• Information necessary for supervision or consultation.

• Information released as outlined in the HIPAA Notice of Privacy Practice • Those required by law.

In the event of concerns regarding your safety as a client or the safety of others, you are authorizing me to use the emergency contact information you provide as well as the primary care physician contact as I find it necessary.

There are risks and benefits to tele-mental health services.

Some risks include:

• Technology failure, and sometimes at the worst possible time. We can minimize this by having

  a plan for what to do if this happens.

• Not all clients benefit from telehealth services. In the event I believe telehealth services are not

  suitable for your needs I will assist in offering referrals for alternative treatment options.

• If someone has access to your email or the device you use to login for sessions, there is a

  chance that person could access our communications.

• The Zoom platform is HIPAA-compliant, however, as with any technology, there is always a

  risk of unauthorized access or data breach. If that ever were to happen, you will be informed.

  EMERGENCY SITUATIONS:
  I am available Monday-Friday 10 am - 4 pm CST. I will be responding to any messages within 24 hours related to scheduling. Please note if you message over the weekend I will respond the following Monday. Holidays may also impact availability. I will notify you if I will be on vacation or away. Contact between consultations will be limited unless otherwise noted. If you feel there is something of significance to discuss please schedule an appointment. Contact information is not shared with the intent of communicating between sessions.

  Please understand that the service provided through Mindful Solutions Behavioral Counseling LLC, is not intended for crisis situations or urgent needs. In a crisis situation, you will need to call 911 or local emergency services, or visit the nearest emergency room.

  If you feel you need crisis services the services offered by this clinician will not meet those needs. If this clinician determines that you need a higher level of care you will be notified and services with this clinician will no longer be available.

  NO SHOW POLICY:
  People are becoming busier and some are adjusting to new daily routines. In recognizing this, scheduling can become a problem. This is a gentle reminder for those who may not be aware that it is customary to let your therapist know when you can not make an appointment within 24 hours. The first "no show" will be billed at 1/2 the session rate. After the second “no show” sessions will be billed at the full session rate. After a third consecutive missed appointment any further scheduled sessions will be cancelled as this limits appointment options for other clients. I recognize this policy can be a challenge and appreciate your understanding. I will hold the session for 10 minutes past the appointment time before deeming the session a missed appointment. 

  DRUG/ALCOHOL USE:
  Coming to treatment intoxicated on alcohol or drugs impairs ability to participate in treatment, whether it is for an initial counseling session, assessment or individual treatment. If it is determined that a client is under the influence the session will be rescheduled. Forming a therapeutic alliance is based on the mutual understanding that services will take place without the influence of alcohol or substance use at the time of treatment. If it is determined that substance use is a factor at the time of the session. The session cannot be held the client will be charged for a no-show session.

  COORDINATION OF TREATMENT:
  It can be beneficial to inform your primary care physician and other healthcare providers that you are working with a counselor.

  NOTICE OF PRIVACY PRACTICES AND CLIENTS RIGHTS: https://privacyrights.org/consumer-guides/health-privacy-hipaa-basics

  GOOD FAITH ESTIMATE:
  A Good Faith Estimate is an estimate of the total expected costs of non-emergency healthcare items or services. Intends to offer predictability & transparency in how much clients will be charged for healthcare services prior to their appointment. Includes all regularly scheduled appointments (i.e. therapy sessions). You will receive the GFE with billing.

  FINANCIAL COMMITMENT
  The following guidelines have been established for payment of financial obligations for services rendered by Mindful Solutions Behavioral Counseling LLC. Please read carefully, your signature is required to assure there is no misunderstanding regarding your financial obligation. Individual sessions are billed at $115 (45 min). Couples sessions are billed at $140 (45 min). *REDUCED RATE $65 PER SESSION (with proof of financial hardship).

  Please initial next to each statement below.

  _______I understand that Mindful Solutions Behavioral Counseling LLC is private pay only and no insurance will be billed for services.

  ______ I agree to using Ivy Pay and will offer a number that receives text messages.

  ______ I agree to keep my card information up-to-date for payment with Ivy Pay and understand that if my payment information is not up-to-date, sessions will not take place.

  ______ I agree to being responsible for half of the session rate when I do not show for an appointment or I cancel an appointment less than 24 hours before the appointment time at my first missed session.

  ______I agree to being responsible for the full session rate when I do not show for an appointment or I cancel an appointment less than 24 hours before the appointment time at my second missed session.

  ______ I agree to being responsible for the full session rate when I do not show for an appointment or I cancel an appointment less than 24 hours before the appointment time at my third missed session. I understand and agree that after a third missed session I will no longer be able to schedule future appointments with Mindful Solutions Behavioral Counseling LLC.

  CLIENT UNDERSTANDING

  ______I understand that telehealth services are completely voluntary and that I can withdraw this consent at any time.

  ______I understand that none of the telehealth sessions will be recorded or photographed by the therapist, and I agree not to make or allow audio or video recordings of any portion of the sessions.

  ______I understand that the laws that protect privacy and the confidentiality of client information also apply to telehealth, and that no information obtained in the use of telehealth that identifies me will be disclosed to other entities without my consent.

  ______I understand that telehealth is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100% guaranteed to be secure and there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties and agree that Mindful Solutions Behavioral Counseling, LLC will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.

  ______I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties and that I or my therapist may discontinue the telehealth sessions at any time if it is felt that the video technology is not adequate for the situation.

  ______I understand that if there is an emergency during a telehealth session, my therapist may call emergency services and/or my emergency contact.

  ______I understand that all policies and procedures apply to telehealth services.

  ______I understand Mindful Solutions Behavioral Counseling LLC will advise me about what telehealth platform will be used and will establish an audio and/or video session.