B. Responsible Party Information:

C. Insurance Information ~Please provide insurance card~*Skip if self pay *

authorize Dr. Shannon Renard Wilkerson, LPC ACS/MindDevelopers Counseling & Supervision PC or any holder of medical information about me to release to my insurance company or its representative, any information needed concerning the examination or treatment rendered to me that is necessary to process the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to be paid directly to Dr. Shannon Renard Wilkerson LPC ACS /MindDevelopers Counseling & Supervision PC in such amount as my benefits allow. This authorization is effective until terminated in writing by the client or their guardian.

The three biggest problems in my life right now are:

authorize Dr. Shannon Wilkerson LPC/MindDevelopers Counseling & Supervision PC or any holder of medical information about me to release to my insurance company or its representative, any information needed concerning the examination or treatment rendered to me that is necessary to process the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to be paid directly to Dr. Shannon Wilkerson LPC/MindDevelopers Counseling & Supervision PC in such amount as my benefits allow. This authorization is effective until terminated in writing by the client or their guardian.

I authorize this information to be faxed to the party indicated above, and understand the limits of confidentiality which doing so creates.

MindDevelopers Counseling & Supervision PC, is committed to providing excellent mental health services to the community. Because of this, from time to time we will engage in training interns and/or newly licensed professionals. This can result in more affordable fees to those who are in need as well as the professional growth of those we train. In order to provide this opportunity, sometimes trainees are required to sit in on sessions, record/take notes of sessions or discuss the case with a fully licensed mental health supervisor. During this, none of your identifying information is ever disclosed and your confidentiality will remain of upmost regard. If you wish to participate in this training opportunity, please sign. You can opt out at any time simply through verbal or written communication.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE PROFESSIONAL SERVICES AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ON THE FOLLOWING PAGES.

Thank you so much for choosing the services that we provide. This document is designed to inform you about what you can expect from us regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to TeleMental Health. TeleMental Health is defined as follows: “TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.” (Georgia Code 135-11-.01)

TeleMental Health is a relatively new concept despite the fact that many therapists have been using technology assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. Therefore, our therapists have completed specialized training in TeleMental Health. We have also developed several policies and protective measures to assure your PHI remains confidential. These are discussed below.

In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you, typically only for purposes of setting up an appointment if needed. Additionally, your therapist may keep your phone number in his/her cell phone, but it will be listed by your initials only and his/her phone is password protected. If this is a problem, please let your therapist know, and you he/she will be glad to discuss other options. Telephone conversations (other than just setting up appointments) are billed at your therapist's hourly rate.

Text messaging is not a secure means of communication and may compromise your confidentiality. Furthermore, sometimes people misinterpret the meaning of a text message and/or the emotion behind it. Therefore, we do not utilize texting in our therapy practice,and your therapist will not respond to a text message for your protection. If you happen to send your therapist a text message by accident, you need to know that she or he is required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy. Furthermore, we will not contact you from personal cellular devices

Email is not a secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to email because it is a quick way to convey information. Nonetheless, please know that it is our policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that we are required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. Furthermore, we will not respond to any communications sent via email, but you may feel free to use our HIPAA compliant Patient Portal to have limited communication with your therapist or to send useful clinical information such as medical releases or psychological reports. We will not respond to communications that are therapeutic in nature.

We also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etcIf you are in a crisis, please do not communicate this to us via email because we may not see it in a timely matter. Instead, please see below under "Emergency Procedures."

It is our policy not to accept "friend" or "connection" requests from any current or former client on any of our therapist's personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of your relationship. However, MindDevelopers Counseling & Supervision PC has a professional Facebook page, professional Twitter page, and professional Instagram page. You are welcome to "follow" us on any of these professional pages where we post counseling information/therapeutic content. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to MindDevelopers Counseling & Supervision PC. Please refrain from making contact with us using social media messaging systems such as Facebook Messenger or Twitter. These methods have insufficient security, and we do not watch them closely. We would not want to miss an important message from you.

During the course of our treatment, your therapist may recommend that you visit certain websites for pertinent information or self-help. She or he may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that your therapist does not make these recommendations. Please let your therapist know by checking (or not checking) the appropriate box at the end of this document. 

Your communications with us will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be stored electronically with Valantmed, a secure storage company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of your PHI in a HIPAA compatible secure format using point-to-point, federally approved encryption. Additionally, your PHI will be kept on our password protected computer in an encrypted file format.

If your therapist is credentialed with and a provider for your insurance carrier, please know that we utilize a billing service who has access to your PHI. Your PHI will be securely transferred electronically to Valantmed. This billing company has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of your PHI in a HIPAA compatible secure format using point-to-point, federally approved encryption. Additionally, if your insurance provider is billed, you will generally receive correspondence from your insurance company, our billing company, or both.

We utilize Complete Merchant Solutions and Valantmed as the company that processes your credit card information. This company may send the credit card-holder a text or an email receipt indicating that you used that credit card at our facility, the date you used it, and the amount that was charged. This notification is usually set up two different ways - either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit card-holder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will also appear on your credit-card bill. The name on the charge will appear as MindDevelopers Counseling & Supervision PC.

For in and consideration of services rendered and to be rendered to will promise to pay MindDevelopers Counseling & Supervision. I understand the total charges are due when services are rendered. I agree to make available any and all insurance information to MindDevelopers Counseling & Supervision and/or billing personnel. I understand that MindDevelopers Counseling & Supervision bills from One hundred and twenty five dollars to two hundred dollars ($125-$200) for sessions lasting 45-60 minutes, based upon therapist and their licensure. I agree to provide insurance claim forms of any insurance company and/or will complete the HCFA 1500 form. I agree to assign any and all benefits to MindDevelopers Counseling & Supervision and sign in the designated areas on the insurance claim form. I agree to pay the entire deductible amount, as well as any co-payment amount due.

I understand that I am financially responsible for missed appointments, in which I do not give a 24- hour notice and that my credit card will be charged if I do not give the 24 hour notice. The fee for a missed visit (in which less than 24- hour notice is given, including weekends) is $75.00.

In addition, if my insurance company fails to pay for each date of service with in four weeks, I will be billed for the date of service. I will be provided with a super bill so you can be reimbursed by my insurance company. In this process, if payment is received after the four week date of service; I will be reimbursed by MindDevelopers Counseling & Supervision PC. By signing this agreement I completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after date of service I understand that MindDevelopers Counseling & Supervision PC will file each date of service one time and any rejection payment from my insurance company will be taken care of by me.

I understand that I am financially responsible for all charges not covered or denied by my insurance company. I understand that if I should receive payment from the insurance company by mistake, which payment was/should be assigned to MindDevelopers Counseling & Supervision PC, I will sign this payment over to MindDevelopers Counseling & Supervision PC and MindDevelopers Counseling & Supervision PC has the right to seek legal action to receive payment for this agreement, relative to payment fees, MindDevelopers Counseling & Supervision PC shall be entitled to reasonable attorney fees and cost of collection.

I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to MindDevelopers Counseling & Supervision PC.

MindDevelopers Counseling & Supervision PC does not accept checks. Please call the office to provide us with your credit card information. The card will ONLY be billed for tele-mental health services, if less than 24 hour notice is given, or on accounts that are 60 days past due.

I understand that if I request my therapist to be on-call for court attendance, MindDevelopers Counseling & Supervision bills at the rate of $60.00 per hour for on-call. I agree to provide MindDevelopers Counseling & Supervision with my credit card information in order for the payment to be charged. I understand that the hours I am requesting the therapist to be on call will immediately be charged to my credit card, and is non-refundable.

Communication with Attorneys/Other professionals/Report writing:

I understand that MindDevelopers Counseling & Supervision bills at the rate of $100.00 per hour for any type of communication with attorneys/other professionals/report writing (phone calls, letter writing, email, consultation, etc I understand that I will need to provide my credit card information prior to any communication my therapist will have with my attorney/outside professional. I understand that a minimum of 30 minute increments will be billed to my credit card and is non-refundable.

Welcome to my practice, MindDevelopers Counseling & Supervision . This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new 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 personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. 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 on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other ways, you would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between my interests and your interests, and then the client’s (your) interests might not be put first. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature. Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change. You should also know that by law and ethically I am required to keep the identity of my clients secret. As much as I may like to, for your confidentiality I will not address you in public unless you speak me first. I also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In addition, I will not accept friend requests from social networking sites such as Facebook, LinkedIn, MySpace, Tagged or any other such kind. I will only respond to emails that are in reference to your treatment. Please note that all email correspondence will become a part of your clinical record. In sum, it is the duty of your therapist to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you or your child in two sets of professional records. One set constitutes your Clinical Record. It includes information about: your reasons for seeking therapy, a description of the ways in which your or your child’s problem impacts on your life, diagnosis, the goals that we set for treatment, progress towards those goals, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself, your child, or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person (or if information is supplied to me confidentially by others), you or your legal representative may examine and /or receive a copy of your or your child’s Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I require that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you or your child with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your or your child’s therapy. They also contain particularly sensitive information that you or your child may reveal to me that is not required to be included in your Clinical Record and information supplied to me confidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you. They also cannot be sent to anyone else, including insurance companies without your written, signed authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your or your child’s record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreement; the attached notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

Clients under 18 years of age who are not emancipated, as well as their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is typically my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, 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 objections he/she may have.

Additionally, if parents are divorced, separated, share custody, etc., it is the primary parent’s responsibility to provide any and all legal documentation that shows who has access to the minors records, able to make decisions, and can schedule appointments.