These disclosures are provided to you for legal or ethical understanding:
Federal Law requires as of January 1, 2022 that I provide you with this information.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call me at 980-253-9841.
I consent to engaging in telehealth counseling (counseling through the medium of electronic devices). I understand that telehealth counseling includes therapy/counseling, diagnosis and treatment, and transfer of personal medical and mental health data via audio and video or data communication. The laws that protect the confidentiality of my medical information also apply to telehealth counseling. This includes all policies which you reviewed and signed in the original disclosure/consent paperwork at the onset of treatment.
• I understand that there are risks from distance counseling include, but are not limited to, the possibility (despite my therapist’s efforts of using a HIPAA compliant service) that: sessions could be disrupted or distorted by technical issues, and the transmission of my medical information could be intercepted by unauthorized persons.
• I understand that I am responsible for the confidentiality and privacy of my own environment. While convenience is a benefit of using mobile devices for telehealth counseling, it is important to find a confidential environment and use a private, secure wifi connection wherever I am located.
• I understand that Telemental health services may feel different than face-to-face therapy and may not be appropriate for everyone. If my counselor believes I would be better served by another form of psychotherapeutic service (e.g. in-person), I will be referred to someone who can accommodate this service. My counselor and I will keep in communication about how distance counseling is going and modify as need.
• In emergencies, in the event of disruption of service, my therapist may communicate with me by phone or secure messaging in the client portal. I understand that SMS text messaging (e.g., through my cellular provider) and non-encrypted email are not secure and should not be used to convey protected health information.
• Location information should be provided to my counselor if I am not at home in case there is an emergency.
• If I am facing an emergency situation that could result in harm to me or to another person; I am not to wait for a telehealth counseling session. Instead, I agree to seek care immediately through a local health care counselor or at the nearest hospital emergency department or by calling 911.
Experience and Counseling Approach
Nature of Counseling
Professional Limits, Ethics, and Confidentiality
Legal Use of Client Records