Thank you for choosing me as your therapist. This document is to inform you of my background and to explain the boundaries of our professional relationship. I am a Licensed Professional Counselor (LPC) with training in working with adults, couples, and groups. I hold a Master's Degree in Counseling from the University of Houston-Clear Lake and have been fully licensed since 2012.Goals of Therapy: Counseling is a process whereby the therapist helps you help yourself with the problems you're experiencing. Together, we assess your concerns and establish goals for counseling. I will not make decisions for you, but will facilitate you making your own. Counseling can be beneficial for most people, though it brings a risk for intense feelings (sadness, anger, fear, guilt, anxiety, etc). It is important to remember that these feelings are natural and part of the counseling process. My primary approaches to counseling are Cognitive-Behavioral Therapy and Solution Focused Therapy. Length of Counseling: Each client will have different issues to address so there is no set number of sessions you'll need to attend. We decide together how often you should attend and for how long. Most new clients start at once a week and reduce frequency as improvement occurs. Termination of counseling may occur at any time and my be initiated by either of us. If there there has been no contact with you for 90 days, your file will become inactive until and unless you choose to return, at which point your file will be reactivated.Messages: Voicemails, emails, and texts are returned as soon as possible, generally within 24 hours, though there are exceptions. If leaving a voicemail, please leave your name and number, with the reason for your call. I do not answer the phone or check emails when I'm in session and do not have administrative staff or an answering service. Please also understand I do not provide 24-hour crisis counseling. If you experience an emergency requiring immediate attention, please call 911 or go to your nearest emergency room.Appointments: Counseling sessions are by appointment only, and all sessions are via telehealth; I am not online unless I have a client scheduled. Sessions are usually 45-60 minutes. Longer or shorter sessions can be arranged as requested but may not be covered by insurance. If you're unable to attend an appointment, please give 24 hours' notice; there is a $50 fee for cancelations made the day of an appointment or for no-shows. Insurance does not cover this fee and it is assessed directly to you. If you're using EAP, sessions not canceled prior to the day of are deducted from the total number of sessions available. If you are more than 15 minutes late, the session will be rescheduled. If you're less than 15 minutes late, the session can occur but will end on time.Session fees: My standard fee for an individual therapy session $150. Sessions that are pre-arranged to be longer or shorter are pro-rated accordingly. This fee does not necessarily reflect reimbursement from insurance or EAP companies. Payments are made by credit, debit, or FSA (or similar) card.Insurance: I file with your insurance and EAP as a courtesy to you. However, you are responsible for all charges that are not paid by your insurance company. In addition, I do not pre-verify your benefits. The client is expected to know what their copay should be and what the limits of their policies are (deductibles, etc) prior to the first session. The client is also expected to update their insurance information if it changes. Furthermore, not all insurance companies will continue covering telehealth; clients should verify this coverage prior to the first session.Referrals: Should you or I believe that a referral is needed, I am happy to provide the names of other providers in the area. You will be responsible for contacting them and evaluating their fit for you and your circumstances. Records: All of our communications become part of your record; records are my property and my responsibility to maintain. Adult client records are disposed of seven years after the file is closed.Court: If you are attending therapy as a condition of a court case or to fulfill a court-related requirement, please let me know. I am not an appropriate therapist for some circumstances. I will not, nor am I qualified, to serve as an expert witness or provide testimonial services. If you or your attorney request records, please provide a signed release of information. If I receive a court order (not a subpoena) to provide records, I am legally obligated to do so even with no signed release. A $100 document preparation fee will be assessed to your account. If I am ordered to appear in court, there will be a fee of $2000 per day, plus travel expenses if applicable.Disability and Workman's Compensation Claims: As of January 1, 2018, I will not complete short term, long term, or social security disability, or Workman's Compensation claims. These forms are best completed by your primary care physician, psychiatrist, or other medical professional.
Clients are assured that confidentiality is protected by ethical practice and the laws of the State of Texas. There are few exceptions to the confidentiality rules, but some are legally mandated. In general terms, they include:
I make every effort to release only the minimum information necessary. Once this information is turned over to the relevant agency or authority, I cannot control how that information is used.I am licensed by the State of Texas and will practice ethical and evidence-based techniques of therapy. For licensure and complaint information, please contact the Texas State Board of Examiners of Professional Counselors at 1100 W. 49th St, Austin, TX, 78756-3183 or call 512-837-6658.
This notice describes how medical information about you may be used and disclosed and how you can get access to your information. Please review carefully.Your health record contains personal information about you and your health. This includes information about you that may identify you and relates to your past, present, or future physical or mental health. It is considered Protected Health Information (PHI). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Texas State Board of Examiners of Professional Counselors. It also describes your rights regarding how you may gain access to and control your PHI.I am required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice. I reserve the right to change the terms of this Notice at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. A copy of this Notice will be available upon request and is on my website. This signed copy will be included in your record.HOW I MAY USE AND DISCLOSE YOUR PHI:For treatment: PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your healthcare treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose your PHI to any other consultant only with your permission.For payment: I may use and disclose PHI so that I can receive payment for the services provided to you. This will only be done with your authorization. Examples of payment-related activities include: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary.For healthcare operations: I may use or disclose your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI to a billing or typing service, as long as we have a written contract with that provider to safeguard your PHI. For training or teaching purposes, your PHI will only be used with your consent.Required by law: Under the law, I must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating our compliance with the requirements of the Privacy Rule.Without authorization: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations. These include:
Deceased clients: I may disclose PHI regarding deceased clients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. a release of information regarding deceased clients may be limited to an executor or administrator or the estate, or the person identified as next of kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.Medical emergencies: I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this notice as soon as reasonably practical after the emergency has been resolved.Family involvement in care: I may disclose PHI to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.Health oversight: I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, or inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (ex: third-party payors based on prior consent) and peer review organizations performing utilization and quality control.Law enforcement: I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative or similar document, for the purpose of identifying a suspect, material witness, or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.Specialized government functions: I may review requests from US military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons, and to the Department of State for medical suitability determinations. I may disclose your PHI based on your written consent, mandatory disclosure laws, and the need to prevent serious harm.Public health: If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with the public health authority.Public safety: I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety or a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.Research: PHI may only be disclosed after a special approval process or with your authorization.Fundraising: We may send you fundraising communications at one time or another. You have the right to opt out of these communications.Verbal permission: I may use or disclose your PHI to people who are directly involved in your treatment with your verbal permission.With authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization:
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request to the Privacy Officer, Shana Sutcliffe.Right of access to inspect and copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set." A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.Right to amend: If you feel that the PHI is incorrect or incomplete, you may request an amendment, although I am not required to agree. If I deny the request, you have the right to file a statement of disagreement with me. I may prepare a rebuttal and I will provide you with a copy. Please contact the Privacy Officer if you have any questions.Right to an accounting of disclosures: You have the right to request an accounting of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in a 12 month period.Right to request restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or healthcare operations. I am not required to agree to the request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or healthcare operations, and the PHI pertains to a healthcare item or service that you paid for out of pocket. In that case, I am required to honor your request for restriction.Right to request confidential communication: You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for meeting your needs. I will not ask you for an explanation of why you are making the request.Breach notification: If there is a breath of unsecured PHI concerning you, I may be required to notify you of the breach, including what happened and what you can do to protect yourself.Right to a copy of this Notice: You have a right to a copy of this Notice. It is posted on my website and is included in your record.COMPLAINTSIf you believe I have violated your privacy rights, you have the right to file a complaint in writing with the Privacy Officer, Shana Sutcliffe, at firstname.lastname@example.org. You may also file a complaint in writing to the Secretary of Health and Human Services at 200 Independence Ave SW, Washington, DC 20201 or by calling 202-619-0257. I will not retaliate against you for filing a complaint.This notice is effective as of August 6, 2014.
Fill out ONLY if you intend to use insurance. Please be reminded that Shana Sutcliffe, LPC will file with your insurance as a courtesy, but client is responsible for fees if insurance denies or fails to cover services.
I, the undersigned, am either uninsured , choose not to use my insurance to cover these services, or am covered by an insurance not accepted by Shana Sutcliffe, LPC. I understand that if I become insured or want to my insurance to cover services, I will notify Shana Sutcliffe, LPC in writing, and that it will cover services going forward but not retroactively.
Appointments are reserved specifically for each client. I require notice at least 24 hours in advance if you are unable to attend. I understand that emergencies happen, and will be happy to work with you in those situations.
Payment is expected at the time of service and will be processed when billing is completed. This information will be stored in your record and will be run electronically.
HIPAA regulations and my professional Code of Ethics both require that I keep your Protected Health Information (PHI) private and secure. Email and text are convenient ways to manage administrative concerns, such as scheduling appointments, but neither are 100% secure. Some of the potential risks include misdelivery of email or text due to incorrectly typed address or phone number, "hacking" which gives a third party access to email content and addresses, and internet/phone/email providers keeping copies of communications on their servers (which then may be accessible by their employees.For these reasons, I will not discuss clinical issues (things we talk about in sessions) via text or email. If you are comfortable with email and text, and understand the risks involved, I'm happy to use those methods to address administrative concerns (scheduling, billing, etc). If you are NOT comfortable, we can address those issues over the phone or in session.I regularly delete texts and emails from clients so that they are not visible from my phone or computer, in case those devices are used by someone else. That said, both my computer and phone require a security code or pin to access them. In addition, I will not send mass emails or texts and these methods will not be used for marketing purposes. I do not add clients to my contacts, so your name will not come up if you call or text.
Teletherapy is the engagement of therapy services via video or phone communication. You have the right to decline at any time; however, as of March 2020, I am no longer offering in-person therapy services. If in-person is preferred, I will offer referrals.Teletherapy is not appropriate for all clients or all conditions for which therapy is sought. Furthermore, teletherapy, like any other form of therapy, is not always effective. If teletherapy is contraindicated, or if the therapist determines that teletherapy is not helping the client reach their goals, referrals for appropriate services will be offered.All polices outlines in the intake forms apply to teletherapy services in regards to privacy and confidentiality. Shana Sutcliffe, LPC uses a the doxy.me teletherapy platform. It is secure and HIPAA compliant, but the use of any technology has inherent vulnerabilities. In addition, I cannot guarantee confidentiality on the client's end - the client should be able to ensure that privacy is available. Certain protocols are in place in the event of an emergency or crisis situation. Emergency or crisis situations include, but are not limited to: thoughts of self harm, suicidal or homicidal ideation, having uncontrolled psychotic symptoms, being in a life-threating situation, abusing drugs or alcohol in an unsafe manner. By participating in teletherapy services, the client agrees to take the appropriate measures to ensure their safety and the safety of others. These measures include, but are not limited to: calling 911, contacting the National Suicide Prevention Lifeline (1-800-273-8255) or another crisis service, going to the nearest hospital or crisis facility. In the event of an emergency or crisis situation, the therapist may also take the above measures on behalf of the client.Teletherapy requires the use of a computer, laptop, tablet, or cell phone. The client is responsible for ensuring proper connection, a disruption-free environment, and a properly charged device. If the session time does not go the full length due to a non-connectivity, non-emergency interruption (background noise or distractions, taking another call, losing power, client choosing to pause or end session, etc) the fee for a full session will still be charged.
I am currently on several insurance and EAP panels. However, there is a plan in place ot gradually separate from those panels.
I understand the attraction to using insurance benefits and will work with all of my clients as we go through the separation process. Ample warning will be provided when a contract is set to expire. I will also have referrals available for other clinicians if a client does want to continue using insurance or EAP.