INFORMED CONSENT FOR INDIVIDUAL THERAPY

Welcome: Before starting your therapy, it is important to know what to expect, and to understand your rights as well as commitments. This consent form is an attempt to be as transparent with you as I can about the therapy process, so you are fully informed prior to starting your journey.

My credentials: I am a mental health counselor who is licensed in the state of Florida by the Florida Department of Health. As a licensed counselor my work is regulated by Florida mental health laws, and the rules and regulations of my license.   I am also a Certified EMDR Therapist and have met all credentialing requirements as designated by the EMDR International Association.

What to expect from therapy: Psychotherapy is a process of opening up about your life experiences and your genuine thoughts and feelings in order to increase your self-awareness of psychological and emotional conflicts that keep you stuck in unwanted patterns. My approach to therapy is psychodynamic and emotion-focused. This means that I focus on helping you uncover the root causes and stuck emotions that contribute to current life distress. The therapy may involve temporary periods of discomfort as you begin to work through past trauma or confront psychological conflicts you have previously been avoiding.

Fees: Individual therapy is billed at the rate of $140 for a 50 min session.

I, the client, agree to pay the stated fee by cash, or credit card at the beginning of each session. If I, the client, am prevented from attending my scheduled session and do not cancel my appointment at least 24 hours in advance, I agree to pay the full session fee. This practice of being charged for no-shows or late cancellations is standard practice in the field, and takes into account that you are not just paying for services rendered, but reserving a time slot which I cannot offer to someone else on short notice.

Insurance: I am in network with specific insurances at this time and can help you verify your mental health benefits, co-pay requirements and any session limits that may come with your insurance plan for insurances I am able to accept.  Some insurance companies may reimburse part of your therapy expenses if you have out-of-network coverage for behavioral or mental health. Upon request, I am happy to provide you with a receipt that you can include when filing an insurance claim with your insurance company. Out-of-network reimbursement is often contingent on receiving a medical or mental health diagnosis and certain diagnoses may not qualify. I do not accept responsibility for collecting payment from your insurance company and cannot guarantee that you will be reimbursed or that you will qualify for a reimbursable diagnosis. Please contact your insurance provider to find out if you have out-of-network coverage and bring any necessary forms to your first appointment.

Confidentiality: The information you share with me during therapy sessions is considered confidential information and is protected by state law. As a mental health counselor I cannot reveal to third parties whether or not you are a past or current client of mine and cannot disclose any of the information you discuss during our sessions without first obtaining your written consent to do so.

In the following instances, however, I may be mandated or allowed to share information without your written consent:

If during your therapy, you are deemed to pose a threat of harm to someone else or to yourself, I am allowed to collaborate with the police or a hospital to take necessary measures to prevent harm from happening.

If you talk about events that lead me to believe that a child under the age of 18 or an elderly or disabled person is at risk for emotional, physical or sexual abuse, neglect, or exploitation, I am required by state law to make a report to Florida Department of Children and Families with or without your consent.

If you are not yet 18 years of age, your parents or legal guardians may have access to your records and may authorize release of information to other parties on your behalf 

If you disclose sexual misconduct by a previous therapist I am required to make a report to the licensing board governing the license of the therapist.

If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena.

If I need to cooperate with legal actions against a mental health professional by a licensing board.

If you submit an out-of-network health insurance claim and the insurance provider needs information to authorize the therapy or the billing.

E-mail notifications: When appointments are scheduled, automatic email reminders of your appointment will be sent to the e-mail you used when scheduling your first appointment. By signing this consent form, I agree to receive these notifications, and understand that email is not a confidential medium for transmitting health information.

The scope of my services: I am qualified to work with a wide variety of clients and problems, but sometimes I may not have the training needed to address a particular concern. If this is the case I will discuss it with you and make sure that you receive a referral to another professional who is better qualified to serve you. If you are having current hallucinations/ delusions, severe thoughts of suicide or self-harm, or extreme   Bipolar mood swings you may need more support than I can offer you through weekly psychotherapy, and I reserve the right to refer you to a different or more intensive treatment if I believe you exceed the level of care I can offer.

I, the client, consent to the above terms and agree to initiate treatment with Renewed Perspective Counseling and Consulting, LLC.  

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" or "PHI" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice at any time. A new Notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. Copies of this Notice are available by mail, or by asking your therapist for a paper copy.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information for Which Your Authorization Is Not Required. Your PHI may be used and disclosed without your prior authorization by your physical therapist, our office staff, and others outside our   office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physical therapist's practice, and any other use required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. For example, your protected heath information may be provided to a physical therapist to which you have been referred to ensure that the physical therapist has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physical therapist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physical therapist. We may also call you by name in the waiting room when your physical therapist is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Opportunity to Object. We may use and disclose your PHI in the following instances. You have the opportunity to object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the

PHI, then your health care provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.

Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person's involvement in your health care. If you are unable to agree or object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member,   personal representative or any other person that is responsible for the care of your location, general condition or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Emergencies: We may use or disclose your PHI in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your healthcare provider or another healthcare provider in our agency is required by law to treat you and the healthcare provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your PHI to treat you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object. We may disclose your PHI in the following situations without your consent or authorization:

Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. This disclosure will be made for the purpose of controlling disease, injury, or disability.

Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs.

Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration (i) to report adverse events, product defects or problems, biologic product deviations, track products; (ii) to enable product recalls; (iii) to make repairs or replacements; or (iv) to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process.

Law Enforcement: We may disclose your PHI, so long as applicable legal requirements are met, for law enforcement purposes.

Coroners, Funeral Directors and Organ Donation: We may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law: We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your PHI to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Criminal Activity: Consistent with applicable federal and state laws, we may use or disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. 

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel: (i) for activities deemed necessary by appropriate military command authorities; (ii) for the purpose of a determination by the Department of Veterans Affairs; or (iii) to foreign military authority if you are a member of the foreign military services.

Workers' Compensation: We may use or disclose your PHI as authorized to comply with workers' compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your health care provider created or received your PHI in the course of providing care to you.

Fundraising: We may contact you to raise funds. We may use and disclose your PHI, including demographic data, dates of health care provided, the department from which you received the services, the name of the treating physician, outcome information and health insurance status, to a business associate or institutionally related foundation for fundraising purposes without your authorization. You have the right to opt out of receiving fundraising communications from us, our business associates and our institutionally related foundations. Each fundraising communication will provide you with a clear opportunity to elect not to receive further fundraising communications.

Required Uses and Disclosures: Under the law, we must make disclosures to you, and when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with requirements of the Code of Federal Regulations, Part 45 Section 164.500 et seq.

Uses and Disclosures of PHI for which Your Written Authorization Is Required. Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You make revoke this authorization, at any time, in writing, except to the extent that your physical therapist or Renewed Perspective Counseling and Consulting has already taken an action in reliance on the use or disclosure indicated in the authorization.

The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes; (ii) uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

2. Your Rights. Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights:

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of your PHI that is contained in a designated record set for so long as we maintain the PHI. A "designated record set" contains medical and billing records and any other records that your health care provider and Renewed Perspective Counseling and Consulting uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You also have a right to restrict certain disclosures of your PHI to a health plan if you have paid in full out-of-pocket for the health care item or service.

Your health care provider is not required to agree to a restriction that you may request. If your health care provider believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another healthcare provider. If your health care provider does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests.

You may have the right to have your physical therapist amend your protected health information. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for general notification purposes. You have the right to receive specific information regarding these disclosures that occurred after June 1, 2019. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this Notice of Privacy Practices from us. You have a right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically.

You have a right to receive notifications of a data breach. We are required to notify you upon a breach of any unsecured PHI. PHI is "unsecured" if it is not protected by a technology or methodology specified by the Secretary. The notice must be made within 60 days from when we become aware of the breach. However, if we have insufficient contact with you, an alternative notice method (posting on website, broadcast media, etc.) may be used.

3. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of PHI, to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI.

This notice was published and becomes effective on or before June 1, 2019.

If you have any objections to this form, please speak with our Privacy Officer in person or at 407-710-6544.

Signature below is only acknowledgement that you have received this Notice of Privacy Practices.

This form is in addition to the regular Therapy, Policies, Agreement and Consent Form and Notice of Privacy Practices for Protected Health Information commonly known as HIPAA.  You must sign both in order to participate in Technology Assisted Counseling (TAC) sessions.  TAC incorporates email, phone and video counseling.  Prior to engage in TAC an assessment/consultation will be done to assure that TAC is an appropriate form of counseling. This is to inform you about what you can expect regarding your participation in TAC counseling.   

Benefits:

The benefits to TAC counseling are:

The ability to expand your choice of service provider.  

More convenient counseling options including location, time, no driving, etc.  

Reduces the overall cost and time of therapy due to not having to drive to and from and office.  

Ability to have real time monitoring and reduces the wait time for scheduling office appointments.  

Increased availability of services to homebound clients. clients with limited mobility, and clients without convenient transportation options.  

Limitations: 

It is important to note that there are limitations to TAC counseling that can affect the quality of the session(s). These limitations include but are not limited to the following:

I cannot see you, your body language, or your non-verbal reactions to what we are discussing.  

Due to technology limitations I may not hear all of what you are saying and may need to ask you to repeat things. 

Technology might fail before or during the TAC counseling session.  

Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.   

To reduce the effect of these limitations, I may ask you to describe how you are feeling, thinking, and/or acting in more detail than I would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.

Logistics: 

When I provide phone/video-counseling sessions, I will call you at our scheduled time or send you link for our secure and HIPAA compliant video session.  I expect that you are available at our scheduled time and are prepared, focused and engaged in the session.  I am calling you from a private location where I am the only person in the room.  You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality.  If you choose to be a in a place where there are people or others can hear you, I cannot be responsible for protecting your confidentiality.  Every effort MUST be made on your part to protect your own confidentiality.  I suggest you wear a headset to increase confidentiality and also increase sound quality of our sessions.  Please know that I cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally.  Please assure you reduce all possibilities of interruptions for the duration of our scheduled appointment.  

Please know that per best practices and ethical guidelines I can only practice in the state(s) I am licensed in.  That means wherever you reside I must be licensed.  You agree to inform me if your therapy location has changed or if you have relocated your domicile to a different jurisdiction.

Connection Loss:

During Phone Sessions: If we lose our phone connection during our session, I will call you back immediately.  Please also attempt to call me at (321)710-6544 if I cannot reach you. If we are unable to reach each other due to technological issues, I will attempt to call you 2 times.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, I will call you from an alternate number.  The number may show up as restricted or blocked please be sure to pick it up.  

During Video Sessions: If we lose our connection during a video session, I will call you to troubleshoot the reason we lost connection.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session. 

Please list your main number and an alternate number in the client portal profile.

Recording of Sessions:

Please note that recording, screenshots, etc of any kind of any session is not be permitted and are grounds for termination of the client-therapist relationship. 

Payment for Services: 

Payments for services must be made during each session.  I will charge your card on file or send you an invoice.   Payment is to be completed prior to our session. 

Cancellation Policy: 

If you must cancel or reschedule an appointment, 24-hour advanced notice is required, otherwise you will be held financially responsible.  Should you cancel or miss an appointment with notification less than 24 hours this will result in being charged the full fee for your missed appointment.  Cancellations must be communicated by phone, email or text.  If clients have more than 2 cancellations during the course of treatment/therapy the therapist and client will address the need for ongoing therapy.  Should a client express and wish and/or desire to continue a client may be asked to pre-pay for sessions when they are scheduled.  If the client cancels or misses the session with less than 24 hours notice and the session is pre-paid, this follows the cancelation guidelines and the payment will not be reimbursed for the missed or canceled session less than 24 hours.  Phone/video sessions should be treated as regular in office sessions.  If you are late getting on the phone, are unable to talk at our scheduled time, your battery has died and you are unable to access another confidential place to talk, or any other variable that would have you not be able to attend our session please know that you will be charged for the session.  Please make the necessary arrangements you need to be available and present for your session.  

Emergencies and Confidentiality: 

I request an emergency contact for you.  Please list the person's first and last name, relationship and phone number(s) of your emergency contact in the client portal.  I also request the address from which you are calling and the number to your local police department including area code in the area in which you are located during the time of our call. Please make sure your address is also up to date in the client portal profile.

If I have concerns about your safety at any time during a phone session, I will need to break confidentiality and call 911 (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact immediately.  Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.

Consent to Participate in TAC Sessions:

By signing below you agree that you have read and understand all of the above sections of TAC informed consent.  You agree that you also understand the limitations associated with participating in TAC counseling sessions and consent to attend sessions under the terms described in this document.