Counseling Services Agreement and Informed Consent

Psychological and Counseling Services
Depending on your individual needs and aspirations, and the scope of work of your clinician, the services that Woven Wellness Group provides may include psychological evaluation, diagnosis, and treatment. During our time together, we will engage in active discussion regarding the services that I will and can provide and collaboratively establish an appropriate plan for your care. It is important to note that all psychological and counseling services can come with both risks and benefits. Benefits may include improvements in the areas in which you are seeking my services, improved well-being, and enhanced connection. Due to the variety of factors that impact outcomes, no specific outcomes can be guaranteed at the beginning of treatment. Potential risks of engaging in these services include increased distress, particularly while addressing challenging aspects of your life. It is my responsibility as your provider to provide ongoing assessment through the course of our work, and to share with you any ideas or concerns I have regarding how our work is benefiting you. I rely on you to share your perspective on these issues as well. As we progress through treatment, I may recommend various interventions, structured assessment tools, or make referrals to other care providers. I will explain to you the specific rationale, risks, and benefits of my recommendations through this process and will invite your questions and ideas.

Psychological and Counseling Appointments Our work together will involve regular meetings together at prearranged times. Our first session will generally begin with a 50-minute intake evaluation which will allow us to discuss in depth your history, important aspects of your experience, and reason for seeking care. We will begin formulating a treatment plan in this session as well. Subsequent sessions are generally scheduled for 50-minutes and will occur at a frequency we determine together. If we determine that we need to schedule a shorter or longer session, we can discuss options together.

I will do my very best to start and end our sessions on time. I ask that you make your best effort to arrive on time. If you arrive more than 15-minutes late to our session, it is up to my discretion as to whether I will be able to conduct a session with you. You will still be responsible for the session fee. If I am late for any reason, I will discuss options with you for extending our time in that or a later session.

Missed Session/Late Cancellations
Please note that missed sessions with less than 24-hours (1 business day) notice provided will be charged the full fee. Weekends are not considered to be within the 24-hour period. As such, Monday appointments will need to be cancelled by Friday in order to avoid a late cancellation charge.

Session fees are subject to change with advanced notice. We will provide you with written notice of any fee changes at least one month in advance of an adjustment. All fees are to be paid at the time of service. Our preference is to keep your credit card on file in order to more seamlessly process payment following our sessions. However, you are welcome to pay by cash, check, or credit card at the time of service.

While we have elected to not be in network with insurance, we are happy to provide you with a Superbill, which is a document that you can submit to your insurance company to seek reimbursement for the services you are receiving. Please let us know if you would like a Superbill.

Contact Outside of Sessions
You are welcome to leave me voicemail or emails outside of our session times to
communicate regarding scheduling or other logistical issues. I will try to respond as soon as I am able, but please note that the timing may be varied. There may be times where it is helpful to communicate outside of a session regarding progress on a particular goal or to clarify an exercise you are working on.

Please be aware that email is not a consistently secure form of communication, and I cannot guarantee your privacy via unencrypted email. Please do not send confidential information via email. I utilize a secure, HIPAA-compliant platform for record keeping, tele-behavioral health services, and secure communication called Simple Practice. If you need to be in contact with me regarding an issue pertaining to our work, I encourage you to contact me via the patient portal. If you communicate private information via unencrypted e-mail, e-fax, or voicemail, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted. Email and voicemail messages are not a substitute for our live work together. If you are experiencing an emergency of any kind, please contact 911 or go to a local emergency room. Do not leave a message for me, as I cannot guarantee when I will hear or see it.

Your Confidentiality
As a consumer of services with Woven Wellness Group, your rights to privacy and confidentiality are paramount. We take this responsibility seriously and want to ensure you understand your rights. Please ask any questions you have regarding this issue. Your communication to Woven Wellness Group and the records we keep regarding our work together will not be disclosed unless you direct us to do so or unless the law compels me to do so. Information communicated to us is protected by my code of professional ethics, as well as by state and federal law and will not be disclosed unless you provide written permission. We are permitted by law to use and disclose your protected health information (PHI) for your treatment, payment, or health care operations purposes. You need to be aware that there are certain situations in which we may need to disclose information about you:

-In the event of a life-threatening emergency, I will disclose information in order to protect your immediate safety. I am also required by law to disclose information you share with me regarding an intent to imminently harm another person.

-By submitting requests for reimbursement to your insurance company, the insurance company may request additional records. We will discuss if I receive such a request.

-As a licensed clinical counselor, I am required by law to disclose any information have related to the suspected abuse or neglect of a child, elder, or disabled individual per state law.

-If I receive a subpoena for information regarding you, I will discuss with you and an attorney prior to disclosing any information. I may be required to disclose information about our work together if mandated under court order.

-If a government agency requests information for purposes of oversight activities, I may be required to provide this information.

Adolescent Patients’ Confidentiality
For adolescent patients, we will discuss the nature of our work together at the outset of treatment. Depending on the presenting concern, we may take a family-based or individually-based approach. It is likely that our work may incorporate these approaches throughout treatment, and it is rare that family or caregivers would not be involved to at least some extent. For sessions (both in office and telehealth) in which a parent or guardian is not present, we require the parent or guardian to be reachable by phone during the entirety of the session, should a need arise.

With adolescent patients, I aim to maintain the amount of privacy that is helpful and therapeutic for our work together. It is important to note that it would not be helpful or therapeutic for me to be aware that you or someone else were at serious risk and to not intervene to help. In these cases, I will use my professional judgment and ethics to decide whether a parent or guardian would need to be informed. I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information. There may be times that your doctor and I may need to work together; for example, if you need to take medication in addition to our work together, or if you need monitoring related to your nutrition or health status. I will always aim to get your written permission and permission from your parent/guardian in advance to share information with your doctor.

Your Records and Your Right to Review Them Both the law and the standards of my profession require that we keep treatment records for at least seven years following your treatment. You have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when we assess the releasing such information might be harmful in any way. In such a case, we will provide the records to an appropriate mental health professional of your choice. When more than one person is involved in our treatment, such as in cases of couple and family therapy, we will release records only with signed authorizations for all the adults (or all of those who legally can authorize such a release) involved in the treatment.

Social Media
I do not knowingly accept friend requests on my personal social media accounts from former or current patients. This is in large part to protect your confidentiality and to maintain the best working conditions for our professional relationship. Our practice maintains professional social media pages. You are welcome, but certainly not required, to follow these pages. Please do be aware that by following or commenting on these pages, you may be revealing your relationship with me. I will generally not respond to comments from you on my professional pages in order to maintain your confidentiality.

Telehealth Services
For individuals for whom these services are appropriate, we are able to provide psychological services virtually via a secure, HIPAA-compliant telehealth platform. In the event that we decide to exclusively or occasionally engage in telehealth health sessions, there are a number of issues of which to be aware:

-We will determine if your virtual services are appropriate to meet your individual needs.

-Prior to starting treatment, we will determine together local emergency resources and plans for how to access one another in the event of a disruption in transmission.

-Prior to each session starting, we will verify your identity and physical location.

By signing below, you are indicating that you understand:

-Telehealth services remain a newer and more innovative mechanism for delivering treatment, and therefore there is a potential for unknown risks to exist.

-While I utilize only secure platforms for virtual sessions, there may be risks to confidentiality that exist by utilizing video or other distance communication.

-No other individual or entity will have access to your transmitted information outside the limits of confidentiality outlined elsewhere in this agreement.

-You must be present in a state in which I am licensed in order to participate in virtual services with me.

Termination of Services
As noted above, we will discuss throughout our work together the progress you are making toward your goals and the ongoing risks and benefits of any treatment interventions and recommendations. I consider it both our responsibility to discuss openly if there are concerns about your ability to benefit from our work. There may come a time when your needs may change or be better served by a different professional, service, or approach. At such a time, I may provide referrals to you if I deem this to be in your best interest. You are hiring me to support you or your family’s needs. You have the right to discontinue our treatment together at any point. If you choose to discontinue treatment, I ask that you discuss this with me live. Due to the nature of services, a sudden discontinuation of treatment may be harmful to you, and I want to minimize any potential harm. Please provide me with as much notice as is feasible about your plans to discontinue our work together and schedule at least one session to discuss and arrange any transition of care that may be needed. If you stop attending sessions without contact with me and I am unable to reach you, you will be responsible for any fees associated with your final scheduled session. After 30 days without contact, I will assume that you are terminating treatment and will no longer consider you an active patient in my practice.

Practice Policies

Appointments and Cancellations
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

A $10.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

Telephone Accessibility
If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24-48 hours. If a true emergency situation arises, please call 911 or any local emergency room.

Social Media and Telecommunication
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Electronic Communication
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what heor she would consider important information, that you may not recognize as significant to present verbally the therapist.

Messaging Terms & Conditions:
You agree to receive informational messages (appointment reminders, account notifications, etc.) from Woven Wellness Group. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at hello@wovenwellnessgroup.com. You can opt-out at any time by replying STOP.

Minors
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Termination of Services
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Professional Service Fees
Services are billed at the rates listed below:

50 minute session: $125-$170

75 minute individual intake: $185-$255

90 minute couple’s intake: $225-$300

50 minute Sexual History Assessment: $250-$340

Phone calls or emails exceeding ten minutes: $30 per 15 minute

Report writing: To be discussed based on specifics of requirements.

We do not generally charge for coordination of care with other care providers but will discuss with you the need to do so for more complex or time intensive situations.

Licensure and Supervision

Please look at individual therapist profiles to see licensure and supervision details.

Procedures Regarding Legal Proceedings

We do not provide forensic assessment for child custody hearings or provide clinical recommendations for divorce proceedings. The minimum charge for a court appearance is $5000 with professional time billed at $300 per hour.

Counselor, Social Worker and Marriage & Family Therapist Board
77 South High Street, 24th Floor, Room 2468 Columbus, Ohio 43215-6171
Tel: (614) 466-0912 Fax: (614) 728-7790
Email: cswmft.info@cswb.ohio.gov