MaryEllen M. Martyn holds a Master of Science from Capella University; Licensed Professional Counselor in Colorado & Texas; Board Certified National Certified Counselor; Board Certified TeleMental Health Provider; EMDR
Trained all Levels; Trained Life Coach
MaryEllen Martyn, LPC has been trained in a variety of specific methods of treatments and will determine what approaches and techniques might be most effective with your specific needs. Although the exact length of treatment is difficult to predict, MaryEllen Martyn, LPC will be glad to discuss time frames that you may expect during your specific treatment needs. She will also be willing to discuss what other treatment options might be available and the possible effectiveness of those alternatives. You may, at any time, seek a second opinion from another therapist/coach and/or may terminate therapy/coaching at any time without penalty.
PAYMENT POLICY
MaryEllen Martyn, LPC sees clients on a fee-for-service basis. The client/parent is responsible for payment in full at the time of each session. Our policy is for each session to paid for at the time the professional services are scheduled or when the service is rendered. Any other arrangements must be made in advance.
INSURANCE PLANS FOR THERAPY CLIENTS
If you are utilizing your insurance plan, you will be responsible for any amount that your company plan does not cover. If a session claim is denied or the reimbursement rates/co-pay has changed, you will be responsible for any
difference. You are responsible to know which is your primary insurance and which is your secondary insurance if you have more than one policy. We can only bill a primary insurance plan for services. You will be responsible for any wrong information that results in a denial of claim.
We require a credit card of file so that payment can be rendered at time of service.
A $75 administrative fee will be required on any credit card charge disputed for a valid therapy session, in addition to, payment for the session.
RATES FOR COUNSELING SELF-PAY/LIFE COACHING RATES
In Office or Video -$165.00 (50min) Therapy or Life Coaching
EMDR Therapy-$270.00 (90min)
**(Rates are subject to change with a 30-day notice)
PHONE CALL POLICY FOR COUNSELING/LIFE COACHING CLIENTS
In general, for non-emergency or non-life-threatening concerns, we prefer the client to wait until their next appointment to discuss issues that arise. If you cannot get a sooner appointment and the issue cannot wait, we will accept a brief phone call. This is not a substitute for therapy/life coaching nor a way to get around paying for a session. Parents are welcome to call or email when necessary. We have an open door policy to protect the child and to allow direct communication within the limits of confidentiality.
EMDR clients please call if you are concerned after an EMDR session; You do not need to wait.
Suicidal clients should call 911;1-800-Suicide; www.befrienders.org, or local emergency room to get immediate help. We cannot provide emergency services or after-hours care.
COURT APPEARANCE AND LETTER REQUESTS
We do not make appearances in Court as a general policy. All client privacy and confidentiality are not protected in Court. If your therapist is subpoenaed to attend a Court proceeding, our rate is $300.00 an hour billed round-trip door to door.
Letters pertaining to the Court case are billed for basic letter at $50.00 a letter and in-depth requests at $150.00 a letter.
Please keep in mind that we are not deemed a court appointed expert for Child Custody cases and will not testify in that capacity.
You will be charged $1000.00 upfront as a deposit. You will be billed for all
expenses incurred and payment is due immediately the day after court concludes BRC's testimony.
APPOINTMENT CANCELLATIONS
We understand that it may, at times, be necessary to cancel an appointment. Please understand that MaryEllenMartyn, LPC reserves the time for you. A required cancellation of all appointments is 24 hours before your scheduled appointment, so that the time slot can have the opportunity to be fill with another client.
Failure to properly cancel or show-up for your appointment will incur a full session fee-$165. You may change your appointment from In Office to a Video Call appointment instead of missing the appointment all together.
Rescheduling For The Same Week
If the client is inside of the 24hr Cancellation window, the fee charged is reduced to $75.00 provided the client attends the rescheduled appointment. The late cancellation fee is still processed because two slots are taken leaving one without the opportunity to be used for another client. (We had clients in the past, repeatedly late cancel hoping to just move the appointment so to not incur the fee. Sorry for having to make policies that even we do not enjoy.)
Appointment Reminder notices go out from the BRC Appointment Scheduler 48hrs in advance. Please keep track of your appointments.
CONFIDENTIALITY
The confidentiality of the counseling/coaching provided by us is protected by law. Unless you grant us permission to do so in writing, therapists/coaches and office personnel will neither inform anyone that you are receiving therapy/coaching, nor will therapists/coaches disclose the content of any session.
The only circumstances under which such professional confidentiality may be broken is if one or more of the following conditions apply:
1) If you pose a serious physical danger to yourself or to another person.
2) If you disclose that you or another person has physically or sexually abused or molested a child, an incompetent or disabled person.
3) If you disclose that a child, an incompetent or a disabled person is suffering because of neglect.
4) If abuse or neglect is disclosed under the conditions given above, we are mandated by law to report such information to an appropriate state agency.
CONFIDENTIALITY AND COMPLIANCE
Provider will take appropriate precautions to keep your health information confidential and to not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act (HIPAA) and any other applicable federal and state laws related to protection of patient information, including but not limited to Public Health Law § 18. There are certain exceptions to when your confidential information would not be protected—for instance, if Provider believes that you will harm yourself or another person or are neglecting or abusing a child or a vulnerable adult.
Waiver of Liability. By signing this Agreement, you agree to waive, release and discharge Provider from any and all liability, including, without limitation, any injuries that may occur during the provision of services under this Agreement.
CONSENT TO RECEIVE TEXT MESSAGES AND E-MAILS
I (Client/Guardian) consent to receive text messages or emails from my provider and her agents on my cell phone or other devices. I understand that text messages and emails sent by Provider may include appointment reminders or changes in previously scheduled appointments or may provide advice or education.
The cell phone number that I authorize Provider to send text messages to is::
{phoneNumber}
The email address that I authorize Provider to send emails to is::
{email}
MaryEllen Martyn, LPC does not conduct therapy or life coaching services via text or email. Please schedule an appointment if you have therapeutic matters to discuss.
Provider does not charge for this texting service, but I understand that standard text messaging rates may apply as provided in my wireless plan. I have been advised that I may contact my carrier for pricing plans and details.
I understand that I may revoke my request for further communications via text or email at any time by notifying my Provider in writing. However, if I continue to communicate with my Provider via text or email, my Provider can assume that my consent remains valid.
Because emails sent over the Internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with e-mail and text messaging, including, without limitation, that emails and text
messages could be intercepted by unknown third parties; email content can be changed without the knowledge of the sender or receiver; backup copies of email may still exist even after the sender and receiver have deleted the messages; and email can contain harmful viruses and other programs.
My Provider has recommended that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.
You may also wish to sign up for a free encrypted email service such as https://www.sendinc.com/
MaryEllen Martyn does maintain an account with SendInc for clients who choose to use this service. This service ensures that only the intended recipient can view the email. MaryEllen Martyn’s email info@bereplenished.com is also encrypted on our end, but your email will need to be encrypted for full security end-to-end
INFORMATION AND INFORMED CONSENT FOR TELEMENTAL HEALTH TREATMENT.
Telemental health or Life Coaching is live two - way audio and video electronic communications that allows therapists/coaches and clients to meet outside of a physical office setting.
CLIENT UNDERSTANDING
I understand that telemental health or life coaching services are completely voluntary and that I can withdraw this consent at any time.
I understand that none of the sessions will be recorded or photographed.
I agree not to make or allow audio or video recordings of any portion of the sessions.
I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health and life coaching, and that no information obtained in the use of telemental health/coaching that identifies
me will be disclosed to other entities without my consent.
I understand that telemental health/coaching is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100% guaranteed
to be secure.
I agree that the therapist/coach and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that I or my therapist may discontinue the telemental sessions at any time if it is felt that the video technology is not adequate for the situation.
I understand that if there is an emergency during a session, then my therapist/coach may call emergency services and/ or my emergency contact.
I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist/coach, or I will make additional plans with my therapist/coach ahead of time for re-contact.
I understand my therapist/coach will advise me about what video platform to use.
INSURANCE-THERAPY CLIENTS
If I elect to use my health insurance plan to assist in the payment of treatment, then I understand that my insurance carrier and the National Information Center will have access to my diagnosis code and other pertinent data needed for claim processing. Information that may be requested includes type of services, dates/times of services,diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.
We currently use Headway to bill insurance policies on your behalf. we are not exclusive to Headway, and we will let you know if we are using a different biller for your claims.
FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT
I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees as stated above. I understand that failure to pay any charges or fees not covered by my insurance company may result in my account being sent to collections. Upon a delinquent account being sent to collections, some of my personal information will be given to the collection agency, however, no mental health or treatment details will be given