Synchrosaic LLC
P.O. Box 345 Richmond, VT 05477
Phone: (802) 922-1612
https://www.synchrosaic.com 

WELCOME AND INFORMATION ABOUT SYNCHROSAIC LLC

Welcome to Synchrosaic LLC, an independent group of mental health clinicians who work in collaboration with Essex Pediatrics to provide you, your child, and/or your family with mental health services and support. All services provided by your clinician are billed by Synchrosaic

Please complete the following intake paperwork in its entirety prior to your first appointment:

• Release of Information
• Policies
• Intake Information
• Informed Consent
• Telehealth Consent Form

Included in this intake packet is information about your clinician. Please review this disclosure SO that you know about your clinician, their background, training, and the best way to contact them in between sessions.

You will also find the "Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information" and, "Preparing for Your Telehealth Appointment". Please review these prior to your appointment.

Your clinician will be happy to review any and all of this information with you at your first appointment. 

Client's Information (Note: if you are a caregiver seeking support through parent coaching, your child should be listed as the client on all documents):

Person to Contact In Case of an Emergency:

Contact Information for Clients under 18 years of Age

School Information

In order to facilitate psychological evaluation and/or treatment, I authorize Synchrosaic LLC to disclose protected health information, as specified below, to and request protected health information from:

Primary Care Practice: Essex Pediatrics

Address: 89 Main Street, Essex Junction, VT 05452

Please release the following protected health information:

I also authorize the Synchrosaic clinician to use the Electronic Health Record at Essex Pediatrics to maintain all records related to my, or my child's, care. I understand that this means all therapy notes and other records will be contained in the Essex Pediatrics Electronic Health Record where they can be reviewed by Essex Pediatrics medical staff.

I agree to and understand the following:

• I may revoke this consent at any time by notifying the above named clinician in writing, except to the extent that action has already been taken based on my previous consent. This consent will be effective unless and until I revoke it in writing.
• The information released in response to this consent may be disclosed by the recipient and may no longer be protected by federal or state law.
• I am not required to sign this consent. My treatment cannot be conditioned on the signing of this consent.

I have read this form and certify that I understand its contents. This authorization will expire one year from the date of this signature.

Please copy and complete this form for any professionals that you would like your Synchrosaic evaluator to be able to communicate with. This may include teachers, special educators, therapists, or other medical providers that you would like to share relevant information about your child to aid in the evaluation.

In order to facilitate psychological evaluation and/or treatment, I authorize Synchrosaic LLC to disclose protected health information, as specified below, to and request protected health information from:

Please release the following protected health information:

I also authorize the Synchrosaic clinician to use the Electronic Health Record at Essex Pediatrics to maintain all records related to my, or my child's, care. I understand that this means all therapy notes and other records will be contained in the Essex Pediatrics Electronic Health Record where they can be reviewed by Essex Pediatrics medical staff.

I agree to and understand the following:

• I may revoke this consent at any time by notifying the above named clinician in writing, except to the extent that action has already been taken based on my previous consent. This consent will be effective unless and until I revoke it in writing.
• The information released in response to this consent may be disclosed by the recipient and may no longer be protected by federal or state law.
• I am not required to sign this consent. My treatment cannot be conditioned on the signing of this consent.

I have read this form and certify that I understand its contents. This authorization will expire one year from the date of this signature.

The information described below is offered to anticipate the most frequently asked questions about Synchrosaic LLC professional services and business practices. Please read this carefully. If you have any questions, it is important that you clarify them with your Synchrosaic clinician prior to signing the consent and disclosure of information form.

Session Information:

Individual therapy sessions are by appointment only and are customarily 45 - 55 minutes in length with children and 55 minutes with adults. Longer sessions (usually 80 minutes) will occasionally be scheduled in consultation with the client. Group therapy sessions range from 60 to 90 minutes depending upon the group topic and age of the participants.

Psychotherapy has both benefits and risks. Since treatment often involves discussing difficult aspects of your life, you may experience uncomfortable feelings. However, therapy has many possible benefits, including the reduction in the symptoms that brought you to care. As we meet to conduct an initial evaluation and treatment plan, it will be important for you to evaluate how you feel about working with me. Successful therapy involves a large commitment of time and resources; you should choose your therapist with care. If you have any questions about my training, my methods, or my recommendations, please feel free to discuss them with me. If your doubts persist, I will be happy to provide you with a referral to another mental health professional.

Cancellations:

The time agreed upon is reserved for you. In the event that you must cancel a session, please call your Synchrosaic clinician at least 48 business hours in advance using their contact number. If such notice is given, the client will not be charged for the sessions. In the absence of such notice, except in extraordinary circumstances, the client will be charged for the session at the usual hourly rate. It should be noted that insurance will not pay for missed sessions, SO the client will be billed directly. In accordance with legal requirements, Medicaid patients will not be charged for missed sessions. However, in the case of all clients, if an appointment is not kept, subsequent scheduled appointments will be forfeited unless and until the client calls to reschedule. Additionally, I reserve the right to discontinue treatment with a client if session attendance becomes a regular problem.

Phone Calls:

Synchrosaic clinicians are not often immediately available by phone and messages are received by their voicemail. Clinicians pick up these messages periodically throughout the day and will return calls as soon as possible. Clinicians will make every effort to return your call within 24 hours. Please leave messages with your clinician using their confidential voicemail.

Email and Text:

Clinicians do not prefer to use text to communicate with clients as this is not a secure form of communication. It is best to communicate with them by phone and voice mail.

If you choose to use email or text to communicate with your clinician, please be advised that this is not a secure form of communication. We require that you review risks and sign a separate release to authorize

Fees:

The regular fee for individual psychotherapy is $165 for a 55-minute session. The regular fee for group psychotherapy is $65 for an hour and $90 for a 90-minute session. Payment of all fees due by the client, including co-payments, is required at the time of service, unless we have discussed your being billed for co-pays. Please contact your provider to determine what your financial responsibility for therapy will be. Telephone consultations of 10 minutes or longer and preparation of reports or letters will be billed at the usual rate, based upon time involved. Consultation to schools or other consultation will be billed at a rate determined prior to initiating services.

Insurance:

If insurance is to be used to pay for services, arrangements must be made in advance with me. Synchrosaic typically bills the insurance company directly, and the client is responsible for deductibles and co-payments at the time of service. In certain situations, Synchrosaic may arrange to bill the client with the understanding that they will apply for reimbursement from the insurance company themselves. All insurance plans vary and you are responsible for learning the details about your plan. Some require pre-authorization by your primary care provider or by the insurance company before they will pay for services. Some plans authorize a set number of sessions. The client is responsible for tracking this information. If your insurance coverage changes, it is your responsibility to inform me to avoid any lapse in coverage. Many insurance companies require that Synchrosaic provide written updates of your treatment on a periodic basis in order for services to be covered. It is understood that Synchrosaic will provide these updates to your insurance company as part of your care unless you request otherwise.

Patient Rights:

You have the right to be treated with dignity and respect. You have the right to necessary and available treatment regardless of race, religion, national origin, age, handicap, gender, or sexual orientation. You have the right to be informed about the services and treatment available for your needs. You have a right to know your diagnosis, if you have one, and your treatment plan. You have the right to consent to treatment or to refuse treatment. You have the right to review your clinical records. You have the right to give or withhold access to your clinical record to others, such as a relative or lawyer. You have the right to complain if you believe your rights, or someone else's rights, have been violated.

Confidentiality:

Confidentiality is a very important part of psychological services. The release of confidential information to a third party requires client authorization through the signed, time-limited Authorization to Disclose Protected Health Information form for each party concerned. We will fulfill a client request to send records to a third-party without unreasonable day and without undue burden to the client.

Under the following circumstances, information might be released without your written permission:

• The psychologist is mandated to act to minimize risk in the event that the client is assessed to be an imminent danger to themselves or others
• The psychologist is mandated to report actual or suspected abuse or neglect involving children and vulnerable adults
• The psychologist is required to respond to a court-ordered subpoena to testify in court or to provide records to the court
• The psychologist may be obligated to report to authorities situations which directly affect the health and safety of others

Further information about confidentiality is included in the Privacy Notice that has been provided to you.

Emergencies:

We will discuss crisis planning as part of your treatment. In the event of a mental health emergency requiring immediate attention, you can contact your clinician by calling their confidential phone, 24 hours a day. Clinicians return calls within a business day. Patients of Essex Pediatrics can call 802-879- 6556 24 hours per day and ask for the physician on call. In a life-threatening situation, contact 911 immediately or go to the Emergency Department.

My signature on the page authorizes Synchrosaic to provide psychological services to myself, my child, or a minor to whom I am the legal guardian. It also verifies I have read, understand, and agree to abide by the conditions and policies described above.

A. I voluntarily consent to evaluation and/or treatment of the above named client by a Synchrosaic LLC clinician. I understand that I am consenting and agreeing only to those services that the Synchrosaic clinician is qualified to provide within the scope of her training. I acknowledge that no guarantees are being made to me as the result of the treatment. I also understand that Synchrosaic LLC is an independent contractor.

B. I acknowledge that no guarantees have been made to me as to the result of the treatment or evaluation.

C.I certify that I am the child's legal guardian or custodial parent and am legally authorized to initiate and consent for treatment on behalf of this individual.

D. I understand that the Synchrosaic clinician may consult with other clinicians for the purposes of professional development and coverage and that such consultations are also bound by the rules of confidentiality. I understand that the Synchrosaic clinician may discuss my child's care in peer supervision and provide information to a covering clinician to facilitate continuity of care.

E. I authorize the Synchrosaic clinician to communicate with my insurance company for care authorization and care coordination upon request from the insurance company.

F. I understand that treatment is confidential with exceptions. These exceptions include, but are not limited to: disclosure to insurance companies and managed care companies for reimbursement purposes; disclosures required by law, such as suspicion of abuse or neglect of children, vulnerable adults, risk of imminent hard, or duty to warn; and disclosure to other health care professionals to facilitate my child's care and treatment or as described above. I understand that there may be other circumstances in which the law requires my therapist to disclose confidential information.

G. I have been given the professional qualification and experiences of the Synchrosaic Clinician, Synchrosaic's professional policies, a listing of actions that constitute unprofessional conduct according to Vermont statutes, and the methods for making a consumer inquiry or filing a complaint with the Office of Professional Regulation.

H. In addition, I have received and been informed of client privacy rights as outlined under state and federal law. These rights include:

a.The right to be informed of the various steps and activities involved in receiving services.

b. The right to confidentiality under federal and state laws related to the receipt of services.

c. The right to humane care and protection from harm, abuse and neglect.

d. The right to make an informed decision about whether to accept or refuse treatment.

e. The right to contact and consult with counsel and select practitioners of my choice at my expense.

I. I understand that I may revoke this consent at any time except to the extent that treatment has already been rendered or that action has been taken in reliance on this consent, and that if I do not revoke this consent, it will automatically expire one year after all claims for treatment have been paid as provided in the benefit plan.

J. I understand that the Synchrosaic clinician will be using the Essex Pediatric Medical Record for all documentation of treatment. I understand that this means all therapy notes are contained in the medical record and can be reviewed by medical staff.

K. I have read this document and understand and consent with the content.

I understand that email, texts and similar communications may not be secure through encryption and other safeguards and, even if encrypted, raise security risks that threaten confidentiality.

• By requesting email and text communication, I represent that I am the person legally responsible for use of the cell phone number provided, that I am at least 18 years of age.
• I understand that texting over cellular devices carries security risks because text messages from my device may not be encrypted. This means that information received or sent by text message could be intercepted or viewed by an unintended recipient, or by my cell phone carrier.
• I understand that my provider does not charge for this service, but standard text messaging rates may apply as provided in my wireless plan (contact your carrier for pricing plans and details)
• I understand that text and email messages are not a substitute for professional or medical attention.

I nonetheless wish to use one or more of these modalities to communicate with my provider. I understand that I may change my mind and, if I notify my provider of this, she/he/they will no longer communicate with me in that way.

I understand that email, texts, and similar forms of communication are to be used only for scheduling or as otherwise agreed upon with my provider. If a matter is urgent, I should contact my Synchrosaic Clinician on their cell phone, or after hours, Essex Pediatrics at (802) 879-6556. If I have a medical emergency, I understand I should call 911.

I hereby consent to engage in teletherapy/coaching with a Synchrosaic LLC Clinician. I understand that "teletherapy" includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy/coaching also involves the communication of my medical/mental information, both orally and visually.

I understand that I have the following rights with respect to teletherapy:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

2. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the other consent forms for treatment I received with this consent form.

3. I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of the Synchrosaic clinician, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; that people who are nearby when I participate in a teletherapy session may overhear my discussion; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

4. In addition, I understand that teletherapy based services and care may not be as complete as face- to-face services. I also understand that if the Synchrosaic clinician believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychologist, my condition may not be improve, and in some cases may even get worse.

5. I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.

6. I accept that teletherapy does not provide emergency services. During our first session, the Synchrosaic clinician and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273. TALK (8255) for free 24 hour hotline support or use the National Crisis Text line 741741 24 hours per day.

7 .I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

8. I understand that I have the right to choose to receive services by audio-only telephone, in person, or by teletherapy, to the extent clinically appropriate.

9. I understand that while email may be used to communicate with the Synchrosaic clinician, confidentiality of emails cannot be guaranteed.

10. I understand that while text may be used to communicate with the Synchrosaic clinician, confidentiality of texts cannot be guaranteed.

11. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.

Audio-only Teletherapy visit:

• Audio-only telephone services are available if clinically appropriate.
• Consenting to receive services by audio-only telephone is voluntary and does not preclude access to in-person or teletherapy services.
• Less information is available to your provider in an audio-only visit and your provider will determine whether an audio-only visit is clinically appropriate.
• Using telephone services, only requires access to a phone line and eliminates the need for internet or devices that enable video services.
• Audio-only telephone services cannot be used for psychiatric examinations related to involuntary commitments.
• Not all audio-only services are covered by all health plans, some services may be billed out- of-pocket, please talk to your provider or the billing department for more information.

I have read, understood and agree to the information provided above.

 

I authorize Synchrosaic, LLC to charge my credit/debit/health account card for professional services. I understand that my information will be saved (in a HIPAA compliant format) for future transactions on my account.

I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied.

After you submit this form, you will be taken to a PDF with important information about relevant Vermont statutes. Please download and read this PDF.