The information you provide in this form is HIPAA-protected.
You will receive an email copy of this document after you have signed and submitted this form.

Payment Information

Please Provide Your Insurance Information

Practice Policies and What to Expect

Appointments and Cancellations

Therapy appointments are scheduled at mutually agreed-upon times. Please provide advance notice if you need to cancel or reschedule an appointment by contacting me via email.

Treatment Planning

Your treatment plan will consist of providing psychoeducation on interoception, mindfulness, and somatic breathing (i.e., mindful breathing). Together, we will strengthen your mind-body connection, enhance emotional regulation, and empower you with practical physiological tools to manage stress, navigate chronic symptoms, and support your long-term well-being. The services you will receive are intended to be intense (frequent weekly meetings at first and short-term (2-4 months).

Documentation Privacy and Confidentiality

Documentation Privacy

Your therapist maintains secure, confidential records of your care—including session dates, diagnoses, goals, and billing—which you may access at any time.

For clinical accuracy, sessions are recorded; transcriptions and notes are stored securely in a HIPAA-compliant Microsoft cloud system but are not part of your medical record. Your progress notes and intake forms, which form your medical record, are stored securely in a separate HIPAA-compliant Dropbox system.

Because our work focuses on psychoeducation for interoception, mindfulness, and somatic breathing, sessions target the mind-body connection rather than traditional talk therapy. We don’t intend to deeply explore specific stressors or mental health concerns unless they directly affect your somatic symptoms; life issues are recorded only as generalities.

Confidentiality

Your privacy is our priority. Communications with me are confidential and protected by law. Whenever possible, we will discuss this with you beforehand. Information about your treatment will not be shared without your written permission, except where legally required, such as:

• Suspected abuse of a child, elder, or dependent adult
• Serious, immediate risk of harm to yourself or others
• Digital child sexual exploitation
• Court orders or legal proceedings involving your records

We use secure, HIPAA-compliant platforms backed by Business Associate Agreements, including Microsoft Office Suite, Jotform, Dropbox, OneDrive, Psychology Today, Zoho CRM, Claude AI, and GoDaddy. For copayment processing, we use Stripe, which encrypts and tokenizes your payment information to keep it secure.

We also use artificial intelligence to help summarize and accurately reflect your care in progress notes. Before any AI processing occurs, personally identifiable information and any health, social, or work-related details not relevant to treatment are manually removed. Where clinically relevant health information remains, we use euphemisms and generalities to further protect your confidentiality. Progress notes are intended to document your specific progress in developing the skills outlined in your treatment plan.

To protect your records, passwords are changed every six months, and multi-factor authentication is applied wherever possible.

Rights and Responsibilities
Your Rights

You have the right to:

Direct Your Care: Stop therapy anytime; you only pay for services already received.
Dignity & Respect: Receive welcoming, non-discriminatory care.
Transparency & Boundaries: Ask about credentials, approaches, and expect professional, conflict-free boundaries.
Referrals: Request referrals to other providers at any time.
Inspect & Copy: Request to view or copy records (written request required; fees may apply).
Amend: Request corrections to your records, subject to legal limits.
Track Disclosures: Request a six-year history of non-routine disclosures.
Request Restrictions: Limit how we share your info
Confidential Delivery: Receive requested records securely
File a Complaint: Report privacy concerns without retaliation to Dr. Jarhed Peña at penajarh@recoveryandbalance.com or (734) 465-6615.

Your Responsibilities

Active and Honest Engagement: Taking an active, honest role in sessions and practicing your interoception and mindfulness tools in your daily life to support your progress.
Copays: Check with your health insurance regarding your copay responsibilities.
Commitment to the Treatment Model: Understanding that this is a short-term, intensive program (2–4 months) focused on psychoeducation and somatic practices rather than traditional talk therapy.
Managing Concurrent Care: Seeking and maintaining a relationship with an external therapist for traditional talk therapy to address general life stressors and broader mental health concerns.
Proactive Communication: Promptly notifying your therapist via email if you need to cancel or reschedule an appointment, and openly raising any questions or concerns about your care as they arise.
Financial Responsibility: Ensuring timely payment for all services received and understanding your financial obligations for the care provided.
Utilizing Appropriate Crisis Resources: Recognizing that this outpatient service does not provide emergency care, and taking responsibility to call 988, call 911, or go to the nearest emergency room if you experience a mental health crisis.
Respecting Professional Boundaries: Partnering with your therapist to maintain a professional relationship focused strictly on your treatment goals and mind-body well-being.

Consent to Pay Fees

To keep our focus on your care, we ask that you review and agree to our financial policies below:

Paying for Your Sessions

Payment Timing: We will charge your card on file for your portion of the session fee once we receive the final payment details and processing from your health insurance.
Payment Methods: We accept HSA and FSA cards, as well as all major credit and debit cards. All payments—including copays—are processed securely through Stripe.
Missed Sessions: If you need to miss a session, please let us know as soon as possible. There are no fees or charges for missed or canceled appointments.

Using Your Insurance

Your Responsibility: You agree to pay any deductibles, copayments, or coinsurance required by your plan.
Coverage Changes: If your insurance benefits expire, you are responsible for session fees from that date forward.
Denied Claims: If your insurance denies a claim—even after we complete all necessary billing steps—you may be responsible for the full cost of the session.

Insurance Authorizations & Sharing Information

Receive Direct Payments: Have your insurance company send payments directly to Recovery and Balance. If they send a check to you instead, you agree to forward it to us promptly.
Process Claims: Share necessary clinical and billing information with your insurance provider to authorize benefits and process claims.
Coordinate Your Care: Request relevant clinical records from your past providers and share updates with other professionals currently involved in your treatment.
If your card was charged in error, please contact me at penajarh@recoveryandbalance.com and I will make it right with you within 24 hours.

Financial Hardship

If you ever face financial difficulty, please let us know. We can discuss a financial hardship arrangement, which may allow us to provide your services free of charge and void any remaining balance. Rest assured, Recovery and Balance will never send unpaid bills to a collection agency for any reason.

Consent to Telehealth Services

I am pleased to offer you behavioral health services—including counseling, psychotherapy, and assessments—through secure, HIPAA-compliant video and audio platforms.

Risks and Benefits of Telehealth

While telehealth offers wonderful convenience, it is important to understand both its benefits and its limitations:

The Benefits: Telehealth provides great flexibility, allowing you to attend appointments from the comfort of your chosen space, and makes accessing care much easier.
The Risks: Technology can occasionally fail or interrupt our connection. There are also inherent security risks with digital data, and virtual sessions make it slightly harder for your therapist to read non-verbal cues.

Your Rights and Privacy

Your privacy is our priority, and our virtual sessions are protected by strict confidentiality laws. You have the right to request and review your records, though in rare cases, access may be limited if clinically necessary for your well-being.

Choosing telehealth is entirely up to you. You can decline or stop virtual therapy at any time.

Confirmation and Copy

Completing and then submitting this form confirms that you have read and understood the documents listed below and agree to their terms as previously indicated:

·      Practice Policies and What to Expect

·      Documentation Privacy and Confidentiality

·      Rights and Responsibilities

·      Consent to Pay Fees

·      Consent to Telehealth Services

The next page will allow you to sign this form. Afterwards, check your email to receive a signed copy of this form.