of $500 per hour due prior to testimony date.

We affirm that we have read, fully understand, and agree with these payment policies for relationship counseling.

Client's Rights

1. The right to efficient and equal service, regardless of race, gender, religion, ethnic background, education, social class, physical or mental disability, sexual orientation, gender identity, or economic status.
2. The right of considerate, courteous and respectful care from all Liberated Counseling, LLC staff.
3. The right to informed consent and full discussion of risks and benefits prior to any invasive procedure, except in an emergency. Alternative to the proposed procedure must be discussed with the client.
4. The right to receive information in an understandable manner.
5. The right to obtain a referral for bi-lingual services or to have an interpreter present in session if needed.
6. The right to the names, titles, and professions of Liberated Counseling, LLC staff with whom the client speaks and from whom services or information are received.
7. The right to refuse examination, discussion, and/or procedures to the extent permitted by law and to be informed of the health and legal consequences of this refusal. 
8. The right of access to the client's own personal health record.
9. The right to confidentiality and privacy of the client's personal mental health records as provided by the law. The details of the client's life and treatment are shared only with the client's parent's or guardian's permission and the client's explicit consent.
10. The right to expect reasonable continuity of care within the scope of services of Liberated Counseling, LLC.
11. The right to examine and receive a full explanation of any charges made by Liberated Counseling, LLC regardless of the source of payment.
12. The right of respect for the client's civil rights and religious opinions.
13. The right to be represented by a family member of guardian if the client is unable to fully participate in treatment

Client's Responsibilities

1. Provide accurate and complete information relevant to your treatment at Liberated Counseling, LLC.
2. Ask questions if you do not understand any aspect of your treatment.
3. Report safety concerns immediately to your therapist.
4. Avoid drugs, alcoholic beverages, or toxic substances while in attendance of your therapy session.
5. Accept the consequences if you do not follow the care, service, or treatment plan provided to you.
6. Respect the property of other people and of Liberated Counseling, LLC.
7. Be considerate of other clients.
8. Sign a written acknowledgement that you have received the applicable Notice of Privacy Practices.
9. Provide accurate information needed for processing your insurance coverage.
10. Be responsible for payment of all services, either through your third-party payers (insurance company) or by personally making payment for any service that are not covered by your insurance policy(s) including second opinions or consultations.

We affirm that we have read and fully understandour rights and responsibilites listed herein.

INFORMED CONSENT FOR RELATIONSHIP COUNSELING

General Information

Please review the following boundaries and information carefully and thoroughly. Please feel free to ask any questions!

• I seek to create a tailored treatment approach drawing on a variety of methods such as Gottman, emotion focused, sex therapy, and more. I seek to build on your relationship’s strengths and addresses your unique situation.
• Once we have started Relationship therapy, I will be unable to offer individual therapy for any of the relationship members. This is due to a conflict of interest. I would be happy to offer a referral if desired.
  • One possible exception to this is if anybody in the relationship requests to meet with me for a single visit individually because they feel unsafe in the relationship.
• In relationship therapy, the relationship is the client rather than any of the relationship's members.

Expectations of the Process

• I will never advocate for you to stay together at all costs or to divorce. These decisions are yours to make and my job is to support you in making your relationship decisions rather than dictate a certain path for you.
• While I seek to support you in your relationship goals, I cannot guarantee any outcome from treatment.
• The continued participation by all members of the relationship is voluntary. Any participant may suspend or terminate the therapy at his or her individual request at any time.

Unique limitations regarding Confidentiality

Due to relationship work involving two or more people, the following boundaries are important to clarify.

• In order for counseling information or records to be released, all members of the relationship must provide their written authorization. If all members of the relationship who participated in this therapy (as identified below) do not provide consent, then records cannot be released.
• Because there are two or more individuals who are the focus of treatment, privilege cannot be guaranteed. This means that confidentiality is somewhat more limited compared to individual therapy where information disclosed is considered privileged. Thus, anything involved with relationship counseling may not be privileged communication.
• I receive occasional professional consultation to help me improve my provision of services. Neither your name nor any identifying information about you and your relationship are revealed during these consultations.
• Because the process of relationship counseling involves a high amount of vulnerability in the efforts to build a closer emotional bond in the relationship, it is understood that all partners will not use the information disclosed during the therapy process against any other partner in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce or custody case.
• Because of the limitations due to my scope of practice, I am unable to make any kind of formal recommendation or state any opinion regarding child custody (Custody recommendations are only permitted by a psychologist custody evaluator).

No Secrets Boundary

My allegiance is to your relationship and not to any of the partners of your relationship as individuals. I find this is particularly important in creating a space where all partners can feel safe. Therefore, I adhere to a strict "No Secrets" policy. This means that I will not hold secrets for any partner. This policy is intended to allow me to continue to treat the relationship by preventing, to the extent possible, a conflict of interest to arise where an individual's interests may not be consistent with the interests of the relationship being treated.

 

We affirm that we have read, fully understand, and agree with this informed consent for relationship counseling.

RELATIONSHIP COUNSELING PAYMENT AGREEMENT

We agree to pay $175 per session, for relationship psychotherapy services received through Liberated Counseling, LLC.

We also agree to and understand the following conditions:

• Sessions are defined as one hour in length. Extended fees may be incurred for longer sessions.
• The client, or responsible party, will be held responsible for all fees charged.
• Sliding scale fees are to be determined using the client's household income and the number of people in the household. All sliding scale arrangements must be made in advance of the session.
• Fees are due at the time of each session and will be accepted in the form of cash, check, credit card,or money order.
• Fees will only be refunded in the event that the service is not delivered.
• Non-payment of fees could result in the discontinuation of services to the client. Clients will be billed for any unpaid services via an invoice by mail. Any unpaid balances may be turned over to collections after 30 days.
• Insurance will NOT be billed for these services; consequently, none of the fees for services will be applied to an insurance plan's annual deductible. Because no diagnosis will be rendered and an individual is not being treated, insurance cannot be billed
• A $25 discount is currently offered during COVID-19 from March 2020 - December 2021. This discount may be extended by the clinician at their discretion. 

We affirm that we have read, fully understand, and agree with this payment agreement for relationship Counseling.

This form will go over a little bit about telehealth, how to electronically complete intake and other paperwork, and will help you set up the tools for our video telehealth sessions.

• We will use secure, encrypted technologies that are free to you for video sessions.
• Telehealth has both benefits and risks, which we will be monitoring as you proceed with your work.
• You can stop work by telehealth at any time without prejudice.
• You will need to participate in creating an appropriate space for your telehealth sessions.
• You will need to participate planning for technology failures, mental health crises, and medical emergencies.
• I follow security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.

 

What is Telehealth?

Telehealth means the providing of mental health counseling through secure video software. Services delivered via telehealth rely on a number of electronic, Internet-based, programs. I provide telehealth via a secure application called vsee messenger or a secure website called doxy:

• Vsee messenger can be downloaded for free here: https://my.vsee.com/download
• If you prefer, we can also meet through the secure doxy website. My doxy’s website is https://doxy.mee/sratcliff
• You will need access to high speed Internet service for your telehealth session.
• If you have any questions or concerns about the above tools, please let me know.

 

POTENTIAL TELEHEALTH BENEFITS

• Receive services when you are unable to travel to the service provider’s office.
• Receive services at times or in places where the service may not otherwise be available.
• Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.
• Receive services without potential risks of transmission of COVID 19 or other transmittable viruses.
• The unique characteristics of telehealth media may also help some people make improved progress on health goals that may not have been otherwise achievable without telehealth.

 

POTENTIAL TELEHEALTH RISKS

Telehealth services can be impacted by technical failures, may introduce risks to your privacy, and may reduce my ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

• Internet connections and cloud services could cease working or become too unstable to use.
• Computer or smartphone hardware can have sudden failures or run out of power, or local power services can fail.
• Interruptions may disrupt services at important moments, and I may be unable to reach you quickly. 

 

Assessing Telehealth’s Fit for You

• Although it is well validated by research, service delivery via telehealth is not a good fit for every person. I will continuously assess if working via telehealth is appropriate for your case. If it is not appropriate, I will help you find in-person providers or shift to in-person sessions.
• Please talk to me if you find the telehealth media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telehealth medium seems to be causing problems in receiving services.
• Bringing your concerns to me is often a part of the process. You also have a right to stop receiving services by telehealth at any time without prejudice.

 

 

Your Telehealth Environment

You will be responsible for creating a safe and confidential space during sessions. Please consider:

• Dress as you would if we were meeting in an office appointment.
• If you have a headset with a microphone, please use it as this helps produce better audio and privacy.
• Please be in an environment where you are alone and have good access to high speed internet.
• Please limit distractions such as multi-tasking. Please turn on do not disturb if you are meeting on your cell phone.
• Have your computer or tablet on a firm surface if possible.
• Please avoid walking around with your device, as this can make me dizzy.

 

Communication Plan

If you need to get ahold of me in between sessions, here are some contact methods and considerations:

• The best way to contact me between sessions is by email steve@liberatedcounseling.com or telephone 505-504-5449. Please note that neither email nor my telephone number are to be used during a crisis.
• I will respond to your messages as soon as I can. Please note that I may not respond at all on weekends or holidays.
• Our work is done primarily during our appointed sessions, which will generally occur during my business hours Monday thru Thursday from 10am to 7pm MST. ​
• Contact between sessions should be limited to confirming or changing appointment times.

 

 

Technology Safety and Crisis / Emergency Planning

As a recipient of telehealth services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with me.

• I will require you to designate an emergency contact at the intake appointment. You will need to provide permission for me to communicate with this person about your care during emergencies.
• Crisis services include Telephone crisis lines (800-273-8255), calling 911, or go to the nearest Emergency Room.
• Except where otherwise noted, I employ software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.
• As with all things in telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with me, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that I have supplied for communications (e.g. Vsee). For more information please see my specific recommendations for electronic security and safety here: http://steveratcliff.com/techrec.pdf

 

 

Instruction for Setting Up Vsee or getting onto the doxy website

• Vsee messenger can be downloaded for free here: https://my.vsee.com/download
  • After you download and install vsee messenger onto a tablet, computer, or smart phone, you will need to set up an account. This process if free but will include using an email address for that account.
  • If you have problems downloading vsee messenger, let me know and I can email you a download invite
  • After you have set up the application and account, let me know what email address you used, and I will reach out to you through the application to connect us.
  • After we are connected, we can send messages, do video sessions, and exchange files securely through the end-to-end encryption that vsee messenger uses.
  • A video showing some of the basic functions of the vsee messenger application is here: https://youtu.be/XZlCfj07MUQ
• If you prefer, we can also meet through the secure doxy website, which is https://doxy.me/sratcliff
  • Click on the link and check in a few minutes prior to our appointment time using whatever name.
  • It will ask you to enable access to your microphone and camera. Click yes.
  • I will start the appointment at our appointment time.
  • This webpage is a tutorial for doxy https://help.doxy.me/en/articles/3751218-how-to-check-in-as-a-patient
• Call me at 505-504-5449 if there are technical difficulties.

 

 

 Recordings

Please do not record video or audio sessions without my consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. I will not​ record video or audio from our sessions.

 

 

Insurance Coverage and Payment Information

• Currently, telehealth services are only permitted to residences of New Mexico, Oregon, and Florida due to licensure law restrictions (I am only licensed or permitted to practice in these states).
• Many insurance companies cover some or all of the cost of services delivered by telehealth. If you have questions about coverage of telehealth, please contact your insurance company.
• Copays and deductibles will be due at the time of service during a telehealth session similar to an in-office session. These fees will be collected by cash, check, credit card, HSA, or FSA means.
• Any credit card, debit card, HAS, or FSA payments will be collected using a secure service called Ivy, which keeps your card on file. Your signature at the bottom of this form indicates your consent to Ivy maintaining your chosen card on file. Ivy can delete your card information upon request.

 

Electronically Signing Paperwork

Prior to our first appointment and periodically throughout therapy, we will need to complete paperwork. I have made my forms fillable online for your convenience. Here are some tips to help you fill out these forms:

• You may fill out forms securely in electronic form or download the forms: www.liberatedcounseling.com

Our signatures below attests to the fact that:

• WE have residency in either the state of New Mexico, Oregon, or Florida.
• WE agree to participate in telehealth-based psychotherapy.
• WE have read, understood, and agree to follow the above policies.
• WE consent to having our electronic payment information stored on Ivy.