Counseling is a cooperative venture between the therapist and client and if the client is a child, the legal guardian. All have responsibilities in the change process. Due to the cooperative nature of psychotherapy and counseling, no guarantee of a cure or positive resolution can be given. We are Licensed Professional Counselors and adhere to the Code of Ethics and Standards of Practice of the American Counselor Association (ACA), the National Association for Alcoholism and Drug Abuse Counselors (NAADAC), the Georgia Composite Board of Professional Counselors, and the World Professional Association of Transgender Health Providers (WPATH). As professional counselors, with additional certifications and specialized interests, we are required to participate in extensive ongoing training. This is to maintain our licenses and continue to grow professionally for the benefit of our clients.

THE RISKS AND BENEFITS OF THERAPY

There are benefits and risks associated with participating in psychotherapy. Psychotherapy has been shown to be effective for the improvement and resolution of many kinds of personal problems. The process of psychotherapy, however, does involve risks on the part of the client. Change, and the processes involved in creating positive change, can at times be difficult and unsettling. Making changes in your behaviors may also be disruptive to relationships in your life. While every attempt will be made to prepare each client for this, each client must make the decision to enter into this process with a clear understanding of these risks. Before starting therapy, it is important that you consider these risks. Therapy often leads to a significant reduction in distress, improved relationships, and solutions to specific problems. Most people find therapy to be helpful and worth the risks; however, there is no guarantee of theoutcomes or what you will experience.

CONFIDENTIALITY

Confidentiality and privacy is maintained on all communication between the client and therapist and is covered by state and federal law. Federal standards for maintenance of your records have been defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The records of clients with alcohol and drug abuse problems may also be subject to further restrictions as outlined in Federal Law 42 CFR Part 2. We will not release clinical information about your treatment unless you give us written permission. However, there are circumstances where, by law, information must be revealed. Those instances are a disclosure is made to medical personnel in a medical emergency, suspected or actual abuse of a child or an elder, the risk of imminent harm to self or others or the occurrence of such harm, disclosure of abuse or criminal activity and a court order to disclose information outside of the scope of privileged communication.

When counseling a minor, we ask that the legal guardian grant us permission to maintain confidentiality with the child. We will consult with the parent on themes of therapy and information we deem in the best interest of the child and healthy overall functioning of the family. Maintaining confidentiality with the child helps to build a trusting relationship, which is the foundation of successful therapy.

ESTIMATED LENGTH OF THERAPY

The length of the course of psychotherapy treatment can vary depending upon the severity of the problems presented, and the ability of each client to utilize therapeutic approaches. Whenever possible, each client will be given an estimation of how much time the psychotherapy process will take.

LENGTH AND COST OF THERAPY SESSIONS

Unless otherwise stated, psychotherapy sessions will consist of 45-50 minutes of direct treatment, with 10-15 minutes allotted after the direct treatment for the clinician to complete treatment notes and review the content of the psychotherapy session. Unless otherwise agreed to, each psychotherapy session will be charged according to each provider’s session rate (found below). Clients who have mental health benefits through their insurance will be billed at the rate covered by their insurance, under the arrangement noted in a section below.

Please note that if we meet beyond your allotted time, you will be billed for the additional time at the prorated hourly fee and this fee will not be billed to insurance. If your provider is late for an appointment, you will be given your full session time. If client is late, you will be allowed the remaining time of your session. Any appointment more than 15 minutes late is subject to cancellation or reschedule.

Provider Rate Information: Intake/Follow-Up Sessions:

Kelly, Jodi, India: $165/$145

Sherri: $145/$120

INDIRECT AND SECONDARY SERVICES

Time spent performing services that support treatment, such as writing reports or letters, completing paperwork or forms for you, and contact with outside parties by phone or letter will be prorated on the provider’s billing rate for their time. Also, contact to the client, or ancillary contacts, outside of regular sessions in excess of 10 minutes per week will result in an additional fee. This includes phone calls, retrieving voicemails, reading and responding to text messages, and reading and responding to emails during a given week. These services are generally not covered by insurance plans and will be billed directly to the client. Contact to reschedule appointments or give or receive brief treatment information will not be billed.

PAYMENT POLICY

Clients are expected to pay for each session at the time it is held, unless firm arrangements are made in advance. Payment schedules for other professional services, such as indirect and secondary services, will be agreed to when they are requested. In circumstances of unusual financial hardship, a sliding scale is available or arrangements may be able to be made for a payment installment plan. The sliding scale may not be applied if insurance benefits are being used.

Acceptable forms of payment are cash and credit and debit cards. Health Savings Account and Flex Spending Account cards are acceptable as long as they have a major credit card logo. Credit card payments are made via the Electronic Health Records system, TherapyNotes. A credit card authorization form is required for all clients regardless of payment method. If using an HSA or FSA card, a major credit or debit card is also required in the event the HSA/FSA card changes or is depleted.

If a client’s account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, legal means can be used to secure payment. This may involve sending the balance to a collection agency or going to small claims court which will require the disclosure of otherwise confidential information. In most collection situations, the only information necessary to release regarding a client’s treatment is their name, the nature of services provided, and the amount due. If such legal action is necessary, its cost will be included in the claim.

INSURANCE POLICY

Where a professional relationship exists between the provider and the client’s insurance carrier, the client will be expected to pay the co-insurance amount designated under the policies of the insurance carrier at the time of each session, unless we have made firm arrangements in advance. Claims will be filed by the provider of services. Where a professional relationship does not exist with a client’s insurance policy, the client will be expected to pay the full amount for each psychotherapy session and to file his/her own claims. In such cases, where necessary, a superbill will be provided by the provider so as to allow the filing of claims by the client.

Please be aware that a contract with a health insurance company requires that we provide them with information relevant to the services given to the client. Providers are required to assess and assign a clinical diagnosis that is shared with the insurance company. Occasionally they request additional clinical information such as treatment plans or summaries or copies of an entire record. In such situations, every effort is made to release the minimum information about the client necessary for the purpose requested. The information provided, including a clinical diagnosis, will become part of a permanent health record.

CANCELLATION POLICY

Clients are expected to provide 24 hours’ notice of cancellation of any scheduled psychotherapy session. For any unkept session not cancelled prior to 24 hours, excepting emergencies, the client will be billed the full amount of the cost of the session, unless agreed to otherwise prior to the unkept session. Emergencies include: illness of the client or immediate family member, accident, or inclement weather. This cost is not covered by insurance, and the full amount will be billed to the client.

ELECTRONIC TRANSMISSIONS

Please be aware that any information transmitted electronically (this includes fax, email, text, and credit card payments) cannot be guaranteed as secure. When sending emails and text messages, be mindful of what information you choose to include. We, in turn, will be careful to not divulge any sensitive or clinical details electronically unless we have your express written permission. Files are maintained electronically in an Electronic Health Records system called TherapyNotes. The system is encrypted, password protected, and HIPAA compliant. We utilize an encrypted mail system called Proton Mail that is HIPAA compliant. The text message program we use is not encrypted or HIPAA compliant, however, we do offer an option for a secure texting method called Signal. You have the
option to choose secure texting on the Communications form.

SOCIAL MEDIA

It is the policy of the therapists at The Resilience Group to refrain from making connections with clients through social media and to decline all invitations to connect with clients on platforms such as Twitter, LinkedIn, Facebook, Instagram, or any other form of social media. These methods have very poor security and we are not prepared to watch them closely for important messages from clients. It is important that we be able to communicate and also keep the confidential space that is vital to therapy. This policy is designed to protect the rights of each client’s privacy and confidentiality. This policy will be followed both during the time a client is in treatment and after a client has discontinued treatment.

EMERGENCIES

The Resilience Group does not have an answering service or administrative assistant. Our therapists are often in session and not immediately available to answer their phone or respond to text messages and email. We do check our voicemail, texts, and email regularly and make every effort to return phone calls within 24-48 business hours and text messages and email by the end of the business day or next morning if it is after 5pm when receive the message.

If you are unable to reach your therapist and need to speak to someone immediately, please call your primary care provider, go to the nearest hospital, or call 9-1-1. You may also call the Georgia Crisis and Access Line at 800-715-4225 24 hours a day. They will send a licensed mental health professional to you.

INTERACTION WITH THE LEGAL SYSTEM

Divorce/Custody Disputes: We are not able to provide evaluations or expert testimony in court. There are mental health professionals who specialize in evaluations for custody and as expert witnesses in family court hearings. General Litigation: We will not engage in any legal issues or litigation that you are a part of during your counseling or after your treatment ends. This includes interaction with the court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug evaluators, or any other contact with the legal system. We will, with proper advance notice and a signed release of information, prepare a summary of treatment letter for you addressed to an attorney, probation officer, judge, or other court officer. We cannot guarantee that the letter will benefit your legal case and encourage you to refrain from making any request for your therapist to be involved in your legal issues. If your attorney subpoenas us, we may elect to not speak with your attorney in order to preserve the therapeutic relationship. Additionally, a subpoena may result in your therapist withdrawing as your provider.

CLIENT RIGHTS

Each client has the right to expect competent psychotherapy treatment in accordance with accepted professional standards. Each client has the right to request information about any aspect of treatment, including but not limited to assessment results, treatment techniques utilized, course and direction of treatment. Each client has the right to provide feedback to the provider about where treatment is being successful and unsuccessful, and to terminate treatment at any time.

CLIENT RESPONSIBILITIES

Each client is held to be responsible for engaging in the therapeutic process in ways that further treatment progress, making available to the provider such information as is needed to provide effective treatment, and participating in directing the course and direction of treatment.

SUMMARY OF CLIENT RIGHTS

When you receive mental health services, your rights are protected by the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, as a recipient of substance abuse treatment, your rights are also protected by federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CRF Part 2). Listed below is a simplified outline of those rights. The Notice of Privacy Practices describes any limitation to these rights and other provisions that may apply and should be consulted if there is a dispute or questions arise regarding any of those rights.

Your Rights Include:

• The right to receive care suited to your needs
• The right to receive services that respect your dignity and protect your health and safety
• The right to know the names and positions of those involved in services planning and implementation process
• The right to be informed of the benefits and risks of treatments
• The right to participate in planning your own treatment
• The right to refuse services, unless a therapist believes that refusal would be unsafe to you or others
• The right to receive a copy of the Notice of Privacy Practices
• The right to inspect and copy your records
• The right to request amendment to your records
• The right to request limitation on the medical information we use or disclose about you
• The right to request how and where you may be contacted
• The right to request an accounting of all disclosures we make about you to other persons or agencies
• The right to exercise all civil, political, personal and property rights to which you are entitled as a citizen
• The right to remain free from physical restraints or time out/seclusion procedures unless such measures are necessary for providing effective treatment or protecting safety of you or others
• The right to be free from physical or verbal abuse
• The right to file a complaint if you think any of these rights have been restricted or denied.

You must be provided with a Notice of Privacy Practices that provides detailed information regarding your rights under HIPAA and CRF Part 2.

The client has had an opportunity to read or have read to him/her the above form to ask questions regarding the data contained therein.

STATEMENT OF CONSENT

My physical or electronic signature on this form indicates that I have read all above information, it has been adequately explained to me, and I understand its contents. I am voluntarily requesting services by The Resilience Group and am applying for and consenting to the prescribed counseling treatment. I understand that my record may be maintained on paper or in electronic format and may only be accessed by health care professionals and providers operating under contractual authority of The Resilience Group or as otherwise permitted by or required under law. It has been explained to me that therapeutic treatment methods/services may include diagnostic assessment, individual, group or family counseling and crisis management services.