Client Informed Consent and Communications Form
This consent form applies if you are an adult seeking to engage in our psychological services for yourself, you are a parent/guardian seeking services for your child, and/or if you are in a relationship/family seeking family or couples counseling. Our organization includes three entities: Deep Eddy Therapy (previously Deep Eddy Psychotherapy), Dallas Counseling & Treatment Center (also known as DallasCTC and DCTC), and Deep Centered Psychiatry (DCP), a collaborative alliance all housed within one organizational entity doing business as Deep Centered Mental Health. Some protocols and procedures are different between our different departments, which will be highlighted in the relevant sections below.
Consent to Psychological Services
We provide short and long-term psychotherapy for individuals, couples, and groups. We also provide psychological assessments, consultations, and other psychological services. In this form, we will refer to these interchangeably but primarily as "psychological services". “Client” and “patient” refer to those receiving care from our providers.
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights.
Our approach to therapy is collaborative. You are encouraged to be an active participant and take responsibility for setting goals, attending sessions, and working. Progress depends on many things, such as motivation, honesty, and effort. We encourage you to speak freely with your clinician about any concerns or questions you have. Counseling intends to help with personal, relationship, and family problems. Your clinician will provide an assessment, set goals, and create a treatment plan with you. Our clinicians use a variety of techniques and approaches based on the clinical needs of each individual.
Occasionally your clinician may provide referrals. While we strive to provide you with high-quality referrals, we do not assume any liability for the services that these resources may ultimately offer. If you have concerns about the treatment received through our organization, we encourage discussing the matter with your clinician immediately or contacting administrative teams (scheduling@deepcentered.com).
Psychotherapy (also called therapy or counseling) and other psychological services have both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.
You may discontinue treatment with us at any point.
Therapy will be deemed "terminated" if the client has either agreed to stop therapy or if no session has been scheduled or attended for 60 days. You may contact us to resume therapy, and we will try our best to accommodate you under our current policies, fees, and availability at that time. You are not considered a client of our organization or your assigned provider until you complete the required paperwork, present valid credit card and insurance information, and attend your intake appointment. Intake forms must be completed at least 24 hours before the intake to prevent any need to reschedule. If rescheduling is necessary due to incomplete forms, a $100 fee will apply.
Confidentiality
We respect the information you share with us, so we want to be as clear as possible about how it will be handled. In general, everything that you share in therapy is confidential. Texas state law mandates these additional exceptions to our confidentiality.
The most common examples include:
1. If you are a danger to yourself or someone else
2. If you are a minor, or an elderly or disabled person, and you divulge information indicating that you have been a victim of abuse, or you divulge information about another such person who is the victim of abuse
3. If records are subpoenaed by the courts, such as in child abuse or a child custody suit
4. If you divulge a history of having been sexually abused by a previous therapist
5. If you file a suit or complaint against us, we may disclose relevant information from our records in our defense
Our organization, which includes Deep Eddy Therapy (previously Deep Eddy Psychotherapy), Dallas Counseling & Treatment Center (also known as DallasCTC and DCTC), and Deep Centered Psychiatry (DCP), is a collaborative alliance all housed within one organizational entity, doing business as Deep Centered Mental Health. Our clinicians coordinate and consult with one another in order to provide the best care possible to our clients. Our clinicians have frequent opportunities to consult with one another regarding their work and may discuss their work with you in case consultation meetings. In those instances, your clinician will do so according to best practices to help protect your privacy (e.g., not using your name, changing details to help protect your identity, etc.). Just like physicians might consult with one another to provide the best treatment to their patients, our clinicians consult to ensure your progress and care.
To protect the confidentiality of our clients, clinicians will not acknowledge clients in public unless the client chooses to engage them first. Therapists may then speak with clients briefly but feel it appropriate to limit discussions in public or outside the therapy office.
Session content and all materials relevant to treatment are confidential unless the client submits a valid release of information (ROI) to have all or portions of such content released to a specifically named person or organization.
If your primary clinician will be absent for an extended period of time, they may discuss finding a substitute clinician to provide support while away. In some cases, this might involve you being transferred to another clinician's caseload. Similarly, if your primary group therapist will be unable to lead group, the standard practice is that a substitute leader will be selected by the therapist to lead the group. Any concerns about absences or substitute coverage should be explored with your therapist.
Telehealth and Other Remote Services
When clinically appropriate, we provide telehealth services. Therapists determine on an ongoing basis whether the condition being assessed or treated is appropriate for telehealth services. Due to licensure restrictions, our clinicians may only provide services to individuals located in Texas at the time of their appointment.
Clients should present to the telehealth session in a quiet, secure location where others will not overhear anything shared by any party. Clients should also ensure that their location is free from distractions. Telehealth should never occur while a client is a driver or passenger in a motor vehicle.
The clinician is legally and ethically able to provide teletherapy within the state of Texas when they deem it clinically appropriate and when you agree to it as a therapeutic option. This teletherapy is governed by Texas laws and the regulations of the licensing board. It is the responsibility of you, the client, to inform the clinician in advance if you will not be in Texas for your session. When you are physically in another state or country, the clinician is required to also comply with the laws and professional licensure requirements of that state or country, which means they cannot guarantee teletherapy services when you are out of Texas.
To avoid a late cancellation or a no-show fee, please let your clinician know in advance if you will be out of Texas for your session. To try to arrange teletherapy for future sessions when you will be out of Texas, please talk to your clinician at least two weeks in advance during one of our sessions, and we can, on a case-by-case basis, see if teletherapy will be possible in your location. Ultimately, your clinician will defer to the laws and regulations of the professional board in both Texas and your travel location as well as the clinician's clinical judgment to determine if teletherapy is viable, ethical, and appropriate. It is your right to discontinue therapy services and/or teletherapy services at any time. It is also within the rights of the clinician to discontinue treatment if the clinician feels it is in your best interests.
It is your responsibility to provide your own equipment in order to conduct the teletherapy session. This includes a computer or tablet, a webcam or camera built into their device, and Internet access to conduct the session.
Teletherapy does not provide emergency services. If you are experiencing an emergency situation, call 911 or proceed to the nearest hospital emergency room for help, or contact your psychiatrist. If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at: 1-800-273-8255.
You have the right to request face-to-face counseling instead of teletherapy, as long as you can physically travel to the therapist's office and agree to meet the schedule of the therapist and as long as meeting face to face is safe for both client and therapist (e.g. Covid 19/global pandemic). Clients can discontinue teletherapy services at any time. Clients have a right to access their medical information and copies of medical records in accordance with HIPAA privacy rules, and the rules of the therapist's licensing board.
Assessment Services
Psychological assessments can be time intensive and costly. Some assessments may take several weeks to complete, especially if the client's availability is limited and the testing process requires extensive report writing. Please expect your assessment to take approximately 1-2 months to complete. Your assessment clinician hopes to complete the assessment before then and will do their best to keep you updated throughout the process. If you have any questions or concerns, please contact our scheduling team.
Our clinicians will not offer an expert opinion or recommendation relating to the conservatorship of or possession of or access to a child unless the licensee has conducted a child custody evaluation relating to the child under Texas Family Code, Subchapter D, Chapter 107. We not provide child custody evaluations.
Couples/Marital/Family Services
If you are in couples/marital/family counseling, you are considered to be, as a group, a client of the practice. Unless otherwise agreed upon with your clinician, all meetings will be done with everyone present. If individual meetings are done as part of couples/marital/family counseling, all parties will agree to this as part of therapy and provide consent at the onset of treatment. If you request a release of these records, all parties must provide a signed authorization for the full records to be released. If the court subpoenas your records, additional authorization is not required. All records will be kept together in one file (primarily under the name of whoever is responsible for billing). If anyone requests that those records be released, all parties must provide a signed authorization for the full records to be released.
Psychiatry Services
Our organization also includes psychiatry services for established clients when referred by their clinician. Your therapist is not a psychiatrist and only psychiatrists can advise you on medication.
Group Psychotherapy and Other Group Services
Group members are committed to learning about themselves and their patterns in relationships. To this end, members are committed to the instrumental goal of expressing all their thoughts and feelings as they occur within the group, especially those feelings toward the other group members and the therapist. Members' thoughts and feelings in the present is the material from which group psychotherapy flows. To foster a safe and productive group, members make several important agreements to the group.
Members will treat matters that occur in the group with the utmost confidentiality. To that end, members are expected not to discuss what happens in the group with people who are not members of the group and will keep the identity of all group members confidential. Members do not make contact with each other outside the group. The group provides an opportunity for learning about one's problems in social relationships; it is not a gathering in which people meet to make social friends, and if used in this manner the group loses its therapeutic effectiveness. If by chance or design members do meet outside the group, it is their responsibility to discuss the salient aspects of that meeting in group.
What members share in the group, meetings with psychiatrists, or in individual or marital therapy may be shared with other members of the "treatment team" when anyone feels that it is important for continuity of care. This communication includes diagnoses and other information from your client record. A person's "treatment team" consists of his/her group therapist, individual and/or marital therapist, psychiatrist, and all the members of the psychotherapy group. Regular and timely attendance at all sessions is an expected and essential part of the process. If possible, members will notify the group in advance (at least by the previous week) when it is necessary to miss a group. Your leader will provide guidance on how to inform the group if you have an unexpected absence, such as an illness. If the primary group leader is unable to facilitate, our practice is for the therapist to choose an appropriate substitute leader to lead the group. Under normal circumstances, leader absences will be announced well in advance, and members will be informed about who will lead the group. If the absence is unexpected or emergent in nature, prior notification of the substitute leader may not be possible. If no substitute is available, the leader may cancel the group, and members will not be charged. Absences, lateness, and substitution of leaders are routinely explored in the group."
EMDR Intensive Therapy
EMDR Intensive Therapy consists of 4-6 hour daily therapy sessions over 3-5 consecutive days for a total of 15-30 hours. To determine if EMDR Intensive Therapy is clinically appropriate, prospective clients receive an initial consultation from an on-site clinical specialist before beginning treatment. Services are billed at $175 per clinical hour, prorated hourly in 15-minute increments. The total cost of treatment must be paid in full at least 14 days in advance to secure session appointment times.
Assist the Officer Foundation (ATO)
We are an independent contractor of the ATO to provide counseling to Dallas Police Officers and their immediate family members. Clients utilizing ATO benefits understand and agree that the ATO will pay for counseling totaling $875.00 per calendar year. Payment for services over the $875.00 limit is the responsibility of the client.
FMLA and Disability Paperwork
Clients must attend a minimum of six therapy sessions before considering a request to complete FMLA or disability documentation. It is then at the treating clinician’s discretion, and requests may be denied based on one or more factors, including the sufficiency of information and the appropriateness of an FMLA recommendation. Clinicians will only provide medical clearance to return to work if they were the provider who initiated the leave from work.
Appointments and Fees
You are responsible for scheduling your appointments. If you decide to change a scheduled appointment, contact us please contact us in advance to avoid fees (see missed appointment policies) and so that we can offer the appointment to someone else. The fee for each session will depend on the service rendered as well as additional factors such as your clinician's degree, license and years of experience. Fees may be charged for more extensive communications and work completed outside of your specific scheduled service with the clinician (e.g., a 30-minute phone call, an email that takes a lengthy response, etc.). These rates are determined by the clinician and used to reasonably and fairly compensate them for their time. For specific information about your clinician's fees, please contact our billing department.
If you have not scheduled with your clinician for a period of 60 days or more, your clinician terminates treatment with you and closes your case. If at any point you would like to continue working with your clinician, you may do so and your case can be reactivated. If you would like to terminate treatment at any point, you may do so by contacting your clinician and/or our scheduling office. Please note that it is best to have at least one final "termination session" with your clinician before ending your work together.
A valid credit card must be on file at all times to continue treatment without disruption. Payment by cash, check, or credit card is due at the time of service unless prior arrangements have been made. Late cancellations or no-shows will incur a $100 fee. Accounts are considered delinquent after 30 days of non-payment, and your card may be charged automatically if you are behind on payment.
When a longer or shorter session is required, the base session fee is prorated. Couples, for instance, sometimes prefer hour-long sessions, as do some individual clients. If other services, such as report writing, telephone conversations, consulting with other professionals with your permission, and preparation of records or treatment summaries, take an unusual amount of time, there will be a charge for them as well. Accounts are considered delinquent after 30 days of non-payment and your card may be charged automatically if you are behind on payment for three or more sessions. Late payment will be discussed in therapy, and, if it continues to be a problem, will result in the discontinuation of treatment until the balance is paid in addition to use of a collection agency. If we send your unpaid dues to collections, a fee will be added to your balance equal to 25% of the unpaid amount to account for losses and interest.
Treatment will be suspended if there is no valid credit card on file for two consecutive visits or if a patient’s balance exceeds $300. Treatment can resume if the balance is paid in full or a payment plan is established to achieve a $0 balance within 3 months. Failure to meet payment plan obligations will result in treatment suspension, with possible exceptions based on clinical need as approved by the Chief Clinical Officer or Clinical Director.
EMDR Intensive Cancellation Policy
Clients scheduled to receive EMDR Intensive therapy must provide additional notice to cancel or reschedule an intensive by 5:00 PM 7 calendar days prior to the scheduled start date.
If less notice is given, the following fees are imposed:
48 hours to 6 days notice: Refund less a $250 administration fee.
Less than 48 hours notice or no show: Refund less a $450 administration fee.
If the intensive is rescheduled and completed within 30 calendar days of the original start date, the fee is reduced
to $150 in the form of a credit toward the intensive.
Payment Policy
Fees are payable when services are rendered and may vary by the therapist and insurance coverage. All services provided, including counseling sessions, forms, documents, letter writing, or similar, are non-refundable. Our organization has a negotiated rate with each insurance company outlined in our contract with that entity. Clients covered by an insurance plan with which the therapist is in-network are billed at that insurer’s contracted rate. We provide a summary of insurance benefits by phone or email to clients as a courtesy. If there is a discrepancy in the amount initially quoted by the insurer or our organization, the client is responsible for the unpaid portion based on the insurer’s Explanation of Benefits (EOB). Payment forms accepted include cash, credit card, check, health savings account (HSA), and flexible spending accounts (FSA). A credit card authorization form is required for all credit card payments. If another individual or organization is responsible for the cost of treatment, we may request permission to speak with the payer(s) regarding financial information. If a legitimate charge is disputed and ultimately found legitimate by the bank, the client agrees to pay all fees associated with the dispute.
The fee for each session will depend on the service rendered as well as additional factors such as your clinician's degree, license, years of experience, and department. Fees may be charged for more extensive communications and work completed outside of your specific scheduled service with the clinician (e.g., a 30-minute phone call, an email that takes a lengthy response, etc.). These rates are determined by the clinician and used to reasonably and fairly compensate them for their time. For specific information about your clinician's fees, please contact our billing department.
If you have not scheduled with your clinician for a period of 60 days or more, your clinician terminates treatment with you and closes your case. If at any point you would like to continue working with your clinician, you may do so and your case can be reactivated. If you would like to terminate treatment at any point, you may do so by contacting your clinician and/or our scheduling office. Please note that it is best to have at least one final "termination session" with your clinician before ending your work together.
Payment by cash, check or credit card is due at the time of service unless prior arrangements have been made. When a longer or shorter session is required, the base session fee is prorated. Couples, for instance, sometimes prefer hour-long sessions, as do some individual clients. If other services, such as report writing, telephone conversations, consulting with other professionals with your permission, and preparation of records or treatment summaries, take an unusual amount of time, there will be a charge for them as well. Accounts are considered delinquent after 30 days of non-payment and your card may be charged automatically if you are behind on payment for three or more sessions. Late payment will be discussed in therapy, and, if it continues to be a problem, will result in the discontinuation of treatment until the balance is paid in addition to use of a collection agency. If we send your unpaid dues to collections, a fee will be added to your balance equal to 25% of the unpaid amount to account for losses and interest.
Dallas CTC Self-Pay Fees
LPC, LMFT, and LCSW:
Intake: $170
53-60 minute session: $150
38-52 minute session: $112.50
16-37 minute session: $75
LPC-Associate, LMFT-Associate, and LMSW:
All sessions: $100-$115
Deep Eddy Therapy Self-Pay Fees
Licensed 20+
Intake: $310
53-60 minute session: $410
Licensed 15+
Intake: $270
53-60 minute session: $345
Licensed 10+
Intake: $225
53-60 minute session: $280
PhD/PsyD/Doctoral Intern
Intake: $205
53-60 minute session: $250
LPC/LMFT/LCSW
Intake: $180
53-60 minute session: $215
MA Associate
Intake: $145
53-60 minute session: $175
Deep Centered Psychiatry Self-Pay Rates
Psychiatrist
$440 for adult intake
$545 for child intake
$210 for follow-up medication management appointments
$350 for medication and therapy
Nurse Practitioner or Physician’s Assistant
$275 for adult intake
$325 for child intake
$200 for follow-up medication management appointments
$250 for medication and therapy
Form Requests
Single page forms: $25 per form
Multi-page forms: $150 per hour billed in 15-minute increments
A new ESA evaluation is required to complete any additional forms after six months.
Insurance Claims
Our organization verifies insurance coverage and submits claims on your behalf when we are in-network with your insurance plan. However, we cannot guarantee that an insurance company will cover the cost of services rendered until the claim processes. If an insurer denies a claim, the client will be responsible for the cost of services rendered. Any appeal of a claim denial is the responsibility of the client. Failure to provide health insurance information to our organization before an appointment constitutes a waiver of the individual’s right to utilize insurance benefits. We will begin filing claims occurring on or after the insurance information is provided to our office. Phone consultations are not covered by most insurance plans and are billed directly to the client at our organization’s private pay rate.
Credit/Debit Payment Authorization
This form gives us permission to:
Charge for no-show or late cancellations (less than 48 hours notice provided).
Charge you to reschedule an intake, should you fail to complete the patient forms at least 24 hours prior to the intake appointment in the AMD Patient Portal.
Charge for a remaining balance that your insurance company has denied and deemed your responsibility.
Charge the retainer fee for a court appearance legally required by a subpoena (see the section on subpoenas).
THE NO SURPRISE ACT (OMB Control Number: 0938-1401)
If you are not using insurance (by choice or because you do not have insurance), you have the right to request a Good Faith Estimate (GFE) explaining how much your therapy or psychiatry services are likely to cost. This includes the total expected cost of any non-emergency item or service such as those offered at our practice. We will provide you with a GFE upon request at least one (1) business day before your scheduled session. You can request your GFE by emailing our Scheduling team. If you receive a bill for at least $400 more than your GFE, you can dispute the bill by visiting https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-are-uninsured. Make sure to save a copy of your GFE. Questions on your rights can be directed to https://www.cms.gov/nosurprises call 201-800-958-3059.
Court Policy
Our organization does not provide custody or home study evaluations and will not make a recommendation regarding custody. Should a therapist be ordered by a court to write a letter or appear in court, regardless of what attorney issued the subpoena, the fee stipulations are as follows:
- In-person appearance: $1600 per day plus $200 - $500 per hour (based on provider credential) for travel to and from the court and $200 per hour for preparation.
- Video appearance: A time estimate is provided to the client once a court order is received. The fee is $200 per hour based on a time estimate as well as $200 per hour for preparation.
- A $2,000 retainer is required upon receipt of a subpoena for an in-person appearance.
- A $1,000 retainer is required upon receipt of a subpoena for a virtual appearance.
Should a case be trialed or continued, clients will pay in full for each day and an additional $1,000 per day as it hinders the therapist's ability to be available to their other clients.
Providers will not agree to be on-call for a court appearance at any time. All court fees must be received by a cashier's check, cash, or credit card at least seven days before the court date. Should the court continue the hearing for another date, the therapist must be served with a new subpoena with the latest court hearing date. Your signature on this form acknowledges consent and agreement to all the above statements. It also provides our organization the permission to charge the card on file for the applicable retainer if you do not make other financial arrangements with our organization by 8:00 AM, seven days before the court date.
In the event disclosure of your records or the provider’s testimony is requested by you or required by law, you will be responsible for and shall pay the costs involved in producing the records and the clinician's rate for giving and preparing for that testimony. Such payments are to be made at the time prior to the time the services are rendered by the clinician. The clinician may require a deposit for anticipated court appearances and preparation.
Feedback and Complaints
If you have any feedback or complaints regarding your experience with your provider, please feel free to inform our managing team directly (at patientexp@deepcentered.com).
You also have the right to file a complaint directly to the Texas Behavioral Health Executive Board:
Website - https://www.bhec.texas.gov/discipline-and-complaints/
Phone - 800-821-3205
Texas Behavioral Health Executive Council (BHEC)
George H.W. Bush State Office Bldg.
1801 Congress Ave., Ste. 7.300
Austin, Texas 78701
Encompasses the following licensing bodies:
Texas State Board of Examiners of Professional Counselors (LPC)
Texas State Board of Social Worker Examiners (LMSW/LCSW)
Texas State Board of Examiners of Marriage and Family Therapists (LMFT)
Professional licenses for all therapists may be verified on the BHEC website www.bhec.texas.gov
Licensed Chemical Dependency Counselor (LCDC) Program
Mail Code 1982, PO Box 149347, Austin, TX 78714-9347 | Ph: 512-834-6605
Our Contact Information
Your clinician's (or their supervisor's) license number is available upon request by contacting our Scheduling office. If your clinician leaves or is no longer able to work (e.g., in the event of their death), the practice will offer to reconnect you with another therapist if you would like to continue therapy, or we can provide you with contact information for other options for psychological services in the area.
DallasCTC Phone: 972-865-8782
Deep Eddy Therapy and Deep Centered Psychiatry: 512-956-6463
Our office addresses are listed on our websites: dallasctc.com deepeddypsychotherapy.com
Preference for Confidential Communications
As per the Notice of Privacy Practice, you have the right to request that this office communicate with you about your health information in a certain way or at a certain location. We collect your contact information to reach out to you via call, text, and email. You have the right to opt out of these communications by messaging our Scheduling team directly. Telephone (including text), email, and videoconference are not encrypted methods of communication, and some confidentiality risk exists with their use. We do not sell, lend, or rent our mailing list to third parties.
Our team communicates using these methods. While we do our best to verify your email address, phone number and address at the time of intake, it is your responsibility to update your record if you would like to communicate via a different means, or if any of your contact information has changed.
By signing this Consent and Services Agreement, you consent to your clinician, or someone from our team, following up with you by telephone, text or email for scheduling, billing, quality assurance, or other reasons. If you would prefer not to be contacted by email and/or text or need to update your information, you may contact our Scheduling team via email or phone.
We are an outpatient practice that provides psychological services for people who are appropriate for that level of care. Your clinician is not always available for urgent appointments and may not always be able to respond to crisis situations. If you (or the client you are signing for) are at risk of harm (e.g., experiencing thoughts or urges of self-harm or suicide), contact the 24-hour Emergency Hotline at 512-472-HELP (4357) or 911 to get immediate care.
If you are not at immediate risk of harm, you agree to share these things with your clinician so that you can address these symptoms and the help you need.
Quality Assurance and Feedback
We are committed to providing quality services. Therefore, you may be contacted periodically by our Chief Clinical Officer and or the business itself to provide feedback regarding your experience. This contact may come via text or email, and you can opt out at any point. You may also provide public reviews online as the business is listed on Google My Business and other directories. Your therapist cannot and will not ask you to provide a review for them, but they may ask for your feedback in-session to ensure you get the best possible care they can provide.
Firearms, Substances, and Other Dangerous Items
All firearms, knives or any other dangerous/deadly weapons are prohibited from being brought onto practice property, unless carried by an officer of the law as part of his or her official duties. Should staff become aware that a client, family member, visitor, or other staff person has brought a firearm onto the premises, staff will request that that individual leave and not return until they are no longer carrying a firearm on their person. Should the individual in question refuse, a member of management should be contacted. Should the individual in question also refuse the request to leave made by the member of management, then the police will be called to have the individual removed. This same policy will apply to other such weapons as the manager may determine to apply, such as hunting knives.
By signing this form, the client agrees to be sober during sessions. If a clinician suspects that a client is under the influence of a substance (e.g., drunk or high during session), we reserve the right to end the session and charge a missed appointment fee. Furthermore, if the clinician suspects that the client is attending sessions under the influence of drugs and/or alcohol, the clinician may opt to terminate therapy and will provide the client with referral options for appropriate care.
Your Risk & Responsibility
You understand that by attending an in-person session, you are assuming the risk of exposure to COVID-19. In doing so, you release our organization from all liabilities related to any loss, damage, injury, or death that you may sustain if exposed to COVID-19 while in, on, or around the premises or while using the facilities that may lead to exposure or harm due to COVID-19.
These precautions may change based on new local, state, or federal orders or guidelines. If that happens, your therapist will discuss the changes with you.
Service Animals
We afford clients with disabilities requiring the assistance of a service animal with equal access to our facility.
Handlers are expected to maintain direct control of their service animal at all times and are responsible for any damage or harm caused by the service animal. We do not permit any other animals in our offices.
Medical Records
Requests for medical records may be submitted by email to your clinician, the scheduling team, or you may contact our records department at records@deepcentered.com. A Release of Information form is required before the release of medical records to any individual or entity. Requests to complete forms or provide clinical letters are billed to the client per our service fee rates.
Clients may transfer to or receive treatment from multiple therapists within our organization. As a client of our organization, you consent that your therapist(s) will have access to all medical records accumulated throughout your care with our organization.
The legal organizational entity of Deep Eddy Psychotherapy Management LLC is the custodian of record on all cases. Custodians have a plan in place regarding custody of medical records in the event of their death or unavailability.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed by our organization and how you can access this information.
Your Rights
If you make a written request for your medical records and other health information. We will provide a copy or summary within 15 days of the request and may charge a reasonable fee.
You can ask us to correct inaccurate health information. We will accommodate all reasonable requests. If we deny the request, we’ll explain in writing within 60 days. You can ask us not to use or share certain health information for treatment, payment, or operations. We may deny the request if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for payment or our operations with your health insurer.
We’ll accommodate the request unless the law requires us to share that information.
You can ask for a list (accounting) of the times we have shared your health information for six years before the date you ask, including who we shared it with and why. We include all disclosures except for those about treatment, payment, health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but charge a reasonable, cost-based fee if you request another one within 12 months.
You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
If someone is your legal guardian or has medical power of attorney, they can exercise your rights and make choices about your health information. We’ll make sure the person has this authority and can act on your behalf before taking action.
If you feel we have violated your rights, you may file a complaint by contacting us directly. To file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights, send a letter to 200 Independence Ave, SW, Washington, D.C. 20201, call 1-877-696-6775, or visit HHS.gov. We will not retaliate against you for filing a complaint.
Your Choices
You can tell us your choices about what we share and how we share your information in the situations described here by contacting our office.
You have both the right and choice to tell us to share information with your family, close friends, or others involved in your care.
We never share or sell your information to other organizations for their marketing purposes.
Our Uses and Disclosures
Within our practice, we may disclose your health information to all professionals who treat you and those that manage our practice in order to improve your care, contact you when necessary, bill, and collect payment from health plans or other entities.
We have to meet many conditions in the law before we can share your information for these purposes. More information is available at HHS.gov.
We are allowed or required to disclose health information about you for certain situations such as with a coroner, medical examiner, or funeral director when an individual dies, to address workers’ compensation claims, for law enforcement and other special government requests, with health oversight agencies for activities authorized by law, for public health and preventing disease. We are allowed to disclose health information about you when reporting suspected abuse, neglect, or domestic violence, for preventing or reducing a serious threat to anyone’s health or safety, in response to a court or administrative order, subpoena, or if state or federal laws require it, and with the Department of Health and Human Services to show compliance with federal privacy law.
Our Responsibilities
Federal law requires us to maintain the privacy and security of your protected health information. If a breach occurs that may have compromised your information, we will let you know promptly. We must follow the duties and privacy practices described in this notice and give you a copy.
We will not use or share your information other than as described here unless you provide written authorization. You may change your mind at any time by letting us know in writing. For more information, visit HHS.gov.
Changes to the Terms of this Notice
We can change the terms of this notice, applicable to all the information we have about you. The new notice will be available on our website and in our office upon request.
By signing this form and proceeding with services, you acknowledge that you have reviewed and received a copy of these Notices of Privacy Practices.
Credit Card Authorization and Recurring Payment Agreement
By signing below, you certify that you are the authorized user of the credit card put on file and that you authorize Deep Centered Mental Health to charge your card for the services and/or products rendered.
You also state that you understand and agree to the following:
Authorization of Recurring Payments: You consent to recurring charges to your credit card for ongoing services or products as agreed upon, which will continue until such services are canceled or this agreement is terminated.
Dispute Liability: In the event of a charge dispute, you acknowledge that you are responsible for all valid charges related to the services and/or products provided. Should a dispute result in a chargeback or additional fees to the practice, I agree to reimburse all such charges, including the original amount due and any fees or penalties incurred by the practice as a result of the dispute.
Card Information: You confirm that the information provided is accurate, and I will notify the practice immediately if my card information changes or if you wish to terminate this authorization.
You certify that you are an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
Final Agreement of Full Consent Form
Your signature below indicates that:
- You have read this form in its entirety, agree to the terms, and provide consent to be treated by the provider.
- You have been given ample opportunity to ask questions and receive clarification regarding psychological services and the terms to which you are consenting.
- You consent to the practice using the online platforms and applications of their choice for administrative purposes.
- You have indicated my preferences and consent for these communications.
- You understand that your clinician may not be available for urgent/crisis situations and that you should contact the Emergency Line at 512-472-HELP (4357) or 911.
- You understand that a copy of this form can be provided to you upon request.
If the patient is a minor with a custody agreement, parental divorce decree, or other legal requirements related to their care, you have provided copies of those to the practice in advance of the first appointment. By signing as the legal representative or parent/guardian of the client, you confirm that you have the authority to consent to treatment and that all legal guardians have provided full consent.
- You certify that you are the authorized user of the credit card put on file and that you authorize Deep Centered Mental Health to charge your card for the services and/or products rendered.