Client Information

I understand that:

• I will be receiving counseling services from Barb LoFrisco, PhD, licensed mental health counselor (MH 10206), licensed marriage and family therapist (MT 25 18), and certified sex therapist practicing at 14499 N. Dale Mabry Hwy, Ste. 164, Tampa, FL, (813) 404 - 9215.

• I understand that my counselor cannot tell me what to do or solve my problems, but rather will provide objective feedback to facilitate change, and that m y progress is largely dependent on my openness to change and willingness to work outside of the sessions (Research estimates this dependency at 40%).

• Different counseling techniques may be utilized during the course of my treatment. Unless other wise noted in writing, I hereby consent to the use of any counseling techniques utilized by my counselor during the course of my treatment.

• I understand that I can terminate therapy at any time, but am encouraged to have a final termination session so that my counselor can help me prevent relapse.

• I understand that my counselor is under an ethical duty to terminate when the counselor determines that I am not sufficiently benefiting from therapy and the counselor believes that I need a different level or ki nd of care.

• I will not make audio/video recordings of my sessions without my therapist’s permission.

• A 30 - day period without an appointment constitutes termination of the therapy relationship. Therapy may be resumed at any time upon agreement of all parties.

• If the mode of treatment is couples therapy, and I decide to stop attending, I giv e my permission for the therapist to see my partner individually, if that partner so chooses.

• I have the right to prompt and reasonable responses to my questions and requests.

• During my treatment with my counselor, I shall be free from abuse, exploitation, or criminal sexual conduct.

• I have the right to participate in the planning of my mental health care.

• This consent will expire 30 days after the termination of treatment.

• I have access to the HIPAA policy.

• All information pertaining to my counseling experience, including the knowledge that I am being seen for counseling is strictly confidential. By law, information cannot be released in spoken or written form by my counselor without my signed consent, with the following exceptions:

1. There is a clear and serious indication of doing self-harm.

2. There is a clear and serious indication of danger to someone else.

3. My counselor receives a subpoena of which I have been properly notified and have failed to inform her that I am opposing the subpoena or court order.

4. There is indication that a child, person with a disability, or elderly person has been abused, exploited, or neglected.

5. When clinical information is required for consultation. (No identifying information will be released).

6. My account is in delinquent status. Appropriate billing and financial information will be released to a collection agency. (No clinical data will be released).

7. I send my primary counselor an email containing private information. Please see the Online Consent portion of this document for more information.

8. My counselor is also a professor and professional writer and occasionally uses case studies as a method to educate others. As per section G.5.a. of the ACA Code of Ethics, the information will be sufficiently modified in order to obscure identity.

9. If I am using insurance, I give this office permission to release any information obtained during treatment that is necessary to support any insurance claims on this account and secure timely payments due to the assignee or myself.

10. If the mode of treatment is couples therapy, I give my therapist permission to utilize information obtained in individual sessions for treatment purposes.

No-show/late cancel

• I wil l be seen on an appointment basis. Whereas CounselorBarb understands that life can be very hectic and full of surprises, a cancellation or reschedule without enough notice costs her income that cannot be replaced. Therefore, barring emergencies, if I cance l within 48 hours I will pay her half the appointment fee, and if I give her no notice at all I will pay the full fee. (If she is able to schedule another client in my place, I will not be charged I will not use email to cancel or reschedule appointments , as this method can be unreliable and I may be held responsible for a missed appointment. If I have a credit card on file, that card will be charged.

If I arrive late

• My appointment time begins when I arrive and concludes at the scheduled ending time. If I will be more than 10 minutes late, I will call or text. Otherwise, CounselorBarb will assume I am not coming, and I may be held responsible for a missed appointment.

Telephone/text/email response time

• CounselorBarb may not respond immediately to my messa ges if she is in session or otherwise engaged. If I am in crisis I will contact the crisis center at 211, go to the emergency room of a hospital, or call 911.

• I will be paying $130 per individual session, $15 0 for individual sex therapy or couples th erapy, or $300/$225 for Discernment Counseling. Out of each therapy hour, CounselorBarb takes 10 minutes to review my case and complete clinical notes. Arrangements can be made (in advance) for shorter sessions.

• If I am using insurance, or want recurring appointments, CounselorBarb requires a credit card kept on file, which will be charged according to the No Show/Late policy, above.

• CounselorBarb will charge me her lowest hourly rate for telephone consultations, composing letters, or any other similar req uests for her time outside of the therapy hour. This includes reading lengthy emails or texts (please see the Online Policies for privacy concerns). CounselorBarb does not complete forms or other tasks related to short term or long term disability benefits . For requests involving photocopying, in accordance with Rule 64B8 - 10.003, Florida Administrative Code, there will be a charge of $1.00 per page for the first 25 pages and $.25 for each additional page.

• Delinquent accounts will be sent to Medical Busines s Consultants, Inc., and will include a $60 collection fee. Returned checks and credit card chargebacks will be subject to a $50 fee.

• CounselorBarb will maintain records of counseling services. These records may include reference notes, copies of t ranscripts of chat and internet communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association, National Board of Certified C ounselors, and the Florida Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling.

• Upon the death or incapacitation of CounselorBarb, Susan Posada, PhD, will take over as custodian of the client records.

Telemedicine is broadly defined as the use of technology to do psychotherapy. Therefore, all of the terms listed in this document apply. Although there are benefits to telemedicine, privacy becomes more of an issue. The main concerns are the possibility that an unsecured connection can be hacked, or that others may have access to your personal computer. Please note that email should not be used for urgent matters, as there may be some response delay time, or the message may get misdelivered. Misunderstandings can also be created by the reduction in non verbal cues or issues with the technology. Telemedicine may also not be appropriate in certain cases. Therefore, it is recommended that you have at least one in-person session before utilizing telemedicine.

Client safeguards: If others can access my computer I will take precautions such as creating passwords, and keeping both my IDs and passwords secret. If I am using technology in a public space such as a library, it is my responsibility to ensure others cannot view my screen or overhear my conversation with my counselor. If I choose to communicate via text or email other than Hushmail, I understand these are unsecured methods of communication, and it is possible that hackers or other unauthorized personnel may see my communications.

CounselorBarb safeguards: To allow for the highest possible security and confidentiality, CounselorBarb uses HIPAA compliant Doxy.me for video counseling, and offers the option of using Hushmail for email communication. Texting, while private, is still unsecured and should be used only for communication regarding appointments.

Disruptions: There could be technical issues causing disruption during a telemedicine session. If this occurs, you are responsible for contacting CounselorBarb. If it becomes impossible to continue the session, it will be rescheduled and you will not be charged.

I understand that CounselorBarb does not accept “Friend” requests on her Facebook profile; so if I want to connect with her on Facebook I will “like” her business page www.facebook.com/counselorbarb. To protect my privacy, I will not share clinical information on social media.

Please be advised that CounselorBarb does not participate in person, by phone or in writing in any court related matter that the client of CounselorBarb may be a party to or become a party to in any way. CounselorBarb does not write letters regarding their client’s treatment to any entity, including court. CounselorBarb at no time will offer an opinion or recommendation in any court matter, especially as it relates to custody.

I understand and agree to all of the terms listed in this document. I also have access to the Privacy Policies: