Informed Consent

I am voluntarily seeking counseling for my particular issue(s) and I am committed to working with my therapist to successfully resolve my issue(s). I realize that counseling can be beneficial both for me and those with who I am in relationship, but that it comes with no guarantees. WHile self-disclosure of relevant information is beneficial to the counseling process, I also understand that counseling may involve discussing relationship, psychological and/or emotional issues that may, at times, be distressing. I am aware of alternative treatment methods available to me. 

My therapist/counselor will meet with me regularlyu, listen attentively, work with me to accomplish mutually stated and agreed upon goals. My counselor will treat me with respect and dignity. I understand that my counselor is bound by the legal and ethical standards of his/her profession. This includes confidentiality, which means that my counselor will not reveal any information about me except in the following situations: 

• Medical Emergency
• Threats of Suicide, Bodily Harm to Self or Others
• Suspected Child Abuse or Neglect; Suspected Abuse of the Elederly

I understand that I have a right to review my records at any time, and that if I have questions or concerns I can reach my therapist through the contact information provided for me. In case of emergency, I will call 911. Should my therapist become incapacitated, an authorized person will contact me and may refer me to another therapist. My records will continue to remain confidential unless otherwise authorized by me. 

Payment is expected on the day that services are rendered. I will notify my counselor at least 24-hours before my appointment if I need to cancel or reschedule my session, otherwise I will be billed for that appointment at a reduced rate of $40. I give my therapist permission to contact me through the information I have provided on my Client Information Form. I understand that email correspondence may not always be a secure/confidential means of communication. 

My therapist has answered all my questions about counseling satisfactorily. If I have further questions, I understand that my therapist will either answer them or find answers for me. I understand that I may leave counseling at any time, althought I have been informed that this is best accomplished with my therapist. 

The following outlines our policies related to the use of Social Media. Please read it to understand how we conduct ourselves on the Internet as mental health professionals and how you can expect us to respond to various interactions that may occur with clients on the Internet. If you have any questions about anything within this document, we encourage you to bring them up when you meet with your counselor. As new technology develops and the Internet changes, there may be times when this policy will be updated. If we do so, we will notify you in writing of any policy changes and make sure you have a copy of the updated policy. 

Friending: We do not 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 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. 

Interacting: Please do not direct message (DM) us on Social Networking sites such as Twitter, Facebook, or LinkedIn. These sites are not secure and we may not read these messages in a timely fashion. Do not use wall postings, @replies, or other means of engaging with us in public online if we have an already established client/therapist relationship. Engaging with us this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact your counselor between sessions, the best way to do so is by direct email for quick administrative issues, such as changing appointment times. See the email section below for more information regarding email interactions. 

Use of Search Engines: It is not a regular part of our practice to search for clients on Google, Facebook, or other search engines. Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with us via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations, and if we resort to such means we will fully document it and discuss it with you when we next meet. 

Google Reader: We do not follow current or former clients on Google Reader, and we do not use Google Reader to share articles. If there are things you want to share with us that you feel are relevant to your treatment. 

Email: We use email to arrange or modify appointments. Please do not email us content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with email, be aware that all such messages are retained in the logs of yours and our Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails we receive from you and any responses that we send to you become a part of your legal record. For these reasons, we do not use email for any reason other than for administrative purposes.

Websites: Zoom is the tele-mental health video conferencing we will utilize.  It is HIPPA compliant and completely free for you to use. At your scheduled appointment time, ensure your computer or mobile device has the camera pointed toward you and direct your browser to the link sent by your therapist. Click to allow the website access to your microphone and camera, and then you are considered to be in the “waiting room.” Simply wait for the therapist to initiate the video session. 

If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to your counselor’s attention so that it can be discussed.

We appreciate the trust you have in us and will provide the quality and confidential care you expect. We do value and know that your time is important. Therefore, you can expect to be treated with respect and we will do our best to keep your appointment on time.

We understand that circumstances occur that interfere with you keeping certain appointments; however, we do kindly ask that you give our office 48-hour notice prior to your appointment cancellation. This will allow us to take your reserved time and offer it to someone else. If missing or cancelling your appointment becomes excessive, we may not be able to reappoint a reserved time for your visit. After three or more missed appointments, we do reserve the right to terminate our therapist-client relationship. 

Although we do have an appointment reminder service in place, it is still your responsibility to remember your appointment. All no-shows and cancellations within 24 hours of appointment will be charged $40. 

TAC PATIENT CONSENT

PURPOSE: The purpose of "Technology-Assisted Counseling Agreement" is to get the patient's consent in order to participate in appointments using alternative modes of communication to further the counseling relationship. The modes of technology that we use in our practice include phone and video conferencing. Email is generally used for coordinating appointments and other administrative non-crisis issues.

The HIPPA compliant video conferencing program that we use is called Zoom. It is completely free for you to use. At your scheduled appointment time, ensure your computer or mobile device has the camera pointed toward you and direct your browser to the link sent by your therapist. Click to allow the website access to your microphone and camera, and then you are considered to be in the “waiting room.” Simply wait for the therapist to initiate the video session.

The most common benefits of using TAC are convenience, flexibility, and feelings of added anonymity. Convenience and flexibility to your therapeutic process can become evident with continuing services during vacations, business trips, sick days, bad weather, etc. Another advantage is that you may tend to feel slightly more detached from the counseling relationship and more open to share information. You may experience other advantages. Be sure to discuss those with your therapist. There is no guarantee that you will feel or experience any of these advantages. 

There are a number of disadvantages posed by technology-assisted therapy. Some of the most common are:

Confidentiality Risks: Although we abide by the federal law, known as HIPAA, that is designed to provide privacy standards to protect patients' medical records and other health information, there can never be a 100% guarantee of securing your electronic information. Hackers and other malicious malware can sometimes penetrate firewalls and eavesdrop with specialized technology. We cannot be held responsible for intrusions like these. You must be aware that the weakest areas of security are at the user end points. Secure your smart phones, tablets, and computers with passwords. Be sure and never leave your devices accessible by any other person, including co-workers, friends, or even family. You must assume the associated risk since confidentiality cannot be guaranteed nor is confidentiality guaranteed when using cell phones or streaming video. In some cases, it might be necessary for you to use another person's computer/phone or go to a public library where computers are generally available for public use.  
Lack of Visual Cues or Delays in Information Flow: Be aware that emotions are very difficult to portray over the phone and sometimes when communicating via streaming video. Therefore, be on the lookout for misunderstandings in the TAC environment and resolve them quickly by discussing it with your counselor. 
Handling Crises: According to ethics codes associated with TAC, therapists are expected to handle crises. The distance imposed in TAC can create special challenges for the counselor. If at any time you feel unable to keep yourself safe, go to your local hospital emergency room. If you have suicidal thoughts, you are agreeing to call 911 immediately. Please assist us in identifying emergency contacts in your area, such as 24-hour mental health services, police, emergency room and ambulance, etc. We will discuss these in one of our first sessions. 
Technology Failure: Unexpected tech problems can occur which are not our fault or the fault of you, the client. For example, a computer can stop working or lose its connection with the Internet, or a phone line can cease to work. Should a technical problem of this nature occur and disconnect you from us, it is your responsibility - the client’s responsibility - to reschedule the appointment directly with your therapist within 48 hours either by email or text:Rebecca@WellspringRenewalCenter.com 

Leah@WellspringRenewalCenter.com   

Sean@WellspringRenewalCenter.com 

Michelle@WellspringRenewlCenter.com 

870-918-5989
  
TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio. Telecommunications with patients will not be recorded and stored.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. In some cases, it might be necessary for you to use another person's computer/phone or go to a public library where computers are generally available for public use. 

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication. You, the client, have the right to request or deny certain TAC services. If in-person therapy is requested, the counselor will make every effort to arrange a session. If a requested in-person session is not possible, the counselor will arrange a referral or do their best to arrange a substitute for the request.

SOCIAL MEDIA POLICY

The following outlines our policies related to the use of Social Media. Please read it to understand how we conduct ourselves on the Internet as mental health professionals and how you can expect us to respond to various interactions that may occur with clients on the Internet. If you have any questions about anything within this document, we encourage you to bring them up when you meet with your counselor. As new technology develops and the Internet changes, there may be times when this policy will be updated. If we do so, we will notify you in writing of any policy changes and make sure you have a copy of the updated policy. 

Friending: We do not 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 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. 

Interacting: Please do not direct message (DM) us on Social Networking sites such as Twitter, Facebook, or LinkedIn. These sites are not secure and we may not read these messages in a timely fashion. Do not use wall postings, @replies, or other means of engaging with us in public online if we have an already established client/therapist relationship. Engaging with us this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact your counselor between sessions, the best way to do so is by direct email for quick administrative issues, such as changing appointment times. See the email section below for more information regarding email interactions. 

Use of Search Engines: It is not a regular part of our practice to search for clients on Google, Facebook, or other search engines. Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with us via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations, and if we resort to such means we will fully document it and discuss it with you when we next meet. 

Google Reader: We do not follow current or former clients on Google Reader, and we do not use Google Reader to share articles. If there are things you want to share with us that you feel are relevant to your treatment. 

Email: We use email to arrange or modify appointments. Please do not email us content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with email, be aware that all such messages are retained in the logs of yours and our Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails we receive from you and any responses that we send to you become a part of your legal record. For these reasons, we do not use email for any reason other than for administrative purposes.

Websites: Zoom is the tele-mental health video conferencing we will utilize.  It is HIPPA compliant and completely free for you to use. At your scheduled appointment time, ensure your computer or mobile device has the camera pointed toward you and direct your browser to the link sent by your therapist. Click to allow the website access to your microphone and camera, and then you are considered to be in the “waiting room.” Simply wait for the therapist to initiate the video session. 

If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to your counselor’s attention so that it can be discussed.

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected information. I understand that this information can and will be used to: 

• Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly or indirectly
• Conduct normal healthcare operations

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time at the address above to obtain a current copy of the Notice of Privacy Practices. 

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out our treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.