Before I begin our work together, it is important that the client has all the necessary information about my professional services and business policies. This document is our working AGREEMENT that so everyone involved understands the parameters of our work together.

CONFIDENTIALITY:  the client's work with me is confidential and protected by HIPAA & state statutes. Please see the separate HIPAA document for full details.

LENGTH OF SESSION: Standard sessions are 50 minutes. Session times can vary as the length of sessions can depend on what the client needs. Times and payment will be discussed prior to the client's appointment.

PART I: THERAPEUTIC PROCESS

POTENTIAL BENEFITS/OUTCOMES: The therapeutic process seeks to meet goals established by all persons involved, usually revolving around specific complaint(s).  Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships.  The therapeutic process may reduce distress, enhance stress management, and increase one’s ability to cope with problems related to work, family, personal, relational, etc. Participating in therapy can lead to greater understanding of personal and relational goals and values.  This can increase relational harmony and lead to greater happiness.  Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided.  There can be no guarantees made regarding the ultimate outcome of therapy.

EXPECTATIONS: In order for clients to reach their therapeutic goals, it is essential they complete tasks assigned between sessions.  Therapy is not a quick fix.  It takes time and effort, and therefore, may move slower than expectations.  During the therapy process, we identify goals, review progress, and modify the treatment plan as needed.

POTENTIAL RISKS: In working to achieve therapeutic benefits, clients must take action to achieve desired results.  Although change is inevitable, it can be uncomfortable at times.  Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions.  Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended.  We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.

STRUCTURE OF THERAPY

1. Intake - During the first session, therapeutic processes, structures, policies and procedures will be discussed.  I may request to meet with the client or the client's guardians, either together or individually, as part of this process to better understand experiences surrounding the presenting problem(s).
2. Assessment - The initial evaluation may last 2-4 sessions.  During this assessment phase, I will be getting to know the client.  I will ask questions to gain an understanding of the client's worldview, strengths, concerns, needs, relationship dynamics, etc.  During this relationship building process, I will be gathering a lot of information to aid in the therapeutic approach best suited for the client's needs and goals.  If it is determined that I am not the best fit for the client's therapeutic needs, I will provide referrals for more appropriate treatment.
3. Goal Development/Treatment Planning - After gathering background information, we will collaboratively identify therapeutic goals.  If therapy is court ordered, goals will encompass the client's goals and court ordered treatment goals, based on documentation from the court.  Once each goal is reached, I will sign off and update the treatment plan.
4. Intervention - This phase occurs anywhere from session two until graduation/discharge/termination.  Each client must actively participate in therapy sessions, utilize solutions discussed, and complete assignments between sessions.  Progress will be reviewed and goals adjusted as needed.
5. Discharge/Termination - As clients progress and get closer to completing goals, we will collaboratively discuss a transition plan for discharge/termination. The appropriate length of the termination process depends on the length and intensity of the treatment. I may terminate treatment following an appropriate discussion and termination process if I determine that the psychotherapy is not being effectively used or the client is in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and the purpose. If therapy is terminated for any reason or the client requests another therapist, I will provide the client with a list of qualified providers upon request. The client may also choose someone on their own from another referral source of the clientr choosing.

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for 50 minutes depending upon the nature of the presenting challenges.  It is difficult to initially predict how many sessions will be needed.  We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.

ANTI-DISCRIMINATION POLICY: The clinician has a policy and/or process in place to ensure that members are not discriminated against in the delivery of healthcare services based on race, ethnicity, national origin, religion, sex, age, sexual orientation, mental/physical disability or medical condition, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information or source of payment.

PART II: PROFESSIONAL FEES & PAYMENTS

Session Fee: My standard fee for each 50-minute session is $350.00. All new clients must be seen for a 90-minute intake assessment. My standard fee for each 90-minute intake assessment is $650.00.

Payment of agreed upon fees are due at time of appointment/service. Acceptable forms of payment are: exact-amount credit/debit card, vemno, paypal, or check. If a check is returned there will be a charge equivalent to what the bank charges Jennie Chung, LCSW-R.  In the event that a scheduled appointment time is missed or cancelled less than 24 hours in advance, the “Cancellation Policy” will apply.

Jennie Chung, LCSW-R has the right to increase the fee at any time, though not typically more thanonce per year.

A. HEALTH INSURANCE: By using insurance, I am required to give a mental health disorder diagnosis that goes into the client's medical record.  The clinical diagnosis is based on the client's current symptoms even though the client may have been previously diagnosed.  The client's insurance company will know the times and dates of services provided.  They may request further information to authorize additional services regarding treatment. In electing to use insurance benefits, the client agree to the release of the client's clinical information, including, but not limited to: dates of service, diagnoses, treatment plans and outcome should they be requested by the clientr insurance provider. Signing this document gives me permission to release to the clientr insurer (via Headway.co or directly) the information needed to obtain payment for my services.

• Insurance & Copays: The client's co-payment is expected at the time of service. I will bill the client's insurance company for the balance (via Headway.co or directly). For those insurances I do not accept, I am glad to give the client an insurance acceptable receipt for fees paid, also referred to as a Superbill. In accordance with HIPAA we will discuss any diagnosis that is required for the client to get reimbursed by the clientr insurance carrier.
• Pre-Authorization: When sessions are authorized, usually only a few sessions are granted at a time.  When these sessions are complete, we may need to justify the need for continued service, potentially causing a delay in treatment.  If insurance is requesting information for continued services, confidentiality cannot be guaranteed.  Sometimes, additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not met.
• Billing: It is important for the client to understand that I may utilize the services of a third-party platform (Headway.co) to manage billing and insurance verification. By agreeing to work with Jennie Chung, LCSW and consenting to the use of my professional services, the client is also agreeing to providing the necessary demographic, insurance, and financial information to Headway.co. required for billing and insurance purposes.
• Insurance Audits: Insurance companies can perform what is called an “audit” on my notes to determine whether the client's diagnosis, symptoms, and treatment meet the conditions of “medical necessity” or accepted standards of medical practice. (For a full definition of medical necessity, please see this link: https://definitions.uslegal.com/m/medical-necessity/.) If the client's symptoms do not meet criteria, the insurance company can deny or limit the client's coverage. I make every effort to document our work together to meet the standards of medical necessity. However, some people simply do not have the symptoms necessary for a clinical diagnosis. This does not mean that therapy is unwarranted. It simply means that a diagnosis cannot be ethically applied to the client's problem and thus, not covered by insurance. If coverage is denied, the client will be responsible for the cost and need to decide whether the client want to proceed with treatment.

Clients are responsible for using their insurance in any way that serves the client. It typically provides some coverage for mental health treatment. It is very important that the client find out exactly what mental health services the client's insurance policy covers; the client's copay, the client's deductible, if the client has met it, and if not, how much is left. Clients agree that the they are 100% responsible for any payment not made by the clientr insurance company.

POTENTIAL NEGATIVE IMPACTS OF A DIAGNOSIS: Insurance companies require clinicians to give a mental health diagnosis (i.e., “major depression” or “obsessive-compulsive disorder”) for reimbursement.  Psychiatric diagnoses may negatively impact the client in the following ways:

1. Denial of insurance when applying for disability or life insurance;
2. Company (mis)control of information when claims are processed;
3. Loss of confidentiality due to the increased number of persons handling claims;
4. Loss of employment and/or repercussions of a diagnosis in situations where the client may be required to reveal a mental health disorder diagnosis on the clientr record.  This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits;
5. A psychiatric diagnosis can be brought into a court case (i.e.: divorce court, family law, criminal, etc.).

It is important that clients are informed consumers.  This allows the client to take charge regarding the your health and medical record.  At times, having a diagnosis can be helpful (i.e.: child needing extra services in the school system or a person being able to receive disability).

Additional Insurance Information: Your contract with the your health insurance company requires that I provide it with information relevant to the services I provide, which includes a clinical diagnosis. Sometimes I am required to furnish additional clinical information such as treatment plans or summaries, progress notes, or copies of the clientr clinical record. I make every effort to release only the minimum information that is necessary for the purpose requested. This information will become part of the insurance company files and will be stored in my password protected computer and encrypted online EHR System. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. It is important to remember that the client always have the right to pay for my services the clientrself to avoid the problems described above.

Additional Fees: If additional reports or meetings not covered by the insurance company are needed, the client agree to pay Jennie Chung, LCSW-R for the time it takes to write these reports and/or attend these meetings. Reports that would incur a fee would be for but not limited to: a disability claim, Workman’s Compensation, a review of treatment for an attorney. Meetings that would incur a fee are, but not limited to: attending an IEP meeting, speaking with an attorney and testifying at court. If I am needed for court, fees may include time lost for cancelled sessions, time for preparation, travel, or waiting, even if the need for testimony is cancelled.

CANCELLATION POLICY
The client is responsible for attending each appointment and agree to adhere to the following policy: ***If the client cannot keep the scheduled appointment, the client MUST provide notification to cancel or reschedule the appointment within 24 hrs of the scheduled appointment time.  If the client cancel or rescheduled more than once, we may re-evaluate the client's needs, desires, and motivations for treatment. The client will be responsible for the full session charge/fee for any late cancellations and/or no shows. ***This is necessary because a time commitment is made for the client and is held exclusively for the client. If the client are late for a session, the client may lose some of that session time.

EXCESSIVE CANCELLATIONS: The clinician reserves the right to terminate the counseling relationship if more than 2 sessions are missed without proper notification. Should the client fail to schedule an appointment for two consecutive weeks (unless other arrangements have been made in advance), for legal and ethical reasons, I must consider the professional relationship to be discontinued and services will be terminated. The client will be informed by letter/email.

LATENESS: If the client is running late for the appointment, please phone or email me as soon as the possible to let me know the client intends to be late. If I do not hear from the client by 20 minutes into the session, it will be assumed that the client does not plan to attend the session and the cancellation policy will apply. If the client is late for the session, we will still end at our regular time.

PART III: AVAILABILITY/EMERGENCIES

Voicemail is available 24 hours a day.  I return calls as soon as able. It is helpful if the client gives me several alternate times to call the client back.  I do not have 24-hour coverage and if the client need such coverage, we will need to decide how to handle it. In case of an emergency please go to the client's local emergency hospital or call 911.

1. Phone: I am glad to answer occasional short calls (5-10 minutes) in between sessions.  If more time is required to handle a difficulty that has arisen, I am glad to do so. The time will be billed at my full fee, in 15-minute increments starting from the time the call began.
2. Text/SMS: Clients often use text as a convenient way to communicate in their personal lives.  However, texting introduces unique challenges into the therapist–client relationship.  Texting is not a substitute for sessions.  Texting is not confidential.  Phones can be lost or stolen.  DO NOT communicate sensitive information over text.  The identity of the person texting is unknown as someone else may have possession of the client’s phone.
3. Email: E-mail is not a substitute for sessions.  If the client need to be seen, please call to book an appointment.  E-mail is not confidential.  Do not communicate sensitive medical or mental health information via email.  Furthermore, if the client send email from a work computer, the clientr employer has the legal right to read it.  E-mails are considered a part of the client's medical record.

Because phone, email, and text messaging are not secure, I prefer that the client use them primarily to arrange or modify appointments, or to let me know the client are running late. Utilization of these modes of communication are at the client's own risk.

I check voicemail, emails, and texts regularly during the day and much less frequently on the weekend.

I am available Monday through Friday, but I will not answer the phone when I am with a client. When I am unavailable, my telephone goes to voice mail. I will make every effort to return the client's call within 24 hours, with the exception of weekends and holidays. In an emergency, if the client is unable to reach me and feel that they can’t wait for a return call, contact the your physician or the nearest emergency room and ask for the psychotherapist or psychiatrist on call.

Vacation, Sick Time, Jury Duty: If I will be unavailable for an extended period of time, I will provide the client with notification, and if necessary, the name of a colleague to contact.

PART IV: CONFIDENTIALITY

Anything said in therapy is confidential and may not be revealed to a third party without written authorization, except for the following limitations:

• Child Abuse: Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc.  If the client reveals information about child abuse or child neglect, I am required by law to report this to the appropriate authority.
• Vulnerable Adult Abuse: Vulnerable adult abuse or neglect.  If information is revealed about vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.
• Self-Harm: Threats, plans or attempts to harm oneself.  I am permitted to take steps to protect the client’s safety, which may include disclosure of confidential information.
• Harm to Others: Threats regarding harm to another person.  If the client threatens significant bodily harm or death to another person, I am required by law to report this to the appropriate authority.
• Court Orders & Legal Issued Subpoenas: If I receive a subpoena for the client's records, I will contact the client so the client may take whatever steps the client deem necessary to prevent the release of the their confidential information.  I will contact the client twice by phone.  If I cannot get in touch with the client by phone, I will send the client written/electronic correspondence.  If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order.  Despite any attempts to contact the client and keep the client's records confidential, I am required to comply with a court order.
• Law Enforcement and Public Health: A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability; to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or action; limited information (such as name, address DOB, dates of treatment, etc.) to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; and information that the clientr clinician believes in good faith establishes that a crime has been committed on the premises.
• Governmental Oversight Activities: To an appropriate agency information directly relating to the receipt of health care, claim for public benefits related to mental health, or qualification for, or receipt of, public benefits or services when the client's mental health is integral to the claim for benefits or services, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
• Upon the Client's Death: To a law enforcement official for the purpose of alerting of the client's death if the there is a suspicion that such death may have resulted from criminal conduct; to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
• Victim of a Crime: Limited information, in response to a law enforcement official's request for information about an the client if the client are suspected to be a victim of a crime; however, except in limited circumstances, we will attempt to get the client's permission to release information first.
• Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services.  I will discuss the information and/or documentation with the client in session prior to sending it to the court.
• Written Request: Clients must sign a release of information form before any information may be sent to a third party.  A summary of visits may be given in lieu of actual “psychotherapy/process notes”, except if the third party is part of the medical team.  If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.
• Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the necessary documentation (i.e., the clientr signature on the “Therapy Consent & Agreement” that covers the cancellation policy to the clientr bank or credit card company should a dispute of a charge occur.  If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted.
• Couples Counseling & “No Secret” Policy: When working with couples, all laws of confidentiality exist.  I request that neither partner attempt to triangulate me into keeping a “secret” that is detrimental to couple’s therapy goal.  If one partner requests that I keep a “secret” in confidence, I may choose to end the therapeutic relationship and give referrals for other therapists as our work and the client's goals then become counter-productive.  However, if one party requests a copy of couples or family therapy records in which they participated, an authorization from each participant (or their representatives and/or guardians) in the sessions before the records can be released.
• Dual Relationships & Public: Our relationship is strictly professional.  In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship).  If we run into each other in a public setting, I will not acknowledge the client as this would jeopardize confidentiality.  If the client were to acknowledge me, the client's confidentiality could be at risk.
• Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients.  If the client chooses to comment on our professional social media pages or posts, the client may do so at the client's own risk and may breach confidentiality.  I cannot be held liable if someone identifies the client as a client.  Posts and information on social media are meant to be educational and should not replace therapy.  Please do not contact me through any social media site or platform.  These platforms are not confidential, nor are they monitored, and may become part of medical record.
• Sessions Outside the Office: From time to time, clients like to meet in an alternate location (i.e., their home, in public, or somewhere more conducive for them).  We may be able to accommodate this request, however, this can put the client's confidentiality at risk.
• Additional Disclosures: I may find it helpful to consult other health and mental health professionals about the client's case. During a consultation, I make every effort to protect the client's identity. The other professionals are also legally bound to keep the information confidential.  Consultations are noted in the client's Clinical Record (PHI) to protect the privacy of the client's information.

PART V: PROFESSIONAL RECORDS

My professional standards and ethics require that I keep a record of our work together. These records are organized into two separate sections as follows.

The Clinical or Medical Record: This Protected Health Information (PHI) includes information about the client's reasons for seeking therapy, a description of the ways in which the client's problem impacts on the client's life, the client's diagnosis, the goals that we set for treatment, the client's progress towards those goals, the client's medical and social history, the client's treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, the clientr billing records, and any reports that have been sent to anyone, including reports to the client's insurance carrier.  Upon written request the client may examine and/or receive a copy of the their Clinical Record, unless I believe that access would be harmful to the client. In those situations, the client have a right to a summary and to have the client record sent to another mental health provider or the client's attorney. In most situations I am allowed to charge a copying fee of $1.00 per page, and I may charge for certain other associated expenses. If I refuse the client's request for access to records, the client has a right of review, which I will discuss with the client upon the client's request. The client's records are stored for 7 years from the date of the record.

Psychotherapy Notes: Another section of the client's PHI consists of my Psychotherapy Notes. These are designed to assist me in providing the client with the best possible treatment.  Psychotherapy Notes vary from patient to patient, and can include the contents of our conversations, my analysis of those conversations, and how they impact the client's therapy. While insurance companies, attorneys, etc. can request and receive a copy of the client's Clinical or Medical Record, they cannot receive a copy of the client's Psychotherapy Notes without the client's signed, written authorization. The one exception is if a judge demands them. Insurance companies cannot require the client's authorization as a condition of coverage nor penalize the client in any way for the client's refusal. the client may examine and/or receive a copy of the client's Psychotherapy Notes unless I determine that it would adversely affect the client's well-being, in which case the client has a right to a summary and to have the client's record sent to another mental health provider or the client's attorney. Again, I am allowed to charge a copying fee of $1.00 per page. 

Should I be required to provide the insurance company with the client's PHI, I make every effort to release only the minimum information that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank.  It is important to remember that the client always have the right to pay for my services the clientrself to avoid the problems described above.

Unexpected Therapist Absence: In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for an Executor to inform the client of my status and ensure the client's continued care in accordance with the client's needs. Please let me know if the client would like the names of my Executor and Secondary Executor. By signing below, clients authorize the Executor and Secondary Executor to access the client's treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.

PART VI: MINORS & PARENTS

Patients under 18 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the patient and his/her/their treatment. I typically provide parents with general information about the progress of the child’s treatment. If I feel that the child is in danger or is a danger to someone else, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any concerns he/she/they may have. A minor’s records are stored until the minor is 21 years of age.

PART VII: TERMINATION OF SERVICES

Ending therapy can be a very empowering process whether terminating because the client have reached the client's goals, are moving, or are unhappy with our work. Planning for the end of therapy and having a final session is ideal. We discuss what worked, what didn’t work, what the client accomplished and what work may be left. Email, texts and voice mail are not an appropriate way to terminate services. Signing this agreement means the client agrees to a termination session.

 

Telehealth involves the use of interactive technologies which enable practitioners at different locations to deliver behavioral health services/psychotherapy or share individual patient medical information for the purposes of improving care. Interactive Technologies, or services by electronic means, include telephone communication, the internet, facsimile machines and e-mail. If you and your therapist choose to use Telehealth for some or all of your treatment, you need to understand that:

1. You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. 
2. All existing confidentiality protections are equally applicable.
3. There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.

PRIVACY & CONFIDENTIALITY: The laws that protect the confidentiality of your protected health information (PHI) also apply to Telehealth services unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; mental/emotional health as an issue in a legal proceeding)

1. You understand that there are potential risks and consequences associated with Telehealth, including but not limited to: the disruption of transmissions by technology failures, technical difficulties inherent with communication systems, interruption and/or unauthorized access (breach of confidentiality) by unauthorized persons, and/or limited ability to respond to emergencies.
2. You understand that you have a responsibility to maintain session privacy on your end (e.g., physical space free from distraction and interruption, updated security measures on my device).
3. To maintain confidentiality, you will not share your Telehealth appointment link with anyone unauthorized to attend the appointment.

APPOINTMENT LOGISTICS/CONSIDERATIONS: When I provide phone/video-counseling sessions, I will call you at our scheduled time or send you a link for our secure and HIPAA compliant video session. I expect that you are available at our scheduled time and are prepared, focused and engaged in the session. I am calling you from a private location where I am the only person in the room. You are also expected to be a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be a in a place where there are people or others can hear you, I cannot be responsible for protecting your confidentiality. Every effort must be made on your part to protect your own confidentiality. I suggest you wear a headset to increase confidentiality and also increase the sound quality of our sessions. Please know that I cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally. Please assure you reduce all possibilities of interruption for the duration of our scheduled appointment.

Please know that I am only licensed to practice/provide Telehealth in the State of New York. This means you must physically be in the State of New York at the time services are being rendered. If your location has changed or if you have relocated you must inform me.

USE OF TECHNOLOGY

1. You understand that you will need to have access to, and have familiarity with, the appropriate technology in order to participate in Telehealth Services. This may include downloading an application and/or software to use the platform as well as audio/video and Internet services.
2. You understand that you are responsible for any connectivity charges.
3. You understand that you or your provider may discontinue the session if it is felt that the connection and/or environment are not adequate for effective therapy.
4. If video services are not available due to an unplanned equipment or service malfunction, you understand that sessions will occur via telephone. In the event of a disruption in video service, I will contact you using the primary/preferred telephone number on record.

CONNECTION LOSS (Video Sessions): If we lose our connection during a video session, I will call you to troubleshoot the reason connection was lost. If your I cannot reach you, I will remain available to you for the remainder of the scheduled session. If you are able to contact me back and there is time left in your session we will continue. If the reason for a connection loss i.e., technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on my end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session.

CONNECTION LOSS (Phone Sessions): If we lose our phone connection during our session, I will call you back immediately. I will attempt to call you 3 times. You should also attempt to call me at (917) 405-4070. Should we be able to reestablish contact and there is time left in your session we will continue as time permits. If the reason for a connection loss (i.e., technology, your phone battery dying, bad reception, etc.) occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on my end, I will call you from an alternate number. The number may show up as restricted or blocked, please be sure to answer.

RECORDING OF SESSIONS: You understand that recording (audio or video), screenshots, etc. of any kind of any portion of any session of the Telehealth session is not permitted and is grounds for termination of the client-therapist relationship.

PAYMENT FOR SERVICES
You understand that Jennie Chung, LCSW-R utilizes the Stripe for credit card billing.

1. You agree to pay Jennie Chung, LCSW-R for services rendered and authorize Jennie Chung-LCSW-R to submit for reimbursement from my insurance company. I understand that Jennie Chung, LCSW-R is not able to guarantee that your insurance plan will pay for Telehealth Services. If your insurance does not pay, you will be responsible for the payment.
2. You authorize the use and disclosure of your personal health information (PHI) for the purposes of obtaining payment for your care. This includes minimally necessary information for the filing of insurance claims. You authorize direct payment/assignment of insurance benefits to Jennie Chung, LCSW-R.
3. You understand that payment is expected at the time of service or when a balance due is presented on my monthly statement. You understand that if your account becomes overdue, services may be discontinued and you may face collection action.
4. You understand that you will be charged for sessions in excess of 16 minutes, even if the session is terminated early due to service interruption and/or technology.

CANCELLATION/LATENESS POLICY: If you must cancel or reschedule an appointment, 24-hours’ advanced notice is required, otherwise you will be held financially responsible. Should you miss or cancel an appointment with notification less than 24 hours’ advanced notice, this will result in you being charged the full session fee for your missed appointment. Cancellations may be communicated by phone or email; NOT text message. If you have more than 2 cancellations during the course of treatment/therapy, we will address the need for on-going therapy. Should you express the desire to continue you may be asked to pre-pay for sessions when they are scheduled. If you cancel or miss a session with less than 24 hours’ notice and the session is pre-paid, this follows the cancellation guidelines and the payment will not be reimbursed/refunded for the missed or canceled session. Phone/video sessions should be treated as regular in-office sessions. If you are late getting on the phone, are unable to talk at our scheduled time, your battery has died, are unable to access a confidential place to talk, or any other variable that would prevent you from attending our appointment please know that you will be charged for the session. Please make the necessary arrangements you need to be available and present for your session.

Standard sessions are 50 minutes in duration, unless otherwise indicated.

 

I am strongly committed to respecting the basic human rights, worth and dignity of each person receiving services. In addition, you have legal rights which are guaranteed by the constitution, state/federal laws and regulations. You also have responsibilities regarding your treatment. These rights and responsibilities include:

The Right to Confidentiality
The right to confidentiality of all records and communications, as provided by Federal law with a few exceptions:

• If I suspect child or elder abuse is suspected.
• If I suspect you may harm yourself or someone else.
• If I receive a court order.
• If you enter into litigation against me.
• If you have an outstanding bill, I can use a collection agency.
• If the client is a minor, I may discuss aspects of the client’s care with the client’s parents or legal guardians.
• If I seek consultation with another professional about your case.

The Right to Treatment

• The right to have all reasonable requests responded to promptly and adequately.
• The right to ask for, and obtain a copy of all rules and policies which apply to clients.
• The right and responsibility to choose a therapist and mode of treatment that meet your needs.
  The modalities I use include but are not limited to: Internal Family Systems, CBT, Mindfulness, and other Trauma-Informed Practices.
• The right to ask questions about my training, therapeutic approach, and progress of treatment.
• The right to be informed, when treatment begins, of expected results and/or side effects of treatment.
• The right to refuse treatment, unless court ordered.
• The right to life-saving treatment.
• The right to refuse to be a research subject.
• The right to adequate care or to be referred to another provider.
• The right to request the name and specialty of any person responsible for care or coordination of care.
• The right to revoke your authorization, in writing, to release or discuss your medical record except when action has already been taken.

The Right to Informed Consent

• The right and responsibility to participate in developing a treatment plan with your therapist.
• The right to receive and read a copy of your medical record, as long as doing so causes no harm.
• The right to maintain HIV status as confidential unless you provide written consent.
• The right to receive an itemized bill, including third party reimbursement paid toward the bill.

The Right of Protection from Mistreatment

• The right to be treated in a manner which is ethical and free from abuse, discrimination and/or exploitation, meaning no romantic or sexual relationship, and your story will not be turned into a movie, book or TV show.
• The right to know that the therapeutic relationship will not be leveraged in an inappropriate manner or develop into a dual relationship.
• The right to be treated with respect no matter your culture, gender, sexual orientation, sexual preference, ability, and religion.

The Right to File a Complaint
If you are concerned about your clinical care and client rights, please speak with me in session or contact me in writing. You may also file a complaint with your State Department of health and my licensing board.

Client Responsibilities

• To keep your schedule appointments and let me know if you cannot keep it by giving 24 hours’ notice.
• To be as honest and as open as possible.
• To think through any insights or concerns you are addressing between sessions.
• To follow through on treatment recommendations and complete any homework agreed upon during session.
• To have a termination session rather than not keeping your last appointment.
• To call 911 or go to your nearest emergency department if you feel you are in danger of harming yourself and then to inform me.

If you have any questions or concerns about your rights and responsibilities, I invite you to please bring them up in session.

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 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 otherwise.

OVERVIEW
I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

PROFESSIONAL RECORD-KEEPING: The laws and standards of my profession require that I keep treatment records. You are entitled to view your records unless I believe that seeing them would be emotionally damaging, in which case I can provide a summary of the records instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them, or the summary I provide, with me or with a licensed mental health professional of your choice.

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:

A. Certain uses and disclosures relating to treatment, payment, or health care operations do not require your prior written consent. I can use and disclose your PHI without your consent for the following reasons:

1. For treatment: I can disclose your PHI to physicians, psychiatrists, psychologists, or any other licensed health care providers who provide you with health care services or are involved in your care. For example, if you're being treated by a psychiatrist, I can disclose your PHI to your psychiatrist in order to coordinate your care.
2. To facilitate payment for treatment: I can use and disclose your PHI to bill for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan regarding the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my healthcare claims.
3. For health care operations: I can disclose your PHI to operate my practice. I may provide your PHI to our accountants, attorneys, consultants, and others to make sure I am complying with applicable laws
4. Other disclosures: I may also disclose your PHI to others without your consent in certain situations. For example, your consent isn't required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so

B. There are additional uses and disclosures that do not require your consent. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state or local law; judicial or administrative proceedings; or, law enforcement: 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. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
2. Lawsuits and Disputes: 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.  Some circumstances may require that I disclose health information in response to a court or administrative order. If you are involved in a lawsuit, I may also be requested disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 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. I If you are 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.
3. For public health activities: For example, I may have to report information about you to the county coroner.
4. For health oversight activities: For example, I may have to provide information to assist the government when it conducts an investigation or inspection of a healthcare provider or organization.
5. For research purposes: In certain circumstances, I may provide PHI in order to conduct medical research.
6. For specific government functions: I may disclose PHI of military personnel and veterans in certain situations. And I may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
7. For workers' compensation purposes: 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.
8. Appointment reminders and health related benefits or services: I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer.
9. Supervision and/or Consultations: 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.
10. To avoid harm: In order to avoid a serious threat to the health or safety of a person or the public, I may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

C. 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 New York State Central Registry.  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 New York State Central Registry.  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, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

D. Certain uses and disclosures require you to have the opportunity to object. Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

E. Other uses and disclosures require your prior written authorization. In any other situation not described in sections A, B, C, and D above, I will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action relying on such authorization) of your PHI by me.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION 
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a.) For my use in treating you.

b.) For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c.) For my use in defending myself in legal proceedings instituted by you.

d.) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e.) Required by law and the use or disclosure is limited to the requirements of such law.

f.) Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g.) Required by a coroner who is performing duties authorized by law.

h.) Required to help avert a serious threat to the health and safety of others.

i.) As a mental health provider, I will not use or disclose your PHI for marketing purposes.

j.) As a mental health provider, I will not sell your PHI in the regular course of my business.

CLIENT RIGHTS & THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

1. 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.
2. For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
3. 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.

Patient's Rights

1. 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.
2. 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.
3. 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.
4. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of your PHI by alternative means and at alternative locations.
5. Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of your 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 advance 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.
6. 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.
7. 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.
8. 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.
9. 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 before I take any action.
10. 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.
11. 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.
12. 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 your PHI and to provide you with a notice of my legal duties and privacy practices with respect to your 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.

COMPLAINTS: If you think that I may have violated your privacy rights, or you disagree with a decision I made about access to your PHI, you may file a complaint with the person listed below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. I will take no retaliatory action against you if you file a complaint about my privacy practices.

Who to contact for information about this Notice or to complain about my privacy practices: If you have any questions about this Notice or any complaints about my privacy practices or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me.

 

Jennie Chung, LCSW-R offers clients the opportunity to communicate via email or text message if they choose. However, although every effort is made to ensure confidentiality, transmitting information electronically, by phone, email or text message is not secure. This form provides information about these risks as well as guidelines for communicating via phone, email or text.

POTENTIAL RISKS OF ELECTRONIC COMMUNICATION

• Senders can misaddress/misdial a number, email or text message which can be received by unintended recipients.
• Email and voice or text messages can be recirculated, forwarded or stored in electronic files.
• Backup copies of emails or texts may exist even after the sender or recipient has deleted his/her copy.
• Email can be used to introduce viruses into computer systems.
• The sender may assume that a message was sent or voice messages were received when they were not.
• There is a possibility of misinterpretation of the message due to nonverbal feedback.
• Email and text messages can be lost in transmission.

POTENTIAL COSTS OF TEXT MESSAGING

• Phone users may incur fees for each message they receive.
• Message & data rates may apply to your communications.

HOW WILL ELECTRONIC COMMUNICATION BE USED?
In general, electronic communication with you will only be initiated to discuss non-sensitive issues such as:

• Appointment reminders
• Scheduling, canceling, rescheduling appointments
• Provision of routine forms
• Benefit information

CONSIDERATIONS FOR EMAIL USE

• You are responsible for protecting your own device, your password, or other means of access. Jennie Chung, LCSW-R is not liable for breaches of confidentiality caused by a client or other third party.
• Clients are responsible for taking precautions to protect the confidentiality of messages, for example, password protecting your phone or computer.
• It is the responsibility of the client to inform Jennie Chung, LCSW-R, of changes to your email, phone, address, etc.
• Clients should be mindful that emails and voice/text messages are legally considered part of your medical/clinical record.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand the risks as outlined above and consent to the conditions outlined above. I further waive any and all claims that may arise against Jennie Chung, LCSW-R from the use or misuse of phone calls, text messaging, email and/or any other form of electronic communication.

1. I understand that Jennie Chung, LCSW-R cannot guarantee absolute security/ confidentiality of electronic communications, including phone, email and text messaging.
2. I release and hold harmless Jennie Chung, LCSW-R from any and all expenses, claims, liabilities damages and losses that may result from email or phone/text communication between myself and Jennie Chung, LCSW-R including technical failures beyond reasonable control such as system crashes, power outages, and network overloads.
3. I understand that I may also communicate with Jennie Chung, LCSW-R via my secure patient portal or during my scheduled appointment time, and that phone, email or texting is not a substitute for care that may be provided during a scheduled session. Appointments should be made to discuss any new issues or sensitive information.
4. I understand that either Jennie Chung, LCSW-R or myself may stop using phone, email or texting as a means of communication.
5. I understand that I may revoke this consent at any time by advising Jennie Chung, LCSW-R in writing. My revocation of consent will not affect by ability to obtain future care, nor will it cause the loss of any benefits to which I am otherwise entitled.
6. I understand that failure to comply with the guidelines delineated in this form may result in termination of any phone, email or texting relationship.