WELCOME TO K&G COUNSELING
This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purpose of treatment, payment and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Psychotherapy/Counseling Services - Consent to Treat
Psychotherapy is a working cooperative relationship between you and your therapist. Each member of this cooperative relationship has certain responsibilities. Your therapist will contribute their knowledge, expertise, and clinical skills. You, as the client, are responsible for bringing a collaborative and committed attitude to the therapeutic process. While there are no guarantees regarding the outcome of the treatment, your commitment may increase the likelihood of a satisfactory experience.
As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following section.
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, fear, 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. But there are no guarantees about what will happen. Psychotherapy requires a great deal of effort on your part. To be most successful, you will need to work on the things we discuss outside of sessions.
I understand that I will be taking part in mental health services, which are psychological in nature. I hereby give permission for K and G Counseling to provide services.
Consent to Treat – Minor
I understand that my child will be taking part in mental health services, which are psychological in nature. I hereby give permission for K & G Counseling to provide services. I understand that consent from both custodial parents is required for treatment services to be provided. I understand that both custodial parents will be provided the opportunity to participate in treatment planning and, when appropriate and recommended by the treating clinician, participate in therapy sessions. I understand that the child is the identified client, and billing will be made through the child's insurance coverage for client and/or family sessions. I understand that the decision to meet with me, my attorney, any other party or other attorneys in any custodial or divorce proceeding is at the sole discretion of the clinician.
For children whose parents hold legal joint custody, written permission from both parents to participate in treatment is required by law. I, as JOINT CUSTODIAL PARENT, hereby give permission for the above-named child to receive and participate in counseling/mental health services with K and G Counseling.
I understand that there will be a paper copy of this consent form that both custodial parents must sign before services can begin.
Fees
The standard fee for hour-long sessions is $90. You are responsible for paying at the time of your session unless prior arrangements have been made. K and G Counseling accepts most insurance plans, but we do not determine the co-pay amount. There may be a delay in knowing the exact amount due or the co-pay based on contact from your insurance company and whether you have met your deductible. If you have private insurance and choose not to use your policy or do not have insurance, the self-pay rate is $90 per hour.
We reserve the right to suspend therapy if the client has an outstanding balance, without prior arrangements, before scheduling. We accept credit cards, checks, and cash. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. It is not a guarantee that your insurance will cover your treatment. Every insurance policy is written differently, so it is the client's responsibility to speak with their insurance regarding their coverage. If your insurance does not cover psychotherapy services or if your coverage lapses, you are responsible for your balance.
We require a credit or debit card to be kept on file for all clients. This card may be used to cover:
Late cancellation fees
No-show fees
Any remaining deductible, co-insurance, or other patient responsibility as determined by your insurance company.
You will be contacted prior to your card being charged for the first time, once we have received documentation from your insurance company confirming your financial responsibility.
In addition to your appointments, it is our practice to charge for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other services which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
Professional Records
I, as your therapist, am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure online electronic health record system. I keep brief recordings noting that you were here, your reasons for seeking therapy, the goals and profess we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
Confidentiality
Communication between you and your therapist is confidential. This means that your therapist will not discuss your care orally or in writing with your expressed written consent.
Your therapist has an ethical and legal obligation to break confidentiality under the following circumstances:
If there is a reason to believe there is an occurrence of a child, elder, or dependent adult abuse or neglect.
If there is a reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit.
If you disclose that you knowingly develop, duplicate, print, download, stream, or access through any electronic or digital media exchanges, a film, photograph, or video in which a child is engaged in an act of obscene sexual conduct.
If you introduce your emotional condition into a legal proceeding.
If there is a court order for the release of your records.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Availability and After Hours Emergencies
Therapists check for voice messages during normal business hours. Messages left outside of normal hours of operation will be picked up the next business day. If you have an emergency that needs immediate attention you may need to seek assistance at the nearest emergency services department.
Contacting Your Therapist
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail or via text message and your contact will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, contact your local hospital emergency room, or call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.
Child Care Release
We do not provide childcare and it is not responsible for children and adolescents left unsupervised in the waiting room. Minors must be picked up on time following their appointments. If you must leave your child in the waiting room during a session, you are responsible for providing appropriate supervision. Children under 13 may not be left unattended in the waiting room.
Additional Rights and Responsibilities
In addition to your right to confidentiality, you have the right to end your counseling at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. You have the right to question any aspect of your treatment with your therapist.
You also have the right to expect that your therapist will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you.
If you are unhappy with what is happening in therapy, I hope that you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist.
You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin. You have the right to ask questions about any aspects of therapy and about my specific training and experience.
We reserve the right to discontinue counseling at any time, including, but not limited to, a violation by you of this Consent for Treatment, a change or reevaluation of your therapeutic needs, our ability to address those needs, or other circumstances that lead us to conclude in its sole and absolute discretion that your counseling needs would be better served at another counseling facility. Under such circumstances, we will suggest an appropriate therapist or counseling agency.
Your signature below indicates that you have read and understand this information and have received a copy of this consent form and give permission to us to provide counseling services and that this contract is binding for all future sessions you may have with this entity.
FINANCIAL & CREDIT CARD AUTHORIZATION
Rates
Charges for individual counseling is $90 per hour if self-pay.
Couples counseling cost is $200 for inital intake. Ongoing rate is $150
These rates are subject to change with market conditions, and clients will be notified of any changes.
Payment
The client is responsible for payment of ALL copayments, deductibles, and/or coinsurance amounts on the day of service, based on the information available through the insurance provider’s portal. Once the insurance claim has been processed, if the amount owed is more or less than originally collected, the client will either be credited toward a future session or charged the remaining balance using the payment method on file.
Any outstanding balance may result in a temporary suspension of services. Regular scheduling may resume once the balance has been paid in full. The client authorizes the practice to charge any outstanding balances to the payment method on file for up to twelve (12) months from the date services were rendered.
We accept credit cards, checks, and cash as payment. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment.
Please review the fee section of the Informed Consent Form for more detailed information.
Cancellation Policy
Your appointment is very important to us and is reserved principally for you. Therefore, we kindly request that all changes and cancellations be made at least 48 hours in advance.
Same-day cancellations (within 24 hours) and no-shows will incur a $90 fee. We will be unable to reschedule you unless this balance has been paid. After 3 late cancellations, we reserve the right to refer you to the office.
We do require a card on file to charge late cancellation, no-show fees, copays, deductible amounts, etc.
These policies are strict and enforced.
Thank you for valuing our services by agreeing with these terms.
Agreement
By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as K&G Counseling. You have the right to request a paper copy of this document.
I authorize K&G Counseling to charge my credit card through Stripe. I also agree that my credit card can be charged for any session that is not canceled at least 48 hours prior to the scheduled session.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify K&G Counseling in writing of any changes in my account information or termination of this authorization.
I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.
TELEHEALTH CONSENT
Telehealth is providing therapy using interactive audio and visual (video) electronic systems in which the provider and client are not in the same physical location. The interactive electronic systems incorporate network and software security protocols to protect patient information and safeguard the data exchanged.
Requirements
A computer, laptop or mobile phone with a webcam and microphone to video conference using a HIPAA-compliant online company specializing in telehealth. As with any medical procedure, there may be potential risks associated with the use of Telehealth. These risks include but may not be limited to.
Therapy conducted online is technical in nature and problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the therapist, and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, the therapist will call the client back at the phone number provided on this form.
The therapist may not be able to provide treatment to the patient using the interactive electronic equipment or arrange emergency care the client may require in the event of a connection failure.
Delays in evaluation and treatment may occur due to equipment deficiencies or failures.
Although highly unlikely, security protocols can fail, causing a breach of privacy of confidential information.
A lack of access to all the information available during a face-to-face visit, but not during a Telehealth session, may result in errors in the therapist's judgment.
My Rights
I understand that the laws that protect the privacy and confidentiality of private health information also apply to Telehealth.
I understand that the technology used by the therapist is encrypted to prevent unauthorized access to my private health information.
I have the right to withhold or withdraw my consent to the use of Telehealth at any time during the course of my care. I understand that my withdrawal of consent will not affect any future care or treatment.
I understand that my therapist has the right to withhold or withdraw her consent for the use of Telehealth during the course of my care at any time.
I understand that all the rules and regulations that apply to the practice of psychotherapy in the state of Kentucky also apply to Telehealth.
I understand that my therapist will not record any of our Telehealth sessions without written consent.
I understand that my therapist will not allow any other individual to listen to, view, or record my Telehealth sessions without my express written permission.
My Responsibilities
I agree to take full responsibility for the security of any communications or treatment information involving my own computer and physical location.
I understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.
I understand that the company my therapist has chosen to conduct the online appointment is an independent company specializing in HIPAA-compliant telemedicine. My therapist has no responsibility for that company’s operations or the security of my protected health information.
I will not record any Telehealth sessions without written consent from my therapist. I will inform my therapist if anyone else can hear or see any part of our session before it begins.
I have read and understand all of the clinic policies of K and G Counseling, and that they apply to all Telehealth and in-person sessions.
I consent to pay fees that are the same as an in-office visit for the type and length of service provided, through the billing department at K and G Counseling.
I understand that a Telehealth appointment is scheduled the same as an in-office appointment, and that if I am not available or cancel less than 48 hours in advance, there will be a charge for a missed appointment equal to the time my therapist has reserved for the scheduled appointment.
I have read and understand the information provided in the preceding pages regarding Telehealth. I have discussed this information with my therapist and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in my care and authorize my therapist to use Telehealth in the course of my diagnosis and treatment.
CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS, AND ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES.
In the course of providing services to you, we may create, receive, and store individually identifiable information, including information that relates to health care and payment for health care (“Personal Information”). It is often necessary to use and disclose this Personal Information to treat you, to obtain payment for our services, and to conduct health care operations at our office.
We have a HIPAA Notice of Privacy Practices that describes these uses and disclosures. As described in our Notice of Privacy Practices, the use and disclosure of your Personal Information for treatment purposes not only includes care and services provided here, but also disclosures of your Personal Information as may be necessary or appropriate for you to receive follow-up care from another health care professional. Similarly, the use and disclosure of your Personal Information for purposes of payment may include, for example, the submission of this information to a billing agent for processing claims or obtaining payment and/or submission of claims to insurers.
When you sign this consent document, you expressly agree that we can and will use and disclose your personal information to treat you, to obtain payment for our services, and to operate our practice. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form.
PRACTICE POLICIES
APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the full fee if you give less than 24 hours' notice.
The standard psychotherapy session time is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session need to be discussed with the therapist to schedule time in advance.
A $10.00 service charge will be applied to any checks returned for any reason, for special handling.
Cancellations and rescheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voicemail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency arises, please call 911 or go to the nearest emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the need to minimize dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any communication via electronic media, including text messages. If you prefer to communicate via email or text for scheduling or cancellation issues, I will do so. While I may try to return messages in a timely manner, I cannot guarantee an immediate response, and I request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel
costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnoses, and interventions based not only on direct verbal or auditory communications, written reports, and third-person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he
or she would consider important information that you may not recognize as significant to present to the therapist.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone yourself or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, I must, for legal and ethical reasons, consider the professional relationship discontinued.
ART (Accelerated Resolution Therapy)
An ART session typically completes one “scene” that represents the problem. If there are many “scenes” related to a problem, it may take an average of 3 sessions to complete treatment.
Past trauma issues differ from ongoing problems. A single episode of past trauma may be able to be resolved within one session. On-going problems such as substance abuse/dependence, OCD, eating disorders, generalized anxiety, etc., will take more sessions, and it is best if you are seen twice the first week and twice the second week and stay compliant with any other treatment programs needed to aid you in your recovery. Clients have noticed feeling very good for 3 days after resolving a problem. A past problem trauma tends to stay resolved after that lift, while an ongoing problem tends to require more sessions. You may be shown how to use eye movements for calming purposes only and, if so, you should follow through as instructed for the best outcome.
Distressing, unresolved memories may surface through the use of ART. Some clients have experienced reactions during the treatment sessions that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations. Rarely, a client will report a headache after a session. Usually, those sensations can be processed during the ART session and most clients leave feeling relaxed. Negative images from distressing memories may seem to fade or disappear, while more pleasant images may take their place during ART.
You should check with an attorney if you need to testify about a legal procedure related to the issue you are working on in ART. When we use ART, many clients report that negative memories have been processed in such a way that they no longer bother them or that they no longer present with distress about those issues.
Subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, flashbacks, feelings, etc. may surface. If this happens, then you may choose to use ART to work with these issues if they do arise. They are usually not the same issues you have resolved during your ART session, although they may be connected in some way. Once uncovered, they can be dealt with using ART in a future session.
I acknowledge that I have been advised to check with a medical physician concerning any medical conditions that might put me at risk due to the possibility of a heightened emotional reaction, for example pregnancy, heart conditions, high blood pressure, rapid back and forth eye movements throughout the session, or any other concerns. I agree to contact my therapist with questions or concerns I may have after reading this document or at any time during the ART training or session.
I HAVE READ THESE CONSENTS AND PRACTICES AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY PERSONAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.
I ALSO ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE HIPPA NOTICE OF PRIVACY PRACTICES.