When we begin working together it is my responsibility to be mindful of the day you will end

therapy. I am planning for the day that you are prepared to move forward living your life without

therapeutic support. It is my goal to get you here as quickly and safely as possible. If I observe

indicators we are not moving forward it is my commitment to you to keep you on track and in

the direction of your goals. Good clinical work can take time. The more work you have to do, the

longer it can take. There is no rule that you have to do all that work in therapy. As your therapist

I am held to an ethical standard which dictates my role and demands that therapy be beneficial to

you in some way in order for it to continue. From the start it is my duty to assist in preparing you

for gaining insight, skills and strategies to move forward independently, confident in continuing

the work. Starting counseling is a major decision and you may have many questions. This

document is intended to inform you of my background, confidentiality, and how to handle

emergencies should one arise. If you have other questions or concerns, please ask. If at any time

you feel our work together is no longer helpful and you wish to stop using my services, simply

let me know as I hope to help in anyway and it is understandable that not every therapist and

patient are a match. Individual, couples and family sessions are limited to 45 minutes. Services

are billed through your insurance via Headway.

IDENTIFYING INFORMATION:

Lindsay Powelson, MA, LPC, LCPC, NCC, CCTP-II, CSTIP. Licensed through the State of Missouri

Committee for Professional Counselors since 2006 #2004024728 MO, and the State of Kansas Behavioral

Sciences Regulatory Board as a Licensed Clinical Professional Counselor since 2023 #03464 KS. Master

of Arts degree earned in 2004 from Lindenwood University in Professional Counseling. National Board

Certified Counselor (NCC), Certified Clinical Trauma Professional Level II (CCPT-II), Certified Sex

Therapy Informed Professional (CSTIP). A few examples of experience include; mood disorders, trauma,

grief, disordered eating, sexual intimacy challenges, GNC affirmative, public school systems, child

protective services, Family Court system, long- term care organizations, adoption and foster care,

infertility, LGBT, family and couples counseling.

CONFIDENTIALITY:

In order to fulfill the requirements set forth by the State of Missouri/Kansas licensure board, full

name, phone, DOB, Primary Care Physician name and contact information, your address as well

as an emergency contact is necessary for my records. I will also need to verify your identity

through a photo copy of your ID. This information and proof of identity is required to be

submitted prior to our first session.

Patient information shared is confidential, except in the following circumstances.

• Mandated reporting of physical or sexual abuse.

• Threats of suicide or homicide.

• Cases where the patient signs a release of information.

• Information necessary for supervision or consultation.

Mindful Solutions Behavioral Counseling, LLC Page of 2 11• 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 patient 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 patients benefit from telehealth services. In the event your clinician believes telehealth

services are not suitable for your needs you will receive assistance in 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:

Office hours are Monday, Tuesday, Thursday, Friday 9 am - 4 pm CST. Emails will be responded

to within 24 business hours related to scheduling. Please note if you message over the weekend

or a Wednesday, responses will be the following business day. Holidays may also impact

availability. You will be notified of availability changes or if this clinician will be away. Contact

between sessions 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 services provided through Mindful Solutions Behavioral Counseling

LLC, are 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 after referral suggestions.

Mindful Solutions Behavioral Counseling, LLC Page of 3 11NO 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 $75. 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 patients. 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 patient 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, the session cannot be held the patient 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 PatientS RIGHTS: https://privacyrights.org/

consumer-guides/health-privacy-hipaa-basics

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 through your insurance provider (45 min). Couples sessions are billed through

your insurance provider (45 min). Letters requested for court, custody, work or any other reason

may be denied at the therapist’s discretion. If a letter is agreed to be written, payment for said

letter will be the rate of $125. This service is not billable through insurance and will require out

of pocket payment for said documentation.

COURT PROCEEDINGS

It is understandable that court cases, whether civil or criminal, can be stressful for all involved.

However, it is the policy of Mindful Solutions Behavioral Counseling, LLC, that therapists are

experts in providing therapeutic care, not testifying in court. Additionally, a therapist becoming

involved in court related matters may complicate or destroy the therapeutic relationship and trust

built.

Mindful Solutions Behavioral Counseling, LLC Page of 4 11Should a subpoena be received for a court case, the card on file will be charged a non-refundable

$3500.00 retainer fee. This retainer will be charged for services related to the court case. These

services include preparation of records, testifying in court, preparing an affidavit, travel time, and

any other services required. These services will be billed against the retainer at your therapist’s

hourly rate. If the retainer is depleted, the card on file will be charged for each hour of services

performed beyond the retainer on a weekly basis. Services related to court cannot be billed to

insurance. Your therapist is unable to provide an opinion on custody, parental fitness, or

visitation recommendations.

Please initial next to each statement below.

______ I agree to keep my card information up-to-date for payment and understand that if my

payment information is not up-to-date, sessions will not take place.

______ I agree to being responsible for $75 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.

Patient 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 patient

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

Mindful Solutions Behavioral Counseling, LLC Page of 5 11situation.

______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.

______I understand and agree that my provider has the right to deny requests for letters for court

documents from my therapist. (Including requests from attorneys.)

______I understand and agree that my therapist has the right to refuse providing letters for work,

custody or any other form of documentation I may request.

______I understand and agree that if I am looking for a provider to provide documentation for

any of the above this is not the correct fit for me for therapy services.

______I understand and agree that if my therapist is willing to provide such a letter, it will be

limited to objective and factual information, and will not include an evaluation or any opinion

from said provider.

______I understand and agree that, if my therapist is willing to provide such a letter, I will be

required to pay the rate of $125 out of pocket for said letter.

______I understand that services related to court proceedings/subpoenas cannot be billed though

insurance and I am financially responsible should such services be needed including a NON

REFUNDABLE $3500 retainer fee.

Mindful Solutions Behavioral Counseling, LLC Page of 6 11Patient Services Agreement (PSA*)

The law requires that obtaining your signature acknowledging that you have been

provided with this information by the end of our first session. It is important that you

understand the service agreement and the HIPAA guidelines for your privacy protection.

We can discuss any questions you have. When you sign the consent form, it will also

represent an agreement between us. You may revoke this Agreement in writing at any

time. That revocation will be effective the date the revocation is received and confirmed

by provider.

While all of these requirements can seem extensive and/or complicated, they are in place

for all patients with a variety of personal circumstances.

Psychotherapy is not easily described in general statements. Your problems and

personality will dictate the nature of your therapy. Psychotherapy is a joint venture

between you and your therapist and will, of course, require your active involvement.

Meetings

Your first sessions will focus on an evaluation of your concerns. By the end of the

evaluation your therapist will be able to offer you some first impressions of what your

therapy will include and a general plan of treatment. Therapy is usually scheduled for one

45 minute session per week. This can vary based on financial needs and concerns as well

as availability.

You should take these same initial sessions to evaluate your experience with your new

therapist. Therapy involves a large commitment of time, money, and energy, so you

should select a therapist carefully. If you have questions, discuss them with your therapist

whenever they arise. If you have doubts that are not answered by your therapist, it is

understandable that not every provider and patient are a match.

Contacting Your Therapist

Communication outside of scheduled sessions is not possible. This service is set up for

those that are not in crisis or in need of emergency services. If you wish to schedule a

session sooner please use the email address and you will be contacted within 24 hrs on

business days. Holidays and weekends will not apply.

Limits on Confidentiality

The law protects the privacy of all communications between a patient and a therapist. In

most situations, the provider can only release information about your treatment to others if

you sign a written Authorization form that meets certain legal requirements. Your

signature on the consent form provides consent for the following:

• Consultation with other mental health professionals about our treatment for you

• Disclosure to administrative staff for processing of your financial ledger

• Disclosures required by health insurers (record of treatments, other protected

health information)

• Collection of overdue fees

Mindful Solutions Behavioral Counseling, LLC Page of 7 11• All these parties are bound by the same rules of confidentiality as your treating

therapist.

There are some situations where your provider is permitted or required to disclose

information without your consent or authorization. These include:

• Child Abuse

• Adult and Domestic Abuse

• Health Oversight Activities

• Judicial and Administrative Proceedings

• Serious Threat to Health or Safety

• Workers Compensation

If such a situation arises, the provider will make every effort to fully discuss it with you

before taking any action and will limit disclosure to what is necessary.

The laws governing confidentiality can be quite complex. Your provider will attempt to

answer your questions, but in situations where specific advice is required you are

welcome to seek your own formal legal advice.

Professional Records

You should be aware that, pursuant to HIPAA, information about you is filed in three sets

of professional records. One set is your financial ledger. Another set is your Clinical

Record. It may include information about your reasons for seeking therapy, a description

of the ways in which your problem impacts your life, your diagnosis, the goals we set for

treatment, your progress towards those goals, your medical and social history, a record of

prior treatment, reports of any professional consultations, your billing records, and any

reports that have been sent to any one.

Usually you may examine and/or receive a copy of your Clinical Record if you request it

in writing. This is not true if disclosure is reasonably likely to endanger you and/or others,

or when another individual [other than another health care provider] is referenced and

disclosing that information puts the other person at risk of sustaining substantial harm. It

is strongly recommended that you initially review them in your therapist’s presence, or

have them forwarded to another mental health professional so you can discuss the

contents. In most circumstances you will be charged a copying fee of no more than 35

cents per page. The exceptions to this policy are contained in the attached HIPAA Notice

Form.

Additionally, your therapist may keep Psychotherapy Notes. These Notes are for your

therapist’s own use and are designed to assist in providing you with the best treatment.

While the contents of Psychotherapy Notes vary from client to client, they can include the

contents of therapy sessions and analysis of those sessions. They may contain sensitive

information that you reveal that is not included in your Clinical Record. These

Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy

Notes cannot be sent to anyone else, including insurance companies.

Mindful Solutions Behavioral Counseling, LLC Page of 8 11Patient Rights and Protection

HIPAA provides you with several new or expanded rights with regard to your Clinical

Records and disclosures of protected health information. These rights include requests to

amend your record; requests for restrictions on information recorded in your Clinical

Records; requests for an accounting of disclosures of protected health information; any

complaints you make about policies and procedures you wish recorded in your records;

and the right to a paper copy of this Agreement and the attached HIPAA Notice form. Feel

free to discuss any of these rights.

It is the policy of Mindful Solutions Behavioral Counseling, LLC that no person shall be

excluded from participation in, or be denied the benefits of any service or be subjected to

discrimination because of race, color, nationality, religion, gender, sexual orientation, age,

or disability. You have assurance that this will adhere to ethical codes and professional

standards and will be open to discussing any complaints you may have in this area.

Social Media

Due to the importance of your confidentiality and the importance of minimizing dual

relationships, it will not be possible to accept friend or contact requests from current or

former clients on any social networking site (Facebook, LinkedIn, etc). We believe that

adding clients as friends or contacts on these sites can compromise your confidentiality

and respective privacy.

Minors and Parents

Patients under 17 years of age who are not emancipated, and their parents, should be

aware that the law may allow parents to examine their child’s treatment records. Because

privacy in psychotherapy is often crucial to successful progress, particularly with

teenagers, it is policy to request an agreement from parents that they consent to give up

their access to their child’s records. If they agree, during treatment, general information

may be provided about the progress of the child’s treatment, and his/her attendance at

scheduled sessions. Before giving parents information, this will be discussed with the

child, if possible, and receive his/her authorization. If we believe the child poses a danger

to self or others, parents will be notified.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination

process to achieve some closure. The appropriate length of the termination depends on

the length and intensity of the treatment and will ideally be a collaborative effort between

the patient and therapist.The therapeutic relationship will not be terminated without first

discussing and exploring the reasons and purpose of terminating. If therapy is terminated

for any reason or you request another therapist, it is possible to provide you with a list of

qualified psychotherapists to treat you. You may also choose someone on your own or

from another referral source.

Mindful Solutions Behavioral Counseling, LLC Page of 9 11Privacy, Confidentiality & Ethical Standards

HIPAA Privacy and Confidentiality

Mindful Solutions Behavioral Counseling, LLC highly regards privacy and confidentiality

and we comply with both Federal and State guidelines under HIPAA, the Health Insurance

Portability and Accountability Act. For additional information on the Federal standards

click here and for the Missouri standards, click here. For Kansas standards follow this

link, https://www.dcf.ks.gov/agency/pages/hippa%20overview.aspx

Ethical Principles of Counselors & Code of Conduct:

Mindful Solutions Behavioral Counseling, LLC, is committed to the highest standards of

ethical behavior. https://www.counseling.org/knowledge-center/ethics

Choosing a Therapist

Therapy is most effective when you feel comfortable with the therapist’s skill, personal

style and ability to empathize with your particular situation. Since psychotherapy is a

process that typically extends beyond one session, here are some factors to consider when

choosing a therapist. You may be able to evaluate some of these factors before the first

session and others during the first session. However, some may take two or three sessions

to become clear.

• Location: are you willing and able to attend virtual telehealth sessions?

• Availability: is the therapist available on days and at a time when you can attend

regularly?

• Fees: can you afford the regular fees the therapist you are considering charges?

Please note Mindful Solutions Behavioral Counseling LLC is private pay only and

does not accept insurance. The patient is welcome to utilize a super bill sent

virtually to submit to their insurance provider for potential reimbursement.

• Gender: does it matter to you if the therapist you will be seeing is a man or a

woman?

• Credentials: is the therapist licensed to practice?

• Experience: does the therapist have experience dealing with your particular issue?

Does this therapist convey understanding of your situation and does he/she offer a

treatment approach that makes sense to you?

• Personal style: are you comfortable enough with this therapist’s style of

interaction that you will be able to discuss personal and possibly difficult

information with them?

• Effectiveness: feeling better is the goal. However, initially, whether or not you feel

better is not the best indicator of effectiveness of your therapy.

Here are some other questions you might ask yourself to aid in evaluating your therapy.

• Is the therapist helping you?

• Is your therapist open to discussing your reactions to his or her interventions?

• Is the therapist striking a constructive balance between supporting you and

challenging you?

Mindful Solutions Behavioral Counseling, LLC Page of 10 11• Are you learning anything about yourself?