Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

Policies and Informed Consent

Your signature indicates understanding that payments will be expected at the beginning of each session. Acceptable forms of payment include Cash, Visa, MasterCard, Discover and American Express. We require a credit card on file to be charged 1) at the time of your appointment or 2)For same day cancellations and no shows (alternatively a $30 non-refundable booking fee can be applied). Cancellations that do not occur prior to 24 hours in advance will result in the FULL SESSION FEE, charged to your card on file. Additionally, outstanding balances left unpaid may be turned over to collections if payment arrangements are not reached.

Therapy Sessions will be limited to a duration of 45-53 minutes. Late arrivals will be deducted from the running clock. If you are 10 minutes late your session will be shortened by 10 minutes, etc.

Our practice is held responsible for your continuity of care; not providing confirmation to scheduled appointments 24 hours prior to the appointment may forfeit your time slot. In this same right, termination is viewed as a process which should be discussed during your termination session. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, the professional relationship must be considered discontinued via termination.

There will be a $50 fee per occurrence for the completion of all documents to be submitted for court, employees, insurance, disability leave and the like. (Please note that such documents are not completed prior to session 3 for new clients.)

This document provides consent from you as the client to contact you via email or a SMS/text message sent to your email or phone via a secure site. We are not responsible for who may see this information once it arrives on your device, computer, etc. Texts are not received via the office phone line.

Email or texts are only used to arrange or modify appointments. Please do not text/email content related to your therapy sessions, as text/email is not completely secure or confidential. If you choose to communicate by email, be aware that all emails are retained in the logs of Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails received from you and any responses sent to you become a part of your legal record. This consent also provides provision for participation in virtual sessions via a HIPAA compliant site such as doxy.me, PocketSuite, HIPPA complaint zoom, etc.

Concerns will be responded to during regular weekday business hours 8a to 5pm. You should seek the assistance of 911 for any immediate emergency needs.

Due to the nature of our group practice, notes and other documentation may be viewed by professionals on staff for concerns, transfer of cases and other needs as they arise. Conversations with the therapist are intended to be and will almost always be confidential with the exception of situations including homicidal/suicidal ideations or abuse/neglect disclosures. The therapist, by law, must report actual or suspected child or elder abuse to the appropriate authorities. In addition, the therapist has a legal responsibility to protect anyone threatened with violence, harmful or dangerousactions (including those to myself) and may break confidentiality of communication if such a situation arises. The therapist will make reasonable efforts to resolve these situations before breaking confidentiality. Your signature provides consent for an intern from an accredited college to observe and record documentation for learning and assistance in this office, of which you have the right to object.

To protect your confidentiality, if you are seen in public outside of the therapy office, the therapist will not acknowledge you or say hello. If you chose to do so, this is completely left up to you and your responsibility as to who may notice this interaction.

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

 

Intake Assessment

I hereby assign to Better Life Therapy LLC, formally Parenting and Therapeutic Services LLC all benefits payable under the terms of my insurance policy listed above. I realize that | am responsible for any expenses incurred in the collection of outstanding balances not covered by insurance be it from a collections agency or attorney. Payment is due at time of service.

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

Structure and Cost of Sessions

Your therapist agrees to provide psychotherapy for the fee of $115 per 53-minute individual, $125 per 53-minute family (2 or more persons present) session as of Feb. 1, 2024, unless otherwise negotiated by you or your insurance carrier. Sliding scale fees are agreed upon for work with Graduate Student Interns. Court related time is billed at $600 per day to clear a calendar. Phone time, preparation time, any appearances and travel time are all billed at this rate. (Professional Life Coaching sessions are $110 per 60 minute session.)

Letter writing is billed at a rate of $50 per document. Doing psychotherapy by telephone is not ideal, and needing to talk to your therapist between sessions may indicate that you need extra support. If this is the case, you and your therapist will need to explore adding sessions or developing other resources you have available to help you.

Telehealth/Virtual Services

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

• You understand that if you are having suicidal or homicidal thoughts, experiencing an acute psychosis, or in a crisis that we cannot solve remotely, we may determine that you need a higher level of care and TeleHealth services are not appropriate.
• You agree to inform your therapist of the address where you will be at the beginning of every TeleHealth session.
• Only applies to TeleHealth/virtual sessions. You agree to inform us of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency where you will typically be during a TeleHealth session Please list this hospital and contact number here:

In Case of an Emergency

If you have a mental health emergency, we encourage you not to wait for a call back, but do one or more of the following:

• Call Behavioral Health Link/GCAL: 800-715-4225
• Call Summit Ridge at 678.442.5800
• Call Lifeline at 988 or (800) 273-8255 (National Crisis Line)
• Call 911
• Go to your nearest emergency room

 

Health Insurance Portability Accountability Act (HIPAA) Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail.

The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask SO I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without authorization:

1.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 the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If youare involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.

2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.

3.If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

4. If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider. 

5. I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:

1.If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the (Georgia) Abuse Hotline. Once such a report is filed, I may be required to provide additional information.

2.If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the (Georgia) Abuse Hotline. Once such a report is filed, I may be required to provide additional information.

3.If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, appropriate family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

• For Treatment - I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
• For Payment - I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
• For Operations - I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

• Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
• Right to Confidentiality - You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
• Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
• Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advanced and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
• Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days. Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
• Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
• Right to Choose Someone to Act for You - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you beforeI take any action.
• Right to Choose - You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.
• Right to Terminate - You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
• Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.

Therapist's Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice in office during our session.

Disclosure Regarding Court

If you are involved in court, divorce or custody litigation, the therapist role is not to make recommendations to the court concerning custody or parenting issues. It is requested that you agree not to request that your therapist appear in court yetif subpoenaed to do so there will be an up front fee of $600 per day of which the therapist is made available due to clearing the schedule. In lue of court appearance the therapist is willing to provide a letter detailing your session commitment and observations noted during sessions.

Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Georgia Department of Health, or the Secretary of the U.S. Department of Health and Human Services.

 

*Updated January 2024

Better Life Therapy LLC *175 Langley Drive Suite A2 

Lawrenceville, GA 30046 *Office 678-882-7924

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.