Client Intake Form

3747 Minnehaha Ave #206, Minneapolis, MN 55406 ~612-715-0754~

Twinflowerpsych.com

Please complete each section by inputing the requested information and acknowledging each section.

If you have any questions, please contact Dr. Linnea Swanson at drswanson@twinflowerpsych.com.

Once completed, a copy of this form will be sent to your email.

The Client(s) listed here are referred to as "I" throughout the rest of this document.

1. I will allow Twinflower Psychological Services, LLC to provide therapy and related services. When I wish to end therapy, I will inform the therapist. I understand that more than 30 days of unplanned absence will automatically end this therapy agreement.
2. I understand Twinflower Psychological Services, LLC is not an emergency service. I understand I may call 911, Hennepin County Crisis Line (612) 347-3161, Ramsey County Adult Crisis (651) 266-7900 or Ramsey County Children’s Crisis (651) 290-8999, Dakota County Crisis 651-288-0400 or
   Anoka County Crisis 763-755-3801, if I need emergency assistance.
3. I understand that all services at Twinflower Psychological Services, LLC are Fee-for-Service and will not be billed to my medical insurance. I assume all financial responsibility for services provided by Twinflower Psychological Services, LLC.
4. I understand that Twinflower Psychological Services LLC does not determine the need for medication. Referrals are given for these services if needed.
5. I understand that it is my responsibility to cancel sessions with as much advance notice as possible. If I miss two or more sessions without notice, the therapist reserves the right to end the therapy relationship.

As a client, you have the following rights:

1. To expect that a therapist has met the minimal qualifications of training and experience required by state law;
2. To examine public records maintained by the Board of Marriage and Family Therapy which obtains credentials of a therapist;
3. To obtain a copy of the code of ethics from the Board of Marriage and Family Therapy, 335 Randolph Avenue, Suite 260, in St. Paul, MN 55102;
4. To report complaints to the MN Board of Marriage and Family Therapy by calling (612) 617-2220; or NY Office of Professional Discipline 1-800-442-8106. 
5. To be informed of the cost of professional services before receiving the services
6. To privacy as defined by rule and law;
7. To be free from being the subject of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services;
8. To have access to their records as provided in Minnesota Statues, section 144.335, subdivision 2;
9. To be free from exploitation for the benefit or advantage of a therapist;

This section contains procedures and policies related to the handling of your private information, including information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law enacted to provide privacy protections and patient rights with regard to your Protected Health Information (PHI). This information identifies you and includes information about your past, present, or future psychological health and medical information; current psychological care you are receiving; or payment for that care.

1. Uses and Disclosures of Your Protected Health Information (PHI) for Treatment and for General Operation at Twinflower Psychological Services, llc.

Information contained in your therapy file is confidential and protected to the best of our ability. Twinflower Psychological Services, LLC can only disclose your personal information with your express written consent. The PHI in your file is used within Twinflower Psychological Services, LLC primarily to help provide treatment (the therapy and other services you receive). With your written consent, your therapist may disclose PHI in your file to other people outside of Twinflower Psychological Services, LLC who may be involved in your treatment. For example, such disclosure might occur when you give permission for your therapist to consult with another health care provider like your physician or another mental health professional.

Twinflower Psychological Services, LLC stores your personal health information (PHI) on a cloud-based system, maintained by Valant. There are benefits as well as inherent risks associated with any cloud-based system. Twinflower Psychological Services and Valant take all precautionary measures to protect your personal health information.

Twinflower Psychological Services, LLC also retains the right to consult with other therapists in order to ensure you are receiving the best possible treatment. Such discussions will remain private and confidential; discussions do not include identifying information.

2. Other Uses / Disclosures Requiring Your Written Authorization

Use or disclosure of the PHI in your therapy file for purposes OTHER than those just described, can ONLY occur if your therapist obtains your express written consent. For example, if you would like your therapist to disclose some information pertaining to your therapy treatment to another family member, you must give the therapist written consent on a specific and legally required form. Twinflower Psychological Services, llc cannot release any information without written consent.

3. Revoking Authorization for the Release of Information

You may revoke a written authorization to use or disclose PHI in your therapy file at any time, provided your revocation is documented in writing. However, you may not revoke your authorization if (1) your therapist has already relied on that authorization to use or disclose your PHI; (2) if you provided the authorization as a condition of obtaining insurance coverage [in this case, the law gives the insurer the right to contest a claim under the policy].

4. Uses / Disclosures without Authorization

Your therapist may use or disclose PHI from your therapy file WITHOUT your consent in the following circumstances:

a. Serious Threat to Health or Safety-- If a therapist believes that you present a clear and imminent risk of serious physical harm to another person; the therapist may disclose any necessary information to help protect the threatened individual. If the therapist believes there is a clear and imminent risk that you will physically harm yourself; the therapist may disclose any necessary information to seek hospitalization or other treatment for you, or to contact any person involved in your protection (ex. Parent/guardian).

b. Abuse of a Child or Vulnerable Adult-- If a therapist reasonably believes that a child or vulnerable adult, either in treatment with the therapist or not, is being abused or neglected, the law requires that therapist to file a report with the appropriate authorities.

c. Judicial and Administrative Proceedings-- If you are involved in a judicial proceeding and a court order has been issued for specific information from your therapy file or information about the services you are receiving, the therapist may provide that information.

d. Health Oversight Activities-- If a government health agency or authority, such as one of the boards that licenses mental health professionals in Minnesota, requests information about your treatment here, we are required to provide the specified information under certain circumstances (ex. Misconduct investigation).

e. Worker’s Compensation Claims-- If you file a worker‘s compensation claim. Twinflower Psychological Services, llc must provide any requested information concerning your physical or mental health condition relative to the claim.

f. Complaints or Lawsuits-- If you file a complaint or lawsuit against any member of Twinflower Psychological Services, llc therapy staff, we must provide any requested information, or any information relating to the therapist’s defense of his/herself.

5. Client’s Rights and the Duties of Twinflower Psychological Services, llc and its Therapists

Client’s Rights:

a. Right to request restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI. However, Twinflower Psychological Services, llc is not required to agree to a restriction you request.

b. Right to receive confidential communication by alternative means and at alternative locations: You have the right to request and receive any confidential communications from Twinflower Psychological Services, llc by alternative means and at alternative locations.

c. Right to inspect and copy: You have the right to inspect or obtain a copy of your therapy file at anytime upon 30 day advance written request. Twinflower Psychological Services, llc may deny your request under certain circumstances, but in some cases you may have this decision reviewed. Upon your request, your therapist will discuss with you the details of the request and denial process.

d. Right to amend: You have the right to request to amend information in your therapy file for as long as your file is maintained by Twinflower Psychological Services, llc. However, we may deny your request.

e. Right to an accounting: Generally, you have the right to receive an accounting of disclosures of any information in your therapy file. Upon your request, your therapist will discuss with you the accounting process.

f. Right to a paper copy: You have the right to request a paper copy of this notice at any time upon request.

6. Duties of Twinflower Psychological Services, llc and its Therapists:

a. Twinflower Psychological Services, llc and its therapists are required by law to maintain the privacy of PHI in your therapy file, and to provide you with a notice of the legal duties and privacy practices of this office.

b. Twinflower Psychological Services, llc reserves the right to change the privacy policies and practices described in this document at any time. Unless we notify you of such changes, we are required to abide by the terms currently in effect.

c. If Twinflower Psychological Services, llc revises its policies and practices regarding privacy while you are currently involved in therapy, we will give you a revised notice in person or by mail. The notice will be posted in our office. You may check the current version at this site at any time either during your therapeutic treatment or after termination of therapy.

7. Complaint Procedure

If you believe your privacy rights have been violated, and wish to file a complaint, you may do so with the Office of Mental Health Practices, Minnesota Dept. of Health, 121 East 7th Place, suite 400, P.O. Box 64975, St. Paul, MN 55164 or call 651-282-5621. You may also send a written complaint to the Secretary of the U. S. Dept. of Health and Human Services. You have specific rights under the HIPAA Privacy Rule. Your therapist understands these rights and will not retaliate against you for exercising your right to file a complaint.
 

This section describes expectations of Communication and Social Media policies.

Communication with your therapist is welcomed via email, phone or text. However, it is important to understand the inherent risks associated with these forms of communication. These methods are relatively easily accessed by unauthorized people, hence the privacy and confidentiality can be compromised. Therefore, your therapist will only send information related to billing and scheduling via electronic methods.

Please let your therapist know if you would like to opt out of these forms of electronic communication.

Social Media
Your privacy in the social media world is very important. Therefore, your therapist does not accept friend requests, following requests, or other social media connections with clients.

Recording Sessions

Recording of sessions is strictly prohibited unless explicit consent by both the client and therapist is obtained in writing.

For clients who are using Teletherapy exclusively or adjunctive to in-person sessions.

Twinflower Psychological Services, LLC, uses the HIPAA compliant platform, Zoom for teletherapy services.

Confidentiality: The information disclosed during the course of therapy is confidential, however there are legal exceptions both mandatory, and permissible, including child, elder, and dependent adult abuse; threats of harm to self or others, or if court ordered, as described in the Client Therapy Bill of Rights. Therapist will take all precautions to ensure online therapy is confidential, but client is informed that transmission could possibly be disturbed or distorted by technical failures, or interrupted or accessed by unauthorized persons.

It is recommended that you prepare for your session by finding a private space and consider using headphones for the session. It is also recommended that you position your phone, computer, or other device so your camera is at eye level. Being as close as possible to your Wifi router and closing all other programs on your computer can also support better connection during the session.

Limitations: Teletherapy plays a useful role in supporting your mental health and related concerns. It also has inherent limitations in not being physically present. For instance, body language is limited by this format and technical difficulties can have poor timing. Due to these limitations, this method is not recommended when in a state of crisis or when at high risk.

When should I seek in-person mental health treatment rather than Teletherapy?

1. If you are having thoughts of harming yourself and or someone else. Please call 911.
2. If you are in an abusive or violent relationship.
3. If you are experiencing severe depression.
4. If you have serious substance abuse dependence.
5. If you are a minor (under 18 years old)

Procedures should we encounter technical difficulties or disruptions in service:
It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, the patient agrees to immediately phone the therapist at 612-715-0754.

By dating this form:

1. I agree that I reside in the state of Minnesota or New York.
2. I have completed the Therapy Agreement, Client Therapy Bill of Rights, the Protection of Client Information, Communication and Financial Obligation Sections,
3. I agree to participate in Teletherapy. I have read, understood and will comply with the above policies.

In compliance with the No Surprises Act and Good Faith Estimates (No Surprises Act and Good Faith Estimates) this section is to inform you about the costs of your care.

The total cost of your care will be determined the frequency and length of your sessions.

One example could be: 1-intake session, weekly 55-minute individual sessions for 6 months (24 sessions); total cost $225+$4,320=$4,545.

This example serves as one of many possible combinations of services. Twinflower Psychological Services, LLC. will do their due diligence to ensure there are no surprise costs to your care.

1. I acknowledge that the initial intake 55-minute session will be charged at a rate of $225. Each standard 55-minute session will be charged at $180/session and 85-minute sessions are charged at a rate of $265.
2. I can pay by cash, check, or credit card, Flexible Spending Accounts (FSA), Health Spending Accounts (HSA). I agree to pay on the same day of each session or my card will be charged on the same day of the session. Receipts can be provided through email. Statements/Superbills will be provided at request for submission for out-of-network benefits.
3. I understand that all services provided are Fee-For-Service. Any reimbursement sought through an FSA, HSA, or Out of Network Benefits is my personal responsibility. I am also responsible to verify that my therapist's services are reimbursable and will not hold Linnea Swanson, Psy.D., M.A., LMFT responsible for any refusals of reimbursement.