Protected Health Information (PHI): By law and professional ethics, what is shared with a therapist remains confidential.  If you consent in writing that information be shared with a third party, this modifies confidentiality per your consent in those situations in accordance to applicable laws and statutes.  To share information with a third party, I will ask you to sign a “release of information form” (ROI).  The ROI will be maintained in your clinical file and/or electronic health record (EHR).

There are exceptions to confidentiality.  I am mandated by the State of Michigan (which has issued my license to practice as a Licensed Professional Counselor) to report to Child Protective Services if I either suspect or receive a disclosure of child abuse and/or neglect.  I am also mandated to report to Adult Protective Services if I suspect or receive a disclosure of vulnerable adult abuse and/or neglect.  I am also mandated to report imminent risks of danger for people regardless of age.  If you have any questions, I am eager to clarify.  

The following statements will serve as notice to you that you have been informed of your Health Insurance and Portability and Accountability Act (HIPAA) rights and practices within my practice:

I understand that my protected health information may be used and disclosed to carry out treatment, payment or health care options.
I understand that I have the right to review the PHI Form prior to signing consent to release information.
I understand that the terms of the PHI Form may change and I may request a revised notice.
I understand that I have the right to request restrictions on uses and disclosures of protected health information for treatment, payment and healthcare operations, but that my provider is not required to agree to the restrictions if they would impair her ability to provide necessary services.
I understand that any restrictions agreed upon by the provider will be binding.
I understand that I may revoke this consent in writing, except to the extent that has already been cited based on my previous consent.

EMERGENCY or CRISIS SERVICES:  If you need emergency mental health and/or medical attention, please call 911 or go to the closest Emergency Department. 988 is a national mental health crisis line available 24 hours each day for calls and texts.

BILLING RATES:  Initial Consults are billed at $250 per session.  Individual sessions from 53-60 minutes are $200.  Copies of Records must be requested in writing.   The cost for copies is a $35 processing fee plus $.50 per page thereafter.  Allow 30 business days for record request to be completed.  Missed Sessions are a fee of $100 and must be paid before rescheduling.  A session is considered missed if less than 24-hour notice of cancellation is given.  Court attendance is charged at $250/hour and rounded to 15 minute increments with travel charged at the IRS mileage reimbursement rate.

ATTENDANCE:  Clients are allotted 15 minutes tardiness before the appointment is considered "missed”.  After 15 minutes, the session will be cancelled and your appointment may likely be filled by someone on the waiting list.  A third missed appointment will result in immediate discontinuation of counseling.   A missed appointment will result in cancellation of all future scheduled appointments.  Late cancellations (less than 24-hour notice) are considered missed appointments. Four weeks without contact from a client will also result in discontinuation of services. If a client is not attending counseling regularly, per expectations stated in treatment, this may likely lead to discontinuation of services.  

ILLNESS:  We give and ask for grace when illness happens.  We ask that if anyone has a fever and/or the flu within 24 hours, please cancel counseling.  Late cancellations for illness will not be assessed any fees.  

BAD WEATHER:  The counseling office does not close for bad weather unless emergency officials request that motorists not travel.  If this occurs, you will be contacted as soon as possible.  Telehealth is a great option when the weather is problematic.  Telehealth is an option for all clients at any time, just ask!  

MINORS, FAMILIES & RELATED LEGAL MATTERS: If you are seeking treatment for your child and are divorced/separated, a copy of the most recent child custody order must be on file.  Parents/guardians who share legal custody will be invited to a consultation regarding their child. The parent/guardian who is initiating counseling must provide the counseling office with the name and address of the non-custodial parent so that a "parent consultation invitation letter" can be mailed.  If the name and address are not provided after the consultation, services will be considered discontinued. Step-parents may not sign consent forms and cannot be present for consultations or counseling without signed consent from parents/guardians. If a child is involved in a juvenile court matter, copies of most recent court orders are requested.  Child custody evaluations are not conducted at this office. Counseling is different than a child custody evaluation to be used to help decide custody matters.  This office does not provide counseling services for use in court proceedings.

PAYMENTS and DELINQUENT ACCOUNTS:  Billing and accounting services in our HIPAA compliant office are completed by Will and he can be reached at 231-683-2101 or  will@heidiweipertcounseling.com.  Our office will work with you to establish payment arrangements.  If you need help paying, please contact our office as soon as possible. Copays and deductibles are due at the time of service. Standing appointments are permitted only when payments are maintained at the time of service due to contractual obligations both providers and clients have with insurance plans.  Those who wish to have standing appointments must keep a valid form of payment on file for automatic payments for copays and deductibles.  If the form of payment is invalid the payment plan will be immediately voided and disrupt services. We are eager to create payment plans for those who need them.  Please talk with us about what you need so we can help.  When payments are due and not resolved with our office, Central Professional Services will be utilized as a collection agency for delinquent accounts.  

RECORDING SESSIONS:  Recording of sessions in any format is strictly prohibited by both client(s) and provider.

CONSUMER RIGHTS: It is your right as a consumer and client to have information about the method and techniques utilized in therapy.  If you have questions about the process or duration or frequency of care, I encourage you to inquire.  I respect your right to seek a second opinion or to terminate services under my care.  Any unprofessional behavior should be reported to:  Michigan Department of Community Health; Complaint and Allegation Division; PO Box 30018; Lansing, Michigan; 48909-7518; 517-373-9196.

Your health benefit plan may or may not provide coverage for all of the health care services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. A nonparticipating provider must provide a good-faith estimate of the cost of the health care services to be provided. A good-faith estimate does not take into account unforeseen circumstances, which may affect the cost of the health care services provided. You also have a right to request that the health care services be performed by a provider that participates with your health benefit plan and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need. Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.

If you and your therapist chose to use information technology 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) Your access to all medical information transmitted during a telemedicine consultation is guaranteed (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) 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. 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. TELEHEALTH GUIDELINES: 1. Telehealth services are NOT emergency mental services and in the event of an emergency, I will use a phone to call 911.  2.  Though my provider and I may be in direct, virtual contact through the telehealth service provider, the telehealth service provider does not provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.  3. I understand that telehealth has potential benefits including easier access to care and the convenience of meeting from a location of my choosing, however, I agree to remain in the State of Michigan during the session and in a private space from others to ensure my confidentiality. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.   5. I do not assume that my provider has access to any or all of the technical information in the telehealth service provider/software or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in telehealth. 6. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. 

I earned my graduate degree from Central Michigan University (CMU) in Counseling Summa Cum Laude. I am a member of Chi Sigma Iota (Mu Kappa), the very first National Honor Society for the Professional Counseling Program at CMU. My undergraduate degree is from Saginaw Valley State University with a major in Psychology with a double minor in Criminal Justice and English; Summa Cum Laude. I am a member of Psi Chi, the National Honor Society for the Psychology program at SVSU. I am board certified by the National Board of Certified Counselors as a Nationally Certified Counselor (NCC). I am an Advanced Certified Trauma Practitioner (ACTP) as certified by The National Institute for Trauma and Loss in Children (TLC). I also earned Diplomate Clinical Mental Health Specialist in Trauma (DMHS-T) from the American Mental Health Counselors Association which renders the DCMHS-T credential. In 2004, I was the recipient of the “Outstanding Achievement Award” by the Michigan Association for Play Therapy. It is my pleasure to serve as a Licensed Professional Counselor and I look forward to supporting clients as they reach for their goals!

Please ask questions before typing your name in the next box. By typing your name below, you are stating that you understand and agree to all of the information above and are consenting to treatment based upon the policies and procedures as described.

My electronic signature what are you gonna do with it but what for indicates agreement to all of the above items in this document and also indicates that I have received an electronic copy of this form.