We are a licensed counseling clinic with several years of experience specializing in various counseling. We value our relationship with our clients and believe that such relationship is the beacon in the healing process.

We believe that each individual is unique and has his own way of addressing resolutions. Thus, we believe in a wellness model that helps our clients empower themselves by focusing on what works for them and not in a systematic approach that provides a generic procedure on working on a treatment. One's journey is not the same as the other.

Client's Rights

1. Unless there is an emergency, all the therapy sessions are private and confidential with the exception of specific exceptions described below:

a. Child, elder or dependant abuse,

b. Expressed threats of violence toward an ascertainable victim,

c. Detailed planning or concrete signs of future suicide attempts,

d. Sharing information is necessary to facilitate client care across multiple providers,

e. Sharing information is necessary for the treatment,

f. Requests from legal and administrative institutions.

2. With the Client's prior written consent, the Counselor may legally speak to another healthcare provider or Client's family members in emergency situations. The Client may direct the Counselor to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission.

 3. The Counselor is allowed to keep brief notes of the therapy session which shall be kept in strict confidence. The Client may, at any time request a copy of the notes kept during the therapy session.

4. The Client may ask questions on what to expect during and end result of the therapy.

5. The Client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.

6. The Client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.

7. The therapist has the right to dismiss the Client from the course of therapy.

Welcome to Zamyra Abdel Hady, LCSW, M.Ed., HT d.b.a August Holistic Therapy, LLC (the “Practice”, “we”, “us” or “our”).  You must review and complete these forms before the Practice can provide professional services.

CONSENT FOR TREATMENT:

The individual signing this form (“you”) hereby consents as or on behalf of the patient named above (the “Patient”) to permit the Practice through its psychotherapist counselor(s) and other staff to provide diagnostic and other behavioral health care and treatment to the Patient that is medically reasonable and necessary in the professional judgment of the Practice’s professional staff, which may include, among other things, receiving and participating in individual / group / family psychotherapy, pharmacotherapy, and/or crisis intervention.  Further, you consent for the Patient to receive a comprehensive diagnostic assessment, after which you, the Patient, and the Practice will mutually determine whether to continue treatment. Finally, you consent to treatment in the care setting agreed-to by both you and the Practice which may include the Practice’s office, your home, a school setting, and/or virtual (e.g., telephone or secure video conference).

CONSENT TO USE AND DISCLOSE HEALTH INFORMATION:

You hereby consent to the Practice’s use and disclosure of medical information in Practice’s possession concerning the Patient’s behavioral health treatment that may identify you and/or the Patient and be considered “protected health information” to:  a) the Practice’s workforce, including employees, contractors, trainees, and volunteers, and any other health care provider involved in the Patient’s care for purposes of providing treatment to the Patient; b) the Practice’s workforce and other permitted parties for purposes of the Practice’s health care operations; and c) any other permitted purpose for which the Practice is not required to obtain a separate, express authorization, as permitted or required by applicable state and federal laws and regulations.

CLINICAL POLICIES AND PROCEDURES

Telephone Communications:  To safeguard the Patient’s protected health information, the Practice will only leave messages regarding the Patient’s medical and billing information at the phone number(s) on record, your patient portal, and/or your email address on record.  When leaving a message or speaking with another person regarding the Patient’s care, the Practice will limit the information disclosed to the minimum that is necessary.

This consent is not valid to permit use or disclosure of the Patient’s protected health information for a purpose that requires an authorization under the HIPAA Privacy Rule (45 CFR § 164.508), or where other requirements or conditions exist for the use or disclosure of the Patient’s protected health information under state laws and regulations.

Telehealth:  Telehealth includes both video and telephone interactions during which psychiatric and/or therapeutic care is provided.  Telehealth provides psychiatric and therapy services using HIPAA-compliant interactive video conferencing tools in which the psychiatrist/therapist and the patient are not at the same location.  Telephone calls without video may be used for cases when video is not viable or preferred, and in-person sessions are not feasible.  Telehealth will allow the patient to receive psychiatric and therapeutic care without the need to visit the office and travel long distances.

Your rights with regards to Telehealth:

The laws that protect the privacy and confidentiality of medical information also apply to Telehealth;

The various forms of Telehealth we employ are known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data.  These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

You have the right to withdraw your consent to the use of Telehealth during the course of your care at any time.

The Practice has the right to withhold or withdraw consent for the use of Telehealth during the course of your care at any time;

Potential risks include, but may not be limited to:

• Information transmitted may not be sufficient (poor resolution of video);
• Delays in medical evaluation and treatment due to deficiencies or failures of the equipment;
• Security protocols can fail, causing a breach of privacy; and
• A lack of access to all the information available in a face to face visit may result in errors in medical judgment.

Alternatives to Telehealth include traditional face to face sessions.

Patient’s Responsibilities:

You will not record any Telehealth sessions without written consent from us.  

You will inform your provider if any other person can hear or see any part of our session before the session begins.  Similarly, the provider will inform you if any other person can hear or see any part of your session before the session begins.

You agree to use a private and secure network if accessing the internet for a Telehealth session and to remain in a private setting so others cannot hear or see you.

You agree that you will be physically located in New Jersey during your Telehealth session.

You, not your provider, are responsible for the configuration of any electronic equipment used on your computer or phone that is used for Telehealth.  You understand that it is your responsibility to ensure the proper functioning of all electronic equipment before your session begins.

Emergencies

The Practice is not available after hours or on holidays and weekends and is not considered an emergency resource.  If there is a potential of any physical danger to you, the Patient, or others, you shall call 9-1-1 immediately, go to the nearest emergency room, or call a crisis hotline (such as the National Suicide Hotline at 800-784-2433).  After the Patient receives emergency attention, you shall contact the Practice as soon as is feasible.

You agree that if you require emergency treatment during a scheduled session and the applicable health care provider determines, in their professional judgment, that an attempt to secure consent to treatment would result in delay of treatment which would increase the risk to your life or health, that no further consent to treatment will be necessary in such circumstance. You understand that the Practice’s staff will work to inform your emergency contact person as soon as practicable in the event of such an emergency. You also understand that to the extent permissible pursuant to applicable privacy laws, your health care information may be disclosed in connection with the provision of emergency treatment.

Electronic Communications

Email & Text Communications:  We attempt to make communication with our clinicians as easy and efficient as possible, which is why we employ SMS text, email, and app based communication.  Based on this consent, the Practice shall use electronic communications, including email, SMS text messages, phone applications, and phone calls to communicate with you and the Patient including with regard to protected health information.  This consent provides you with information about how we use these types of communications and the associated risks.  It will also be used to document your consent to use these types of electronic communications to communicate with you, the Patient, or others you may designate above.  You hereby agree to create an account or otherwise sign up with such a vendor, at no cost to you or the Patient, in order to receive and send electronic messages (text, email, and application based messaging) and receive phone calls.  However, text and email or, by nature, not completely secure.  We therefore ask for the Patient’s consent to employ email or standard SMS messaging regarding various aspects of the Patient’s medical care, which may include, but shall not be limited to, care questions, appointments, and billing.  The patient understands that email and standard SMS messaging are not confidential methods of communication and may be insecure.  The patient further understands that, because of this, there is a risk that email and standard SMS messaging regarding their medical care might be intercepted and read by a third party.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You hereby confirm that the Patient has been provided with a copy of the Practice’s current Notice of Privacy Practices before electronically signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of the Patient’s protected health information that will occur for the Patient’s treatment, payment of my bills or in the performance of healthcare operations of the Practice and the Practice’s duties regarding the Patient’s protected health information. The Notice of Privacy Practices also describes the Patient’s rights with respect to the Patient’s protected health information and how the Patient may exercise these rights. The Practice reserves the right to change practices described in the Notice of Privacy Practices by calling the Practice’s office and requesting a revised copy. By digitally signing below, you acknowledge the receipt of the Notice.

APPOINTMENT POLICIES AND PROCEDURES

Late Cancellation Fee: We do not overbook appointments. Your appointment time is a reservation just for you. If you are not able to come to your appointment, please reschedule through email or leave a message on the office line during office hours to reschedule. If you contact the office within 48 business hours (excluding weekends and holidays) of your appointment, you may reschedule with no additional cost, and the appointment will be offered to someone else. For example, if your appointment is on a Monday, the cancellation must be made by the same hour on the preceding Friday. Weekend appointments must be canceled by the same hour on the Thursday before the appointment. If an appointment is not canceled or rescheduled more than 48 business hours ahead, the standard appointment fee will be applied to your account. Stating that you did not receive a reminder does not exempt you from a no‐show/late cancellation fee.

Should you arrive more than 10 minutes late for any appointment, you will be asked to reschedule so that an appropriate amount of time and attention may be devoted to your care. You will still be responsible for payment of the missed session. This fee is not covered by insurance and cannot be submitted for insurance reimbursement.

Failure to show for your first appointment may result in an inability to schedule further appointments before you pay the session fee for the missed appointment. Failure to show for your follow up appointments (or violation of this cancellation policy) on two or more occasions may be grounds for discharge from the Practice. Note that the cancellation fee may be waived in special circumstances, determined on an individual basis (e.g.: medical emergency- patients may be asked to provide documentation of the same).

PAYMENT POLICIES AND PROCEDURES

Payment and Fees:  We accept payments via credit or debit card through a secure service called Square Payments (https://squareup.com/).  Square Payments will securely store your credit or debit card information in their system.

• For new clients, we require a downpayment in advance of $350 to secure the appointment, paid through a link to Square Payments we will send you. This is refundable for clients that cancel in accordance with our cancellation policies (see above for more on that).
• Follow up appointments, billing will occur automatically through the credit card saved in the Square Payments or our Electronic Health Record. You can change your preferred card by contacting us at least 2 business days in advance of your appointment.  If you notify us later than 2 business days, we cannot guarantee that the credit card on file will be changed in time for the next appointment payment.

We also accept cash and checks in person (although we still require a deposit via CC that can later be refunded if cash is preferred).  In addition to other fees discussed in this document, the Practice will charge a $35 administrative fee for any credit card chargebacks or disputes, in addition to the charges originally invoiced.

Session Charges:  Session fees cover the cost of the visit and paperwork associated with completing the visit.  We will complete two occasions of filling out brief forms (five or fewer minutes) or brief phone calls (ten or fewer minutes) at no charge.  The Practice will charge for any additional occasions and any time beyond those limits at the same rate as our twenty-five-minute follow-up appointment, in five-minute increments.

Balances and Collections:  Balances more than thirty days past due are subject to a 10% monthly fee.  Balances more than ninety days past may be submitted to a collection agency or law firm for collection efforts.  If we need to send your account out for collection, you hereby agree to reimburse the Practice for the costs of collection, along with all other amounts due and owing by you.

NO SURPRISE ACT

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing” and their rights to receive a “Good Faith Estimate.”

You have the right to receive a “Good Faith Estimate (GFE)” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. The estimate is based on information known at the time the estimate was created. The GFE does not include any unknown or unexpected costs that may arise during treatment.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. You can request that your health care provider give you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (206) 627-0109.