Client Services Agreement & Consent to Treatment

SECTION 1: PROFESSIONAL DISCLOSURE STATEMENT
The therapists and supervisors at The Briggs Institute, Inc. are committed to offering affordable, high quality therapeutic services to the community. We are dedicated to helping meet the mental health and relationship care needs of individuals, couples, and families and to the post-master’s supervision of skilled, pre-licensed marriage and family therapists.

There are two types of therapists at the Institute: Licensed Marital and Family Therapists (LMFT) and Pre-Licensed Clinical Fellows (TLMFT, M.MFT).

An LMFT is any person who has met the qualifications for licensed marital and family therapist and holds a current, unsuspended or unrevoked, license which has been lawfully issued by The Board for Professional Counselors, Marital and Family Therapists, and Clinical Pastoral Therapists in Tennessee.

After graduating with a master’s degree, all therapists seeking licensure in Tennessee are required to spend at least two years gaining post-graduate clinical experience and ongoing supervision. This stage of therapists' careers is similar to when medical doctors graduate and spend several years in a residency program. The pre-licensed clinical fellows at The Briggs Institute, Inc. have taken this step in their careers and are currently earning the post-graduate experience required for independent licensure.

Pre-licensed Clinical Fellows at the Institute provide mental health and relationship care services under the supervision of AAMFT Approved Supervisors. This designation signifies that these supervisors have "...attained the educational, experiential and supervisory training required for the competent supervision of marriage and family therapists and trainees." This places the pre-licensed clinical fellows at the Institute under the mentoring of clinicians who have earned the highest supervision designation in the mental health field. To learn more about AAMFT approved supervision, visit www.aamft.org.

As you begin work at the Institute, it is important for you to know that experiences in therapy vary depending on the personalities of the therapist and client(s) and the particular problems being addressed. There are many different methods that may be used to deal with the problems that you hope to focus on. Visiting a therapist is not like a visit to a medical doctor. Rather, it calls for a very active effort on the part of the client(s). In order for therapy to be most successful, you will have to work on things at home that are talked about during your sessions.
SECTION 2: RISKS & BENEFITS
Therapy has both potential risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, helplessness, and other difficult emotions. We believe that therapy has stronger benefits than risks. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees, however, regarding your experiences in therapy or the outcome of your therapy.

Your first few sessions will involve an evaluation of your needs and could include your completion of several assessment instruments. By the end of the evaluation, your therapist may offer you some first impressions and present you with a general treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your opinions of whether you feel comfortable working with your therapist. Therapy involves a large commitment of time, money, and energy, so you should be careful about the therapist with whom you select to work. If you have questions about procedures at the Institute, you should discuss them with your therapist whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.
SECTION 3: VOLUNTARY PARTICIPATION
Your decision to enter therapy with a therapist at The Briggs Institute, Inc. is voluntary. You can stop therapy at any time and discontinuing treatment will not result in any penalty.
SECTION 4: EVIDENCE-BASED PRACTICE
All of the therapists at The Briggs Institute, Inc. practice an evidence-based approach to therapy. This means their treatment plans for you are significantly influenced by scientific theory and research. Your therapist will ask you to contribute to this process by inviting you to complete brief questionnaires that let us know how you feel about your life in general, your relationships with others, and your experience in therapy. We use this information to track your progress and to inform our decisions as we try to help you reach your goals. We look forward to finding out what therapy can help you accomplish.
SECTION 5 A: LIMITS ON CONFIDENTIALITY
The Briggs Institute, Inc. offers confidential counseling in so far as allowed or required by applicable federal and state law. This means that your therapist has a responsibility to protect information received from you during treatment. In order for any information about you to be shared outside of The Briggs Institute, Inc., usually you must first sign a Release of Information that allows your therapist to communicate only with the person or organization identified on the release and only regarding specific information identified by you.

Because of the Institute’s commitment to evidence-based practice, therapists regularly discuss their clinical work with supervisors and colleagues to make sure that they are providing their clients with the best care possible. During these consultations, therapists most often do not share their clients’ personally identifiable information. When circumstances do require identifiable information to be shared for business operations and clinical reasons, all of the Institute's business associates (e.g., Microsoft, Jotform, Square Credit Card Processing, etc.), Institute staff, supervisors, and consulting clinicians are legally and ethically bound to keep your information confidential.

Under certain conditions, the laws of the State of Tennessee allow exceptions to client confidentiality. In general, exceptions are allowed when the therapists must act to protect or warn a person or people who may be in physical danger. these exceptions occur under the following circumstances:
1. Your therapist is required to report suspected child abuse or neglect and to report suspected abuse of the disabled or elderly. This information is required to be shared with the Department of Children’s Services, County Sheriff, chief law enforcement official where the suspected victim resides, or a judge having jurisdiction.
2. Your therapist may give information to law enforcement, medical personnel, or other parties in order to protect clients and others when there is a probability of imminent physical danger, including the potential for suicide, homicide, or serious injury on the part of the client. Your therapist may also disclose information to law enforcement or medical personnel in order to protect you from immediate mental or emotional injury. Your therapist may be required to disclose information to the courts regarding treatment information in proceedings affecting the parent-child relationship.
3. Confidentiality is not protected in connection with criminal proceedings, except communication by a person voluntarily involved in a substance abuse treatment program.
4. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by client-therapist confidentiality. Your therapist cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
TN Code 33-3-206. Duty to predict, warn or take precautions to provide protection Liability.

IF AND ONLY IF

(1)  a service recipient has communicated to a qualified mental health professional or behavior analyst an actual threat of bodily harm against a clearly identified victim, AND

(2)  the professional, using the reasonable skill, knowledge, and care ordinarily possessed and exercised by the professional's specialty under similar circumstances, has determined or reasonably should have determined that the service recipient has the apparent ability to commit such an act and is likely to carry out the threat unless prevented from doing so,

THEN

(3)  the professional shall take reasonable care to predict, warn of, or take precautions to protect the identified victim from the service recipient's violent behavior.

According to §164.502 of 45 CFR (i.e., the Omnibus Final Rule) it is not considered a violation of client confidentiality when health professionals disclose protected health information, provided that:
1. They believe in good faith that the covered entity (e.g., treatment facility) has engaged in conduct that is unlawful or otherwise violates professional or clinical standards, or that the care, services, or conditions provided by the covered entity potentially endangers one or more patients, workers, or the public; and
2. The disclosure is to:
  A health oversight agency or public health authority authorized by law to investigate or otherwise oversee the relevant conduct or conditions of the covered entity or to an appropriate health care accreditation organization for the purpose of reporting the allegation of failure to meet professional standards or misconduct by the covered entity; or
3. An attorney retained by or on behalf of the workforce member or business associate for the purpose of determining the legal options of the workforce member or business associate with regard to the conduct described in paragraph (j)(1)(i) of this section.
4. Disclosures are also permitted when the protected health information disclosed is about the suspected perpetrator of the criminal act; and
5. The protected health information disclosed is limited to the information listed in §164.512(f)(2)(i) (e.g., name, address, treatment date, physical description).
6. It is to a law enforcement official and the disclosure is made in good faith that the client took part in criminal conduct that occurred on the treatment premises.
While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss with your therapist any questions or concerns you may have now or in the future. This summary is for general information purposes only and does not, and is not intended to, constitute legal advice. If you have any questions about your confidentiality rights, you should consult with your attorney.
SECTION 5 B: CLIENT CONFIDENTIALITY RESPONSIBILITIES AND ACCIDENTAL DISCLOSURES OF CLIENT INFORMATION
In psychotherapy practices, respecting the confidentiality of fellow clients is a responsibility for all clients. This includes refraining from disclosing information overheard or the identity of others seen in the waiting room, recognizing that therapy is a private and sensitive journey for everyone.

Unfortunately, accidental disclosures of confidential information may happen despite best efforts to maintain confidentiality. To reduce the likelihood of accidents occurring, the Institute has trainings, policies and procedures, risk analyses and management, information access controls, security protections, and other factors put in place to keep client information secure.

The response to a HIPAA breach depends on the sensitivity and impact of the information that was shared. Not all breaches are treated the same. For example, breaches that were deliberate or those that release especially sensitive information such as diagnosis, financial information, etc., are usually treated much more severely than those that are accidental or those that release information that is not as sensitive. Of course, "sensitive" is a subjective term, but, for example, accidentally sharing a client’s email address is often considered much less severe than sharing something such as a client’s diagnosis or financial information like a credit card number.

If someone ever accidentally receives information intended for another, such as an email misaddressed (e.g., sent to johndoe@fakeemail.com instead of johndoe1@fakeemail.com), it is imperative that the recipient respects this other person’s confidentiality. The ethical response is to promptly inform the sender of the error without exploring the message content and deleting the misdirected communication including any attachments.

In the highly unlikely event that your information is accidentally disclosed without your authorization, we apologize. We will notify you of any breaches of your information. We will accept responsibility for any role we played in the unauthorized disclosure of client information and will do our best to mitigate any impacts should they occur.
SECTION 6: ADDITIONAL LIMITS ON CONFIDENTIALITY IN RELATIONAL THERAPY AND OFF-SITE LOCATIONS
Relational therapy includes couple, family, or group therapy. It involves both joint sessions and individual sessions tailored to relational goals (e.g., one-on-one sessions with each partner in couples therapy).

When therapy occurs in a relational context (i.e., couple, family, or group therapy), you acknowledge and agree that additional limits will apply to your confidentiality. For example, your confidentiality may be violated if one of the other clients in the session shares something you said in session with someone else.

Normally, Institute clinicians will keep separate case files for each client taking part in relational therapy. Keeping separate case files for each client allows the supervisors and therapists to create unique client records that we keep confidential in so far as allowed or required under applicable federal and state laws; however, if you take part in relational therapy, you acknowledge and agree that it is impossible for us to keep all of your information out of the other client case file/s.

You also acknowledge and agree that verbal communication with other members of the client system (e.g., spouse, family member) will require us to discuss your information. Examples of such verbal communication include, but are not limited to, conversations with another member of the client system (e.g., spouse, family member) in session or for scheduling purposes.

This means that your personally identifiable information, including, but not limited to, your dates of service, diagnosis and CPT codes, reasons for seeking therapy, a description of the ways in which your problems impact your life, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, may also be verbally shared with or recorded in the case files of those you are working with in therapy (e.g., your relationship partner, family member/s). For example, when a therapist provides couple therapy, both clients’ names, diagnoses, a description of what they discussed in session, and the therapist’s assessment of their mental health, relationship, and reactions to treatment will appear in both client case files and may come up in conversations pertaining to treatment (e.g., session scheduling, etc.).

Most clients receive clinical services on-location at the Institute; however, there are times when therapists provide therapy services at off-site locations either in-person or through telehealth (e.g., video conferencing, phone sessions). When this occurs, there are additional limits on confidentiality. Sessions held off-site or via telehealth may be more likely to be overheard by others due to building design limitations and lack of soundproofing measures such as insulation and white noise machines. Additionally, any paper case file materials such as signed informed consent and notice of privacy practices documents may be carried on the person of the therapist, making them more vulnerable to being stolen or lost than materials that are signed and stored directly at the Institute.

Please let us know if you have any questions about limits on confidentiality in relational therapy and off-site locations and we will do our best to answer them.
I, the client (or authorized representative), have fully read and agree to the terms outlined in this SECTION 6, ADDITIONAL LIMITS ON CONFIDENTIALITY IN RELATIONAL THERAPY AND OFF-SITE LOCATIONS and give consent for treatment under the terms and conditions outlined here.*

I agree with this statement
SECTION 7: MINORS & PARENTS
When treating a minor client (a person under the age of 18), your therapist may advise a parent, managing conservator, or guardian of a minor with or without the minor’s consent, of the treatment needed by or given to a minor. If the treatment, however, is for suicide prevention; chemical addiction or dependency; or sexual, physical, or emotional abuse, the law provides that parents may not access their child’s records. For adolescents between ages 16 and 18, because privacy in therapy is often crucial to successful progress, this can lead to potential problems in therapy. Older children have special rights with regard to mental health services in Tennessee. Youths 16 years and older may provide their own consents for mental health treatment. When these youths give consent, additional consent from the parent, legal guardian or legal custodian is not needed. Institute therapists will work diligently to maintain a balance between a teenager’s need for privacy/confidentiality and a parent’s desire to access their child’s records. All therapists will work prudently with their clients to find a balance that is good for the teenager, unless they feel that the teenager is in danger or is a danger to someone else, in which case therapists will notify the parents of their concern.
SECTION 8: SESSIONS
You can expect the initial assessment and evaluation period to last from 1 to 3 sessions. During this time, you and your therapist can decide if s/he is the right person to provide the services you need in order to meet your treatment goals. Sessions are normally around 50-55 minutes in length and typically occur weekly or every other week. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation (or unless both you and your therapist agree that you were unable to attend due to circumstances beyond your control). If the Institute closes for inclement weather or any other reason, reasonable attempts will be made to contact you if you are scheduled for an appointment. If you are working with a therapist using a telehealth service, you may still be able to have a session even if the Institute is closed to in-person therapy due to weather-related circumstances; please check with your therapist if you are uncertain whether or not you are scheduled for a session.
SECTION 9: TELEHEALTH & GOOGLE MEET
Telehealth services allow for remote treatment and are ideal for clients who are in Tennessee but unable to meet with their therapist on location in our Nashville office. Our telehealth services allow us to provide innovative, high quality care for our clients whenever in-person therapy isn’t a good fit.

Another benefit of telehealth services is that they allow us to serve all Tennessee residents, not just those who live in an around Nashville.

Meet, a video meeting experience from Google, allows for Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant use between health professionals and their clients. This is important because the things we will talk about while using Meet are likely to be personal and taking appropriate steps to help keep our conversations confidential is required by law and is considered best practice in the mental health field. All video and audio streams in Meet are encrypted and Meet users can join securely even when they're out of our office. This means that you and your therapist will be able to communicate with the added confidence that the content of our discussion is secured according to industry standards.

In order to use Meet, you will have to download the Meet application from the Apple App Store or Google Play Store.
SECTION 10: LIMITS ON CONFIDENTIALITY FOR TELEHEALTH SESSIONS
Even though Meet is an encrypted service and Google has sought and received security certifications such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits, I do ask you to please remember that there is always a risk of a breach of confidentiality whenever you share your personal information. I also want you to be aware that your computer and other electronic devices may not be secured according to health industry standards.
SECTION 11: INFORMATION SECURITY CONSIDERATIONS
In order to decrease the chances that the confidentiality of your personal information is compromised, I highly suggest you consider doing the following:
1. Only use telehealth services when you have taken steps to decrease the likelihood that you can be overheard. These steps include:
  1. Making sure you are alone in a room when using telehealth services.
  2. Placing a sound dampening device such as a white noise machine outside the room where you are using telehealth services.
2. Enable two-step verification when logging into your email accounts. This security measure makes it harder for someone to breach your email and gain access to your computer or other electronic devices.
3. Limit access by being careful who you allow to use, look after, or borrow your computer or other electronic devices.
4. Be sure to log out of telehealth services after use.
5. Encrypt your computer and other electronic devices
  1. To encrypt Apple-made mobile devices, you need to enable password protection on your iOS device. This can be done via the Touch ID & Passcode section of Settings. iOS mobile devices used to access clients’ PII should not be backed up to cloud storage services.
  2. On Android devices, encryption can be enabled in the Security or Lock Screen area under settings.
  3. To encrypt a Mac computer, enable Apple's FileVault encryption in the Security & Privacy system preferences. If there are multiple user accounts on the Mac, be sure to enable encryption on each one that requires protection. I suggest using a different FileVault password than the one associated with an iTunes or iCloud account; if an unauthorized individual gains access to an iTunes or iCloud password, it cannot be used to decrypt the computer. Apple Time Machine backups and any external drives also need to be encrypted. When setting up a backup drive, the Time Machine can by encrypted in the Time Machine system preference by clicking Select Disk, selecting the backup drive, enabling the Encrypt Backup option, and clicking Use Disk. In OS X El Capitan, external drives can be encrypted, including a Time Machine backup drive, by right-clicking or Control-clicking it in the Finder and choosing Encrypt from the contextual menu that appears. In older OS X versions, Disk Utility can be used to encrypt a drive: select the drive in its Sidebar, then choose File > Encrypt or File > Lock, depending on the OS X version.
  4. On a PC, enabling encryption is accomplished by activating Microsoft's BitLocker. The PC will likely need to have a Trusted Protection Module (TPM) on its motherboard, but it's often missing on cheaper PCs and even expensive older PCs. The computer must also be running the Pro, Ultimate, or Enterprise editions of Windows Vista or later. If the PC is BitLocker- compatible, the BitLocker Drive Encryption settings (called Manage BitLocker in Windows 10) can be found in the Security control panel. In some cases, external drives can also be encrypted here. If a PC doesn't support BitLocker, a third-party encryption tool like VeraCrypt must be used.
6. Regularly implement software patches and update antivirus software on personal computers.
7. Avoid the following to reduce the likelihood of malware getting installed on your computer and other electronic devices:
  1. Downloading bundled free software programs. Programs advertised as “free” often come with the cost of downloading malicious software to a computer.
  2. Using file sharing, BitTorrent, and other peer-to-peer sharing services
  3. Connecting removable media (e.g., USB chargers, thumb-drives, etc.) of unknown origin to computers. These devices can contain malware if they were previously connected to an infected computer.
  4. Downloading scareware. Scareware is also known as rogueware and it is usually presented as Internet security software. These programs are advertised in pop-up windows that say things like “Your computer is infected!”
  5. Clicking on unknown links in emails and on websites. These links often masquerade as advertisements and phishing emails that play on the reader’s emotions. These links may say something like “You won’t believe what happened in this video” or “These people need your help!”
8. Use a secured internet connection when conducting sessions via Google Meet. Publicly available internet connections like those available in coffee shops and airports are often not secured, meaning that others can access and monitor your internet activity, including your telehealth session.
SECTION 12: FEES & GOOD FAITH ESTIMATE
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
12.1 Therapy Costs
Usually, the standard fee per 50-55 minute clinical hour is $150 when working with a Licensed Marriage and Family Therapist or Pre-Licensed Clinical Fellow. Some Institute clinicians may have a higher standard fee than $150 depending on their caseload characteristics (please note that Dr. Briggs' standard fee is $250+ per 50-55 minute clinical hour). Clients may request to use our sliding fee scale that runs from $60-$250+ per clinical hour depending on their household income and therapist caseload characteristics. When clients are referred or mandated by the courts or when clients begin therapy with the expectation that their clinical work is likely to be considered during court proceedings, the fee per 50-55 minute clinical hours is $275. Group therapy rates are variable depending on factors including group size and clinician characteristics. Regardless of the type of therapy you are receiving (individual, couple, family, group), you should have been informed about your fee when you initially made your appointment. If you are unsure what your fee is, your therapist or other Institute staff will be able to tell you. The fee given to you is for each 50-55 minute time period that you are scheduled to spend in therapy. Payment is requested at the time services are rendered and may be made with cash, check, or major credit cards (i.e., Visa, MasterCard, American Express, and/or Discover).

There are times when fees may change. Most commonly, fee changes occur when a client’s therapist moves from a pre-licensed status to a fully licensed status or when clients experience a change in income. Client fees may also change when clients exhibit a pattern of canceling sessions or not paying for sessions on time; in these circumstances, any sliding fee scale adjustments may be discontinued and fees raised to the standard fee. Normally, fee changes occur after a therapist and client have talked about them either in session or over the phone. If you have questions or concerns about fee changes, please let your therapist know.

We want our clients to have a good idea what therapy will likely cost. Clinicians normally determine a per-session fee with clients during an intake phone call prior to the first session; if clients are ever uncertain about what their session fee is, we are happy to remind them. Having an understanding of their per-session fee and average treatment duration allows clients to get a good faith estimate of treatment costs (fee x number of sessions = cost). Based on our data, estimated average total cost ranges are the following:

6 or fewer sessions cost $360-$1500 (approx. 44% of clients)

7-10 sessions cost $420-$2500 (approx. 16% of clients)

11-15 sessions cost $660-$3750 (approx. 16% of clients)

16-20 sessions cost $960-$5000 (approx. 8% of clients)

≥ 21 sessions cost a minimum of $1260 (approx. 16% of clients)

(These estimates are based on a per-session fee range of $60-$225)
12.2 Less Common Costs
Although less common, there may be additional items or services provided as part of the course of care that must be scheduled or requested separately and are not reflected in the Good Faith Estimate. The fee for report writing (psychological evaluations, treatment summaries, etc.) is identical to the client's session fee with a minimum of one hour paid in advance. The fee must be paid in full before the requested document is released. Phone conversations and other consultations are billed to the nearest quarter hour and based on the client’s session fee (e.g., 10 minute phone consultation for a client who is normally charged $150 for a session would cost $37.50). Clients and/or attorneys must pay $300 per hour for courtroom testimony by a clinician, with a minimum of three hours payable in advance, when honoring a subpoena and/or when providing testimony in court, regardless of whether or not the clinician actually testifies. If clients or someone representing our clients requests their clinical record, there is a $50 file location and/or printing fee.
12.3 Obtaining a Good Faith Estimate
Clients may ask their clinician for a Good Faith Estimate at any time. This Good Faith Estimate shows the costs of items and services that are reasonably expected for client health care needs for an item or service. The Good Faith Estimate document includes, but is not limited to, the following information:

Client name (included below)

Client date of birth (included below)

Description of the services that will be provided, in understandable language: At the Institute, these services are individual, couple, or family therapy. The CPT codes most often associated with these services are:

90832: Psychotherapy 30 minutes with patient
90834: Psychotherapy 45 minutes with patient
90837: Psychotherapy 60 minutes with patient
90846: Family psychotherapy 50 minutes without the patient present
90847: Family psychotherapy 50 minutes conjoint psychotherapy with the patient present
90849: Multiple-family group psychotherapy
90853: Group psychotherapy (other than of a multiple-family group)

Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services: In our practice, this would be the expected number of individual, couple, and family therapy sessions based on a description of the average client experience (i.e., number of sessions, fee range).

Diagnostic codes, service codes, and expected charges associated with each of those goods or services. Before the first session or prior to the completion of a biopsychosocial assessment (i.e., usually within the first three sessions), it is impossible to provide clients with a specific disorder/dysfunction diagnosis (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, etc.) on their documented good faith estimate. “Other Counseling or Consultation (V65.40)” is the diagnosis we use when clients do not meet the criteria for another diagnosis in the DSM, when clients have yet to complete their biopsychosocial assessment with their clinician, or when the primary topics discussed in treatment are not related to a specific disorder/dysfunction diagnosis met by a client.

Provider name, NPI, and tax ID number (included above)

Office location where services will be provided. This may include in-person or telehealth sessions. (included above)
12.4 Disclaimer
The Good Faith Estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider and does not include any unknown or unexpected costs that may arise during treatment. Clients could be charged more if complications or special circumstances occur. If this happens, federal law allows clients to dispute (appeal) the bill.
12.5 Right to Dispute
If clients are billed for more than their Good Faith Estimate, they have the right to dispute the bill. Clients may contact the clinician or facility listed on this document to let them know the billed charges are higher than the Good Faith Estimate. Clients can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. Clients may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

If clients choose to use the dispute resolution process, they must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee (at last check) to use the dispute process. If the agency reviewing a client dispute agrees with the client, the client will have to pay the price on this Good Faith Estimate. If the agency disagrees with the client and agrees with the health care provider or facility, the client will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call (800) 368-1019.

For questions or more information about client rights to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

Clients should keep a copy of their Good Faith Estimate in a safe place or take pictures of it. Clients may need it if they are billed a higher amount.
SECTION 13: PAYMENTS
Payments Due

You will be expected to pay for each session at the time it is held. You will not be seen by your therapist when your account is in arrears (i.e., after three sessions without payment) until you pay the balance on your account unless some prior arrangement has been made between you and your therapist. You will be required to pay the fee for scheduled sessions you do not attend for which you do not provide cancellation notice at least 24 hours prior to the session. Your card information that is stored on file with our payment processor may be charged for any session that you miss without providing at least 24 hours notice to your therapist of other Institute staff.

Third-Party Payers

The Institute does have preexisting partnerships with several organizations to provide services to their employees and/or clients. If you are associated with one of these organizations, please let your therapist know so that appropriate arrangements can be made. If you are associated with an organization that has agreed to pay for your therapy at the Institute, you will be asked to sign a Release of Information that will allow us to bill the organization for your time in therapy. Unless you specify otherwise, only the number of sessions you have attended and the amount billed for those sessions will be shared with the organization. If you do not wish to sign this release, we will not be able to bill the organization, and you will be responsible for payment.
Credit Card Authorization

Please complete all fields. You may cancel this authorization at any time by contacting us at 615-593-3999 or by sending an email to drbriggs@thebriggsinstitute.com. This authorization will remain in effect until canceled.
The Briggs Institute, Inc. has partnered with Square, a trusted payment processing platform, to manage credit card transactions. For your protection and privacy, The Institute does not store or maintain your credit card information directly. Instead, when a payment is processed, your card information is securely stored exclusively with Square, a PCI-DSS compliant processor recognized for stringent data protection standards. This approach minimizes the risk of unauthorized access to your financial information, ensuring that your card details remain confidential and safeguarded through Square’s secure systems. Please complete the authorization below to enable The Briggs Institute, Inc. to process payments on your behalf.
By selecting "I accept" below, I hereby authorize The Briggs Institute, Inc. and its designated staff to use any credit card information I provide for payment purposes. As is the case with any payment made via credit card, I understand that use and storing of my card information comes with a risk of interception or unintended disclosure of my information. Despite these risks, I consent to the use of my credit card information for payment purposes. I acknowledge that I can revoke this credit card authorization at any time by providing written notice to The Briggs Institute, Inc., understanding that revocation will not affect actions taken before receiving my notice. This authorization remains effective until revoked. My signature on this document indicates my agreement to these terms.*

I accept
SECTION 14: CONTACT INFORMATION & PROCEDURES
Due to therapists’ busy schedules, they are often not immediately available by telephone. When your therapist is unavailable, a phone message will be left for them to contact you as soon as possible. Your therapist will make every effort to return your call within 1-2 business days (this time frame may be longer around holidays, vacations, or other exigent circumstances). If you are difficult to reach, please inform the therapist of some times when you will be available. If it is an emergency, or if you are unable to reach your therapist and feel that you can’t wait for them to return your call, contact your family physician or the nearest emergency room (i.e., call 9-8-8 or 9-1-1) or call the Tennessee Office of Crisis Services and Suicide Prevention at 855-274-7471.

The only approved means for communication with therapists is via telephone, the therapist's Institute email account, or our HIPAA compliant telehealth platform. Social media, texts, and other means of communication are prohibited.
SECTION 15: EMAIL COMMUNICATIONS
At The Briggs Institute, Inc., therapist and supervisor email accounts are secured by Google according to industry standards. Google has sought and received security certifications such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits. We do ask you to please remember that there is always a risk of a breach of confidentiality whenever you share your personal information. We also want you to be aware that your email account may not be secured according to health industry standards. Therefore, please use discretion and reveal only the minimum necessary personal information when communicating via email. Email sent to therapists and supervisors at The Briggs Institute Inc. are saved and may be included in your clinical record.
SECTION 16: CLINICAL AND PROFESSIONAL RECORDS
We keep your PII in up to two sets of professional records. The first is a paper case file containing various components of your clinical record including any signed hard copy consent forms. Because most clients sign electronic copies of consent forms, only a small minority of clients have a paper case file. The second set of records that contains your PII consists of your EMR. Your case file and EMR make up your clinical record (clinically relevant emails sent to therapists and supervisors may also be included in your clinical record).

Your clinical record contains PII that may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. This clinical record is kept for seven years post treatment for adult clients and for ten years past the 18th birthday of minor clients.

Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your clinical record if you request it in writing. Therapists and supervisors at the Institute charge a fee for locating, assembling, and copying your clinical file. If you request a case file copy for personal records, the copying fee is equal to your most recent session fee. The fee for copying your clinical file for legal purposes is $300.00. If we refuse your request to obtain a copy of your clinical record, you have a right of review it, which we will discuss upon your request. In addition to your EMR, we maintain an electronic directory of your contact information and other information including your name, address, email address, ID number, the date we opened your case file, the date we closed your case file (if applicable), and whether you are currently attending therapy sessions with a therapist at the Institute. We also keep an electronic spreadsheet that records the number of therapy sessions you have received and other information including your ID number, dates of service, fees charged, fees you paid, cancellations, and missed sessions.

All PII that we store electronically is secured by our partners at Google and Jotform. Unlike free online accounts that many people are familiar with, The Briggs Institute, Inc. has established a contractual relationship with Google and Jotform that includes a business associate agreement. Our Google and Jotform accounts come with security measures and services not available in the more common, free online accounts.

A list of security and privacy controls available with Google Apps can be found on their security and privacy website. The Google Apps core services are audited using industry standards such as ISO 27001 certification and SOC 2 and SOC 3 Type II audits, which are the most widely recognized, internationally accepted independent security compliance audits. To make it easier for everyone to verify Google security, they have published their ISO 27001 certificate and new SOC3 audit report on their Google Enterprise security page.

In addition to the clinical record, your therapist may also keep a set of psychotherapy notes. These notes are for the therapist’s use and are designed to assist in providing you with the best treatment possible. While the contents of the notes vary from client to client, they can include the contents of your conversations with your therapist and his or her analysis of those conversations. Psychotherapy notes may also contain particularly sensitive information that you may reveal to the therapist that is not required to be included in your clinical record. These notes are kept separate from your clinical record and are not typically released to others. You may examine and/or receive a copy of your psychotherapy notes unless it is determined that releasing them would be harmful to your physical, mental, or emotional health.
SECTION 17: CASE FILE CLOSINGS AND DESTRUCTION OF CLINICAL AND PROFESSIONAL RECORDS
When your case files are inactive for a period of 5-weeks or more, we will close the case file. Normally, case files can be reopened at any time should you decide to return to therapy. If we are not able to reopen your case file for whatever reason (e.g., limited therapist availability), we will be happy to provide you with a referral to see another therapist. Once closed, a client case file and other PII is kept for 7 years after a client’s final session if the client is 18 years of age or older and for 10 years after the client’s 18th birthday if the client is under 18 at the time of treatment.
SECTION 18: ASSESSMENT RESULTS
It is routine for our clients and clients at similar mental health and relationship care centers to fill out assessment instruments at the request of their therapist. Assessment instruments give us information about the types of problems our clients are dealing with and help us track clients’ progress in therapy. The information you provide in an assessment instrument helps us to improve our services to the community and may also be used for marketing and research purposes. No PII (e.g., your name, initials, birthdate, etc.) is included on any marketing materials or published research. Upon your completion of an assessment instrument such as a questionnaire, your answers will be stored securely according to state and federal standards. Therefore, by filling out an assessment instrument at the Institute, you will take on a minimal risk of harm or discomfort no greater than what you would experience when filling out paperwork at your medical doctor’s office. If you have any questions or would like additional information about how we use assessment results for service and research purposes, you may ask the Institute President, Dr. Justin Briggs, by calling 615-593-3999.
SECTION 19: PARENT/GUARDIAN INFORMATION

This section only applies when a parent/guardian is completing this paperwork on behalf of a dependent client.
Are you a parent/guardian filling out this paperwork on behalf of one of your dependents (e.g., minor child)?*

YesNo (I am at least 16 years of age and consenting to my own treatment)
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Is Parent/Guardian 1 authorized to make health care related decisions for the dependent client?

YesNo
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Phone
ex. 555-555-5555
Is parent/guardian 2 authorized to make health care related decisions for the dependent client?

YesNo
Please describe any additional relevant information about those with authority to make health care decisions on the part of the dependent client (e.g., "According to the parenting plan, both parents must provide written consent for health care decisions regarding our minor child"):
If custody of the dependent client is shared across more than one household, please describe the custody arrangements (i.e., Who does the dependent client live with and when?)
Describe any visitation schedule (i.e., if applicable)

SECTION 20: CLIENT AUTHORIZATION FOR TREATMENT
I, the client, have fully read and agree to the terms outlined in this Consent Form and give consent for therapy. I have discussed any questions I had with my therapist and/or Institute staff and I understand the information in this consent. Furthermore, I understand that the Institute will abide by the above mentioned policies, procedures, and techniques in providing my treatment and training its therapists. I hereby hold harmless and release The Briggs Institute, Inc. and all of its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any treatment that I or my minor children receive as set forth in this Consent Form. However, I reserve the right to seek to collect compensation for losses, damages, claims, demands and actions related to malpractice, fault, or blame on the part of The Briggs Institute, Inc. and any of its trustees, agents and employees. I hereby give my informed consent for treatment at the Institute for myself and on behalf of any of my minor children who receive therapy services as discussed above.
SECTION 21: ELECTRONIC SIGNATURE AGREEMENT
In an attempt to expedite the verification process, The Briggs Institute, Inc. asks that you, the client, read and sign this Consent Form electronically before receiving therapy at the Institute. The electronic consent process requires all documents to be sent through your personal email account specified in this consent form.

By selecting the "I accept" button below and inserting your name, initials, email, signature, and date at the bottom of this Consent Form, you acknowledge and agree that you are signing this Consent Form electronically and agreeing to its terms and conditions. You acknowledge and agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this Consent Form.

By selecting "I accept" using any device, means or action, you consent to the legally binding terms and conditions of this Consent Form. You further acknowledge and agree that inserting your name, initials, email address, signature, and date at the bottom of this Consent Form (hereafter referred to as your "E-Signature") is as valid and legally enforceable as if you manually signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and The Briggs Institute, Inc. You acknowledge and agree that you are the client authorized to enter into this Consent Form.

By selecting the “I accept” button below, you specifically agree to receive, obtain, and/or submit any and all Institute documents and information electronically. These documents and information will be collectively known as Electronic Medical Records (“EMR”), and may include information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that the Institute receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. You acknowledge and agree that you are able to use your personal email account specified below and are able to retain electronic communications by printing and/or downloading and saving this Consent Form and any other agreements, electronic communications, documents, or records that are signed using your E-Signature. You accept such electronic communications provided via email as reasonable and proper notice for the purpose of fulfilling any and all rules and regulations, and agree that such electronic communications fully satisfy any requirement that communications be provided to you in writing or in a form that you may keep. We recommend that you print a copy of this Consent Form for future reference. You acknowledge and agree that you will keep or maintain all electronic communications records, including this Consent Form, and print or make an electronic copy of all such records.

You have the right to withdraw and revoke your consent to submit communications via your personal email at any time. By selecting “I accept” below, you acknowledge and agree that you are aware that any such revocation may delay the process of reviewing your medical record. If you wish to withdraw and revoke your consent, you must contact the Institute director, office manager, therapists, or other staff.

You are responsible for installation, maintenance, and operation of your computer, browser and software. The Briggs Institute, Inc. is not responsible for errors or failures due to any malfunction of your computer, browser or software. The Briggs Institute, Inc. is also not responsible for computer viruses or related problems associated with use of an online system. Your E-Signature indicates that you have access to the Internet, an email account capable of receiving communication from The Briggs Institute, Inc. and appropriate software to review any and all electronic communications (e.g., a .pdf reader).

You may not sign/e-sign a document or transaction at The Briggs Institute, Inc., including this Consent Form, on behalf of another individual, unless you have been granted specific, written and legal authority to do so by that individual or by a court of competent jurisdiction.

You agree to report any suspected fraudulent activities related to electronic signatures immediately to the supervisors, therapists, or staff at the Institute. You acknowledge and agree that if you falsify an electronic signature, you may be subject to appropriate civil or criminal penalties or proceedings under applicable federal and state laws.

Because of the nature of federal, state, and institutional guidelines affecting mental health and relationship care services, the information contained in this Consent Form is subject to change. You agree to indemnify, hold harmless and release The Briggs Institute, Inc. and its trustees, agents and employees from and against any and all losses, damages, claims, demands and actions arising from or related to any changes made to this Consent Form.
SECTION 21: ELECTRONIC SIGNATURE
By inserting my name, initials, email address, signature, and date below, I hereby acknowledge and agree that I have read and understood this Consent Form, am at least 16 years old and fully competent, and have executed the same as my own free will. (Parents giving consent for the treatment of any of their minor children will put their name and email information, not the minor child's name and email information, in the following "Client First Name," "Client Middle Initial," "Client Last Name," "Initials," and "Client Email Address" sections.)
By selecting “I accept” below, you acknowledge and agree all of the terms and conditions in this form, CLIENT SERVICES AGREEMENT & CONSENT TO TREATMENT*

I accept
Client First Name*
Client Middle Initial (if applicable)
Client Last Name*
Initials*
Client Email Address*
By selecting "I accept" below, I hereby authorize The Briggs Institute, Inc. and its designated staff to use my email address for communication regarding my therapy, including scheduling, appointment reminders, sending or receiving treatment-related documents, and communicating Protected Health Information (PHI) pertinent to my therapy. I understand that email communication comes with a risk of interception or unintended disclosure of my PHI. Despite these risks, I consent to the use of email for these purposes. I acknowledge that I can revoke this email authorization at any time by providing written notice to The Briggs Institute, Inc., understanding that revocation will not affect actions taken before receiving my notice. This authorization remains effective until revoked. My signature below indicates my agreement to these terms.*

I accept
Client Phone Number*
Client Street Number (e.g., 123 Main St)*
Client City*
Client State*
Client Zip*
Client Date of Birth*

MonthDayYear
Minor Child's Full Name (if applicable)
Today's Date*

MonthDayYear
Signature*

Powered by Jotform SignClear
Thank You
We want to thank you for taking the time to complete this form. Please feel welcome to contact The Briggs Institute, Inc. with any additional questions you may have. We look forward to working with you.

Please note that I (i.e., Dr. Briggs) may change the terms of the Consent Form and the changes will apply to all information I have about you. Reasons for any future changes to this form may include, but are not limited to, upgrading security protocols, improving operational efficiencies, and revising policies and procedures to reflect changes to industry standards and state and federal laws.
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SECTION A-1: INTRODUCTION

SECTION A-2: LYRA HEALTH STATEMENT OF UNDERSTANDING

SECTION A-3: MODERN HEALTH STATEMENT OF UNDERSTANDING

SECTION A-4.1: NOTICE OF PRIVACY PRACTICES

SECTION 1: PROFESSIONAL DISCLOSURE STATEMENT

SECTION 2: RISKS & BENEFITS

SECTION 3: VOLUNTARY PARTICIPATION

SECTION 4: EVIDENCE-BASED PRACTICE

SECTION 5 A: LIMITS ON CONFIDENTIALITY

SECTION 5 B: CLIENT CONFIDENTIALITY RESPONSIBILITIES AND ACCIDENTAL DISCLOSURES OF CLIENT INFORMATION

SECTION 6: ADDITIONAL LIMITS ON CONFIDENTIALITY IN RELATIONAL THERAPY AND OFF-SITE LOCATIONS

SECTION 7: MINORS & PARENTS

SECTION 8: SESSIONS

SECTION 9: TELEHEALTH & GOOGLE MEET

SECTION 10: LIMITS ON CONFIDENTIALITY FOR TELEHEALTH SESSIONS

SECTION 11: INFORMATION SECURITY CONSIDERATIONS

SECTION 12: FEES & GOOD FAITH ESTIMATE

12.1 Therapy Costs

12.2 Less Common Costs

12.3 Obtaining a Good Faith Estimate

12.4 Disclaimer

12.5 Right to Dispute

SECTION 13: PAYMENTS

Credit Card Authorization

SECTION 14: CONTACT INFORMATION & PROCEDURES

SECTION 15: EMAIL COMMUNICATIONS

SECTION 16: CLINICAL AND PROFESSIONAL RECORDS

SECTION 17: CASE FILE CLOSINGS AND DESTRUCTION OF CLINICAL AND PROFESSIONAL RECORDS

SECTION 18: ASSESSMENT RESULTS

SECTION 19: PARENT/GUARDIAN INFORMATION

SECTION 20: CLIENT AUTHORIZATION FOR TREATMENT

SECTION 21: ELECTRONIC SIGNATURE AGREEMENT

SECTION 21: ELECTRONIC SIGNATURE

Thank You