The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important that you have a clear understanding about the nature of this relationship, and what can be expected. This consent will provide a clear framework regarding how information related to this relationship is used and protected. Feel free to discuss any of this with your therapist. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. There is no promise that your behavior or circumstance will change. There is the offer to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally behavioral health professionals may need to consult with other professionals in their areas of expertise in order to provide the best treatment. Information may be shared in this context without using identifying information.
If you see your therapist accidentally outside of the therapy office, He or she will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge the therapist first, He or she 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.
Telehealth involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications.
Telehealth includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.
1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that there are risks and consequences from telehealth and counseling in general, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Alba Wellness utilizes secure, encrypted audio/video transmission software to deliver telehealth.
4. I understand that if my counselor believes I would be better served by another form of intervention (e.g., face-to-face services), I will be referred to a different mental health professional.
5. I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my counselor, I may be directed to “face-to-face” psychotherapy.
6. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.
8. I understand that my express consent is required to forward my personally identifiable information for billing purposes only.
9. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.
10. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.
11. I understand that different states have different regulations for the use of all counseling services.
Payment for Telehealth and in-office Services
Self-pay clients are required to pay for services in full at the time of service.
Deductibles and co-pays are due at the time of service.
Alba staff provides quotes for copays and deductibles from your insurance company. These are only quotes provided to us by your insurance company. Your responsibility is determined when insurance claims are finalized. However, insurance companies have the right to retroactively change your responsibility. We have no control over this process and do our best to keep you updated in regards to your responsibility. It is your responsibility to update us regarding changes in your policy, changes to your copay and deductibles.
Your insurance policy is a contract between you and the insurance company. We are not party to that contract and our relationship is with you. We cannot become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and "usual and customary" charges. Not all services are a covered benefit in all contracts.
We verify all insurance coverage for all clients, but these are only quotes per insurance companies. It is your responsibility to notify the office of changes or updates regarding your insurance.
Alba will submit claims for services to your insurance company on your behalf. If for any reason, your insurance company should fail to pay the contracted allowable rate or deny any services as a non-covered benefit, you accept full responsibility for those service and associated fees.
In the event that insurance does not cover in-office service or telehealth, and the individual wishes to pay out-of-pocket, or when there is no insurance coverage, a prompt pay discount may be available if requested.
By signing this form, I understand and agree to the following fee schedule. I am responsible for the applicable service fees, if insurance does not pay.
|LPC 60 min. Initial Assessment
|LPC 45 min Counseling
|LPC 30 min Brief Therapy
|LPC 45 min family/couples counseling
|LPC 15 min Phone Consultation
|LPC Group Therapy (45-60 min)
|LPC legal/court rate
|Late cancellation(Less than 24 hr or No Show)
|LPC intern 60min Intake (Initial Assessment)
|LPC intern 45min Counseling
|LPC intern 30min Counseling
|LPC intern 45min Family/Couple counseling
|LPC intern 15min Phone Consultation
|LPC intern Legal/Court rate
|Medical Records/Simple Letters/Reports
At AWI, we attempt to balance the client’s wellbeing with the need to create a comfortable working environment. It is a simple reality that there are times when life is challenging and paying for services is difficult. Our process for addressing this concern is as follows:
a. Client may qualify for a fee on a sliding scale.
b. Client may see an intern for a reduced rate.
c. Client may be considered a “pro bono” case.
d. Client may be given references for services at another agency.