PRACTICE POLICIES
This form is called a Consent for Services (the "Consent"). Your counselor, Tressie Seegers, MA, LPC, ATR-P, ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.
BIOGRAPHY
Tressie Seegers is Licensed Professional Counselor (LPC), a Registered Art Therapist (ATR) and EMDR trained.
The counseling interventions that Tressie uses in her practice are reflective of each individual's goals and reason for seeking therapy.
The interventions she uses can be described as person-centered, trauma informed and collaborative with the client.
The interventions may include dialectical behavior therapy (DBT), cognitive behavior therapy (CBT), Eye Movement Desensitation Reprocessing (EMDR), mindfulness and somatic awareness. In addition to providing counseling and art therapy services through My Favorite Day, PLLC.
CANCELLATION OF APPOINTMENTS, 24 HOUR POLICY:
In the event that you will not be able to keep your scheduled appointment, please notify your provider by text or voicemail at least 24 hours in advance (903-780-0765) to avoid a late-cancel or no-show fee
The late-cancel or no-show fee is $95.00 and charged at the time of the session.
If you miss more than two sessions in a row without calling in advance, your Provider may choose to terminate services as poor attendance makes it difficult to benefit from therapy.
THE THERAPY PROCESS
Therapy is a collaborative process between you and your Provider working together to achieve goals identified at the beginning and throughout the therapeutic process. During this time, you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process and are often associated with a good relationship between you and your Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
EFFECTS OF THERAPY
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in the process. Therapy can stir up thoughts and feelings that might be upsetting or unsettling. At any point, clients may experience deterioration in emotional and psychological stability as they become aware of previously unconscious, emotionally-laden materials. Although your Provider expects you to benefit from therapy, they cannot guarantee any specific results. Therapy is a personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Your Provider intends to work together with you to process whatever comes up to achieve the best possible results for you.
CLIENT RIGHTS
Some clients achieve their goals in only a few sessions; others may require months or even years of therapy. As a client, you may terminate or transition out of therapy at any time. When therapy comes to an end, either temporarily or permanently, a final session can be helpful to review your progress, identify supports that will help you maintain your progress and discuss how to return to therapy if you need it in the future. If you are dissatisfied with your Provider's services, please let them know. If they are not able to resolve your concerns, they will provide you with resources and referrals.
USE OF ELECTRONIC COMMUNICATIONS
Your Provider uses email communication and text messaging only with your permission and only for administrative purposes (scheduling, appointment confirmation, etc). Matters pertaining to scheduling, rescheduling or cancelling appointments is permissible via text message to 903-780-0765. To discuss a clinical matter between sessions, please do not text this private information, call instead if it cannot wait until your next scheduled session.
CONTACTING YOUR PROVIDER
Your Provider uses a cell phone for office and personal use, 903-780-0765. You are welcome to text or call for non-emergencies, however your Provider is not available to answer a call or text during sessions throughout the work day, after 6pm Monday-Friday, on weekends, on holidays or during vacations. You may email your Provider at tressie.myfavoriteday@gmail.com, however response times may be longer than a text. If you are contacting your Provider about canceling or rescheduling a session, please use text 903-780-0765.
EMERGENCIES, INCLUDING AFTER HOURS
My Favorite Day, PLLC is not an urgent care or emergency facility. In case of an emergency (example: thoughts of self harm or harm to others, intoxication, overdose or adverse drug reaction, psychosis, acute mania, etc) please go to your nearest ER, call 911, visit the nearest Urgent Care Facility or Psychiatric Hospital or call the 24/7 Poison Control Hotline at 1-800-222-1222.
NON EMERGENCIES, INCLUDING AFTER HOURS
If you need someone to talk with immediately but it is not an emergency, you can call a 24-hour crisis line at (512) 472-HELP.
FEES AND PAYMENT FOR SERVICES
For an individual 60 minute session, the cost is $150.00. A superbill can be provided upon request. If you have out-of-network benefits, your insurance company may reimburse your when provided with a superbill. Call your insurance company and verify prior to scheduling.
Please refer to Tressie Seegers profile on Headway for a full list of accepted insurances. Tressie Seegers' Headway Profile Click Here
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by Headway. Headway has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. Headway keeps records of all log-ins and actions within the system.
INSURANCE BENEFITS
If your Provider is in-network with your insurance company, your provider will need to verify your benefits prior to scheduling your fist session. Your Provider will need a picture of the front and back of your insurance card, your date of birth, address and phone number to verify benefits. If Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session. You can request a "super bill" as a receipt from your Provider that you can file with your insurance company for reimbursement. It is up to you to find out if your insurance company will honor a super bill for reimbursement.
INFORMATION WITH INSURANCE COMPANIES
If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
BALANCE ACCRUAL
Full payment is due at the time of your session. If you are unable to pay, tell your Provider prior to the session beginning. If you need to transfer to a sliding scale payment, please ask your Provider if any spots are available. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
PAYMENT METHODS
The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges. Acceptable forms of payment are credit cards, cash or checks made payable to My Favorite Day, PLLC.
ADMINISTRATIVE FEES
Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance.
LITIGATION POLICY AND FEES FOR COURT-RELATED SERVICES
Your Provider does not want to be involved in the litigation of their clients. If you become involved in any legal proceeding during your therapy with your Provider, inducing but not limited to divorce, custody dispute or personal injury lawsuit, you agree that neither you nor your attorneys, nor anyone acting on your behalf will subpoena records from your Provider's office or subpoena your Provider to testify in your, in a deposition, or in any legal proceeding. By your signature below, you acknowledge your understanding of this litigation policy and you agree to abide by it. Your provider will comply with lawfully issued subpoenas. The hourly charge for all time related to court cases or litigation is $300.00. You also agree by your signature below to make the required payment for the time spent on your litigation. If your Provider is subpoenaed to provide records or testimony in violation of the agreement and against your Provider's stated preference, you also agree to pay for all of the Provider's professional time, including but not limited to preparation, record review, transportation charges (door-to-door), waiting time, and time spent testifying in court or deposition regardless of which party issued the subpoena or requires your Provider to testify. If your Provider is required to testify in court or give a deposition outside of Travis County, your Provider will require a retainer in the about of $1800.00 (6 hours at $300 an hour), which will include preparation time, travel time (door-to-door), and attendance of any legal proceeding. If your Provider is to testify in court or give a deposition outside of Travis County, they will require a retainer in the amount of $1800 (6 hours at $300 an hour), which will include preparation time, travel time (door-to-door), and attendance at any legal proceeding. By your signature below, you agree to pay the applicable retainer no later than 48 hours prior to the litigation event. If the testimony or deposition exceeds 4 hours in Travis County or 6 hours outside of Travis County, your credit card on file will be charged $300 per hour for every hour spent at any legal proceeding, including court or deposition. By your signature below, you agree that your Provider will issue an itemized statement showing the breakdown of time and your further agree to that the amount of the invoice can be charged to the credit card on file.
PAYMENTS FOR COURT AND DEPOSITIONS
Accepted forms of payments for court and deposition fees are credit card, money order or cashier's check. No personal checks will be accepted for these services. All payments are due 48 hours prior to the scheduled court appearance or deposition.
COURT AND DEPOSITIONS CANCELLATION POLICY, 48 HOUR POLICY
There is a 48 hour business day cancellation policy for court and depositions in the amount of the retainer fee and is non-refundable. An example is, if the court appearance or deposition is scheduled for a Monday, your Provider's office must be notified of any cancellation by Noon on the Thursday before. The reason for this is your Provider has to cancel sessions and not see other clients during this time which can have a negative effect on the therapy of others. If your Provider is subpoenaed to provide records or testimony in violation of their agreement and against their stated wishes, your Provider reserves the right to terminate the professional therapeutic relationship immediately and refer you to other mental health providers. Your Provider will not perform child custody evaluations or provide recommendations regarding possession, custody, access to or visitation with minor children. Your Provider will not provide legal, medical or medication advice because these services are not within the scope of their practice.
VIDEOTAPING OR AUDIOTAPING SESSIONS
I do not allow the videotaping or audiotaping of sessions (or telephone calls) unless we have agreed to do so in advance and you have signed a specific written authorization of the taping to occur. For this reason, I request that you turn off your phone when you enter your Provider's office. By your signature below, you acknowledge that you understand this policy on the audio-taping of sessions and you agree to abide by it.
SOCIAL MEDIA
Due to the importance of your confidentiality and the importance of minimizing dual relationships, your Provider will not engage in communication or relationships via social media such as Twitter, Facebook, LinkedIn, Snapchat, Tic Toc or other platforms. This is for the protection of your privacy as well as the therapy relationship. Your Provider will not accept "friend" requests from current or former clients on any social networking site due to the fact that these sites can compromise clients' confidentiality and privacy. If your Providers discovers that they inadvertently established a social media relationship with you, they will cancel it. Your providers participates on various social networks, but not in a professional capacity. If you have an online presence it is possible that you may encounter your Provider. If that occurs, please discuss it with your Provider during your session. Your provider believes that all social communications with clients online have a high potential to compromise the professional therapeutic relationship.
WEB SEARCHES AND BUSINESS LISTINGS
Your Provider will not use web searches to gather information about you without your permission because this violates your privacy rights. Your Provider understands that you might choose to gather information about your Provider in the way. With an incredible amount of information available on the internet, some of the information may be known to your Provider and some may be inaccurate or unknown. If you encounter any information about your Provider through web searches or online, please discuss this with your Provider during your session to discuss the potential impact on you. Business listings you might encounter on sites such as Google, Yahoo Local, Yelp, etc. sometimes include forums where users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find your Provider's listing on any of these sites, please know that it is NOT a request for a testimonial, rating, or endorsement from you as my client. Of course you have a right to express yourself on any site you wish, however your Provider urges you to take your own privacy as seriously as your Provider takes their commitment of continentality to you. Your Provider cannot legally tell anyone you are their client and their ethics code prohibits them from requesting testimonials. If you choose to write something on a business review site, please keep in mind that you are sharing personally revealing information in a public forum. Under state and federal law, your Provider cannot respond to any review on any site whether positive or negative. You should also be aware that if you use any of these sites to communicate indirectly with your Provider regarding your feelings about your therapeutic work, there is a good possibility that your Provider may never see it.
INTERACTIONS OUTSIDE OF THE OFFICE
If you happen to encounter your Provider outside the professional setting, for confidentiality reasons your Provider will not say hello unless you speak to them first. If you are with someone that you do not want to know you are going to therapy, it may cause an issue if your Provider said hello first and you had to explain who your Provider is. If you initiate a greeting, your Provider will be happy to say hello. The protection of your privacy is the main focus, that is why you must initiate a greeting if you do not mind others know about your therapy.
CONFIDENTIALITY AND LIMITS TO CONFIDENTIALITY
In general, the privacy of all communications between you and your Provider, and even the fact that you are a client, is confidential and protected by state and federal law. This includes giving information to the parents or spouses of clients who are 18 years old or older, even when the spouse or parent is paying for the services.
Generally, your Provider can only release records or information about your work together to others outside other therapeutic relationship with your written authorization.
There are some important exceptions to confidentiality, which include the following:
1. If you are involved in a court proceeding and a request is made for the information concerning your diagnosis and treatment, that information is protected by the therapist-client privilege. Your Provider cannot release records or provide any information without your written authorization. However, if your records are subpoenaed or if a judge issues a court order for your records, I am legally obligated to comply. In the case of a subpoena, your Provider will contact you so that you (or your attorney) can take steps to contest the subpoena. If you do nothing to challenge the subpoena after being notified by your Provider, your Provider will comply with the subpoena.
2. If your Provider believes that you are a danger to yourself or to other persons, your Provider may contact medical or law enforcement personnel.
3. If your Provider learned that you are seeing another counselor for any reason, your Provider is required to contact that counselor to discuss coordination of your care.
4. If you disclose information that leads your Provider to suspect that a minor child, an elderly person or a disabled person is being abused or neglected, your Provider is required by law to notify authorities within 48 hours and your Provider will comply with this requirement.
5. If. you file a lawsuit or a complaint against your Provider for any reason, they are allowed to use confidential information to defend themselves.
6. If a court order or other legal proceeding (such as a grand jury) requires the disclosure of your information or records, your Provider will obey the court order or the grand jury subpoena. Confidentiality for mental health treatment does not exist in criminal cases in Texas.
7. If you waive your privilege or give written authorization to disclose information, your Provider will comply with your authorization.
8. Information contained in communications via computers with limited security / control, such as e-mail and telephone conversations via cell phone is not secure and can compromise your privacy.
9. If your Provider learns of previous sexual exploitation by a mental health provider, your Provider is required to report it to the District Attorney in the county of the alleged exploitation and the appropriate licensing board of the provider.
10. The matters discussed during a family therapy session on a couple's therapy session are not confidential as to the persons present since those persons hear the statements made and participate in the discussion. However, all matters discussed during the family or couple's sessions are confidential and privileged as to thread parties who were not present in the session.
11. Your Provider requires a "no secrets" approach to counseling multiple individuals in a family or couple. Members of a family or a couple should not disclose information to your Provider in a private session that they do not want to be shared by the Provider to the other family members or partner. Your Provider will not be responsible for keeping track of what information can or cannot be shared with other participants in the family's or couple's therapy.
RECORDS
All of the communication between you and your Provider become part of the clinical record, which is maintained in the form of electronic files once the clinical services are complete. Texas law requires that your Provider maintain appropriate treatment records for at least seven years from the last date of service for adult clients, and five years from the date a child client turns 18. Your Provider will not release any information about you to anyone without your written consent unless authorized or required to do so by law. As a client, you have the right to obtain a copy of your records upon submission of a written authorization. Texas law requires that all requests to review or obtain copies of your records must be made in writing. The records of your treatment will contain confidential information about you and the information in the records can be misinterpreted or upsetting to lay readers. If you request a copy of your records in writing, your Provider will provide them to you upon payment of the records fee unless she believes that releasing the records would endanger your life or physical safety or the life / physical safety of another person. If your Provider believes that she should withhold the record due to a situation involving life or physical safety endangerment, she will write you a letter to explain her reasons for withholding the records. For family or couple's therapy, the family's or couple's relationship is as much of a "client" as the individual parties. For that reason, your Provider will not release her records of couples counseling unless both of the individuals pay the records fee and sign an Authorization allowing for the release of records, or present your Provider with a Court Order requiring that the records be released. In either event, your Provider will provide a complete copy of her records to both members of the couple, or to all adult members of the family upon receipt of the Authorization or Court Order, and payment of the records fee.
RECORDS FEE
Providing a copy of your records is $30.00 for files that are less than 100 pages. For any file that is more than 100 pages, the fee is $50.00. The cost of shipping or mailing is an extra charge according to the actual cost at that time.
PLAN FOR PRACTICE IN CASE OF DEATH OR INCAPACITY
In the event of the death or incapacitation of your Provider, she has made arrangements for another therapist to take over my practice, assume control of my records, meet with clients, make referrals to other providers, as appropriate, and take all reasonable steps to manage the practice for the benefits of the clients. By your signature below, you authorize your Provider's designee to contact you directly and use or disclose your confidential mental health information and records for the stated purpose.
COMPLAINTS
You have a right to have your complaints heard and resolved in a timely manner. If we cannot work things out to your satisfaction, you may inform your insurance carrier and file a complaint with them or with your Provider's licensing agency, the Texas Behavioral Health Executive Council, 333 Guadalupe Street, Suite 3-900, Austin, TX 78701, Telephone: 1-800-821-3205, or online: http://www.bhec.texas.gov/wp-content/uploads/2020/07/BHEC-Complaint-Form.pdf. If you have a complaint concerning the HIPPAA Privacy Regulations, you may contact the U.S. Department of Health and Human Services, Office for Civil Rights, at: OCRMail@hhs.gov.
TERMINATING THERAPY
Ending therapeutic relationships can be difficult. As a result, it is important to clearly communicate how therapy may be concluded in order to achieve sufficient closure. The appropriate time to conclude services depends on the length, nature, and intensity of the treatment.
Concluding services is done collaboratively and there is generally adequate time to discuss and explore what best suits your needs and expectations, although you have the right to end or take a break from therapy at any time without my permission or agreement.
In our final sessions, we can discuss what you have experienced and learned thus far and explore ways you can continue to reach your goals. In some circumstances, I may determine that ending services is appropriate if treatment is not being effectively used or if you are in default on payment. I understand that any termination may be difficult but my decision on this matter will be final. If therapy is concluded for any reason or if you request another therapist, I will provide you with a list of qualified referrals. You may also choose another therapist on your own or from another referral source. If you do not schedule an appointment for two consecutive weeks, I will assume that you have chosen to discontinue our professional relationship unless other arrangements have been made in advance. Upon termination of therapy for any reason, the termination will be conferment in writing.
INFORMED CONSENT TO THERAPY
By signing below, I acknowledge and agree that:
• I have received, have read (or have had read to me), and understand this Therapy Services Information and Informed Consent Form.
• I provide my informed consent for psychotherapy with My Favorite Day, PLLC and Tressie Seegers, MA, LPC, ATR-P
.• I understand that no promises or guarantees have been made to me as to the results of therapy.
• I understand and agree to pay the session fee in full at each session unless prior clear written agreement has been made.
• I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel with 24 hours' notice or do not show up, I will be charged the fell fee for that appointment and I agree to pay that fee.
• I understand that if I experience a mental health or a medical emergency, I will call 9-1-1 or go to the nearest emergency room for treatment.
• I have read and understand the Litigation Policy and agree to pay the stated fees if I choose to involve her in my litigation or court case.
I have read this Agreement carefully. I understand the terms of this Agreement and I agree to comply with them. I understand that this Agreement is a contract between me and My Favorite Day, PLLC and may be legally enforced as a written contract. I agree that this Agreement will stay in effect until I revoke it in writing and I understand that any written revocation must be dated after the date of the Agreement and must be provided to My Favorite Day, PLLC. I agree that a copy of this Agreement has the same force and effect as the original. I have read the Telemental Health Service Agreement (if I am attending therapy through Telemental Health). I understand the terms of the aforementioned documents listed, they have been provided to me and I agree to comply with them.