With my signature below I submit to, agree with, and will comply with this information:

WS Notice of Privacy Practices (NOPP):

• This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. 
• As Required By Law: We may use and disclose your protected health information when required to do so by federal, state, or local law.
  Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful processes. 
• Accounting: You can ask for a list (accounting) of the times we shared your health information for six years prior to the date you ask, who we share it with, and why. We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge you a reasonable, cost-based fee if you ask for another one within 12 months. We reserve the right to decline more than three requests in one year or an additional request where there is no new information to include. 
• Treatment: Your Protected Health Information (PHI) may be used and disclosed without your prior authorization by Wellness Solutions, LLC. Our office staff and others outside our office may disclose PHI without your authorization to those who are involved in your care and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of Wellness Solutions, LLC, and any other use required by law. We will use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, Wellness Solutions, LLC would disclose your PHI, as necessary, to insurance companies. 
• Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of Wellness Solutions, LLC. These activities include, but are not limited to, quality assessment activities, employee review activities, employee training, licensing, and conducting or arranging for other business activities. For example, we may disclose or share your PHI to third parties for normal business practices. We may call you by name in the waiting room to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment or other treatment related activities. We may use and disclose your health information for healthcare and business operations. 
• Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for treatment may require that your relevant PHI be disclosed to a health plan or employee assistance plan (EAP) to obtain approval for coverage and payment.
• Emergencies: We may use or disclose your PHI in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonable and practical. If your healthcare provider or another healthcare provider is required by law to treat you and the healthcare provider has attempted to obtain your consent then he or she may still use or disclose your PHI to treat you.
• Request Confidential Communications: You can request communication preferences based on how you would like to receive and share information with Wellness Solutions, LLC. We will agree to reasonable requests based on individual circumstances.
• Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for the care of your location, general condition, safety concerns, emergency situations, or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare. 
• Social Service, Fundraising, & Community Activities and Events: We may use and disclose your health information in order to contact you for social service fundraising, and community activities and events being held or sponsored or supported by Wellness Solutions, LLC. Examples of these activities and events may be No Suicide Prevention Walks to Raise Awareness and food or clothing drives. If you do not want Wellness Solutions, LLC to contact you for these types of activities and events, you may opt out at any time by calling (713) 893-3989 Monday-Friday from 9 AM to 5:00 PM CST or email Admin@wellnesssolutionsllc.com .
• Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. This disclosure will be made for the purpose of controlling disease, injury, or disability.
• Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
• Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs.
• Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child, elder, or persons with disabilities for suspected abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
• Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration (i) to report adverse events, product defects or problems, biologic product deviations, track products; (ii) to enable product recalls; (iii) to make repairs or replacements; or (iv) to conduct post-marketing surveillance, as required.
• Coroners, Funeral Directors, and Organ Donation: We may disclose your PHI to a coroner or medical examiner for identification purposes, determining the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be disclosed for cadaveric organ, eye, or tissue donation purposes.
• Research: We may disclose your PHI to researchers when their research has been approved by an Institutional Review Board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
• Criminal Activity: Consistent with applicable Federal and state laws, we may use or disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and/or imminent threat to the health or safety of a person or the public.
• Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel: (i) for activities deemed necessary by appropriate military command authorities; (ii) for the purpose of a determination by the Department of Veterans Affairs; or (iii) to foreign military authority if you are a member of the foreign military services.
• Workers’ Compensation: We may use or disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally established programs.
• Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your health care provider created or received your PHI in the course of providing care to you.
• Copy of this Notice:  You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. This may include medical and billing records but does not include any psychotherapy notes. We will provide you with a paper copy promptly. You may also find a copy of this notice on the Wellness Solutions, LLC website which is WWW.WellnessSolutionsLLC.COM All individuals who sign documents via electronic signature receive their own copy. Wellness Solutions, LLC reserves the right to provide a clinical summary of care instead of clinical notes, progress notes, or psychotherapy notes. If you request copies, we may charge you a reasonable fee to locate and copy your information and postage if you want the copies mailed to you.
• Amendment: You have the right to request that we amend your health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. The specific restrictions you are requesting must be made in writing and give Wellness Solutions, LLC a reasonable time to implement your request. Your health care provider is not required to agree to a restriction that you may request. If your health care provider believes it is in your best interest to permit the use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another healthcare provider. If your health care provider does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.

Wellness Solutions, LLC Responsibilities:

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it. 
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• We can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website.
• Contact Information: You can complain if you feel we have violated your rights by contacting the Corporate Privacy Officer Danielle C. Ellis MA, MCJ, LPC, NCC at (713) 893-3989 Monday-Friday 9 AM - 5 PM CST or by emailing Admin@WellnessSolutionsLLC.COM . Wellness Solutions, LLC mailing address is as follows: 8000 Research Forest Dr, Ste 115 PMB 1168, The Woodlands, TX 77382 . Wellness Solutions, LLC does not retaliate against anyone for filing complaints or concerns. 
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775 or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

With my signature below I submit to, agree with, and will comply with this information:

WS Client Rights, Expectations, & Responsibilities:

Clients Rights 

• You have all the rights of any other resident of the State of Texas and the United States of America. 
• You have the right to not be discriminated against based on age, race, ethnicity, gender, sexual orientation, religion, national origin, physical or mental disability, or other attributes. 
• You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs. 
• You have the right to be free from abuse, neglect, and exploitation. 
• You have the right to be told about the treatment you will be given, the risks, side effects, and benefits of all treatments you will receive, the other treatments that are available, and what may happen if you refuse treatment. 
• You have a right to a treatment plan designed to meet your needs and you have the right to take part in developing that plan or request changes to any part of your treatment plan.
• You have the right to have information about you kept private and to be told about the times when the information can be released without your permission. 
• You have the right to withdraw at any time your permission for something you agreed to earlier. 
• You have the right to receive full information about the provider’s knowledge, skills, preparation, experience, and credentials. 
• You have the right to be informed about the options available for treatment interventions and the effectiveness of the recommended treatment.
• You have the right to request and pursue a second opinion and request a referral to another provider.
• You have the right to be involved in discharge planning from treatment.
• You have the right to submit complaints and grievances.
• You have the right to make a complaint and receive a fair response from the provider within a reasonable amount of time.
• You have the right to be considered capable of making a decision.
• You have the right to be treated with autonomy, dignity, and respect.
• You have the right to privacy and confidentiality.
• You have the right to have your personal preferences, opinions, beliefs, values, and needs to be taken into account throughout the treatment process. 
• You have the right to have treatment matters discussed and explained in a manner that you are able to understand.

Client Expectations & Responsibilities:

• Clients are expected and responsible to attend all scheduled appointments and to reschedule or cancel appointments within the appropriate time frames. 
• Clients are expected and responsible to be on time for appointments. 
• Clients are expected and responsible to complete treatment assignments or homework in a timely manner. 
• Clients are expected to take responsibility for their financial obligations. 
• Clients are expected and responsible for understanding his/her insurance benefits and policy provisions including the network status of providers.
• Clients are expected and responsible to pay for all services provided or charges incurred by the client regardless of any reimbursement with third-party payors.
• Clients are expected and responsible to be honest throughout the therapeutic process. 
• Clients are expected and responsible to communicate feelings that his/her needs are not being met by the services of the provider.
• Clients are expected and responsible to communicate concerns regarding the quality of care and/or progress in treatment. 
• Clients are expected and responsible to be active participants in developing and implementing his/her treatment plan.
• Clients are expected and responsible to follow through with recommendations for treatment, such as, referrals to other providers or clinically relevant services for consultation or support. 
• Clients are expected and responsible to inform the provider of ANY and ALL concerns for safety such as thoughts, ideas, or compulsions for self-harm, suicidal behavior, homicidal behavior, psychosis, substance use or dependence, eating disorder behavior, self-injurious behavior, oppositional or defiant behavior that may put the client or others in jeopardy, non-compliance with prescribed medications; any or all behaviors or symptoms that place the client or others in jeopardy or at risk for potential safety concerns, or non-compliance with his/her treatment plan. 
• Clients are expected and responsible to cooperate, comply, honor, and adhere to all aspects of Wellness Solutions, LLC Informed Consent and Disclosures and any/all other Wellness Solutions, LLC policies and procedures.
• Clients are expected and responsible to provide accurate and complete information about all matters pertaining to one’s health, symptoms, distress, and mental health.
• Clients are expected and responsible to report changes in their condition or symptoms in a timely and honest manner.
• Clients are expected and responsible to identify, communicate and report any safety concerns that may affect one’s care.
• Clients are expected and responsible for complying with his/her safety plan.
• Clients are expected and responsible for honoring and abiding by the boundaries of the therapeutic relationship.
   

With my signature below I submit to, agree with, and will comply with this information:

WS Informed Consent & Disclosures:

1. Introduction to Wellness Solutions, LLC Informed Consent & Disclosures:

• Informed consent and disclosures is a process of developing an understanding regarding the therapeutic process. It is a thorough, detailed, and ongoing information-sharing agreement between the provider and the client. The purpose of informed consent and disclosures is to ensure that the client, the parent(s)/guardian(s) of clients, and/or a client’s representative(s) is/are able to make an informed decision to engage in the treatment process with a comprehensive foundation of knowledge, such that, the client, the parent(s)/guardian(s) of minor clients, and/or client’s representative(s) is/are educated about what he/she is consenting to when he/she/they agree to participate in treatment. 
• Informed consent and disclosures provides an explanation about what treatment is, how the treatment works, the possible benefits and risks of treatment, alternatives to the treatment process, the boundaries (rules) of the therapeutic relationship, the responsibilities of the client, the client’s financial responsibilities to the provider, and the client’s rights and limitations to privacy and confidentiality. Informed consent and disclosures helps define the roles and responsibilities of all individuals engaged in the treatment process to effectively address and manage expectations by providing thorough information regarding consent and detailed disclosure regarding the treatment process. 
• It is imperative that the client actively and honestly participate in the informed consent and disclosures process and the therapeutic process in a proactive and forthcoming manner. Wellness Solutions, LLC believes that the informed consent and disclosures process is not merely “signing off” on a document, therefore; all parties are encouraged to conceptualize informed consent and disclosures as the first step of the therapeutic process, as well as, an integral component throughout the course of treatment. Any questions regarding this information or anything else pertaining to treatment is welcome and encouraged. It is important for the client to be aware that he/she is responsible for knowing, understanding, agreeing with, and being compliant with all information contained herein. 

2. Disclaimer About Wording:

• For the purposes of this document the term "provider" includes any and/ all of the following: Clinical staff, Administrative staff, Billing Staff, and any/all Sub-Contractors, and any/all employees of Wellness Solutions, LLC, unless stated otherwise. For the purposes of this document, the term “client” includes any/or all of the following: Clients, the parent(s)/guardian(s) of a client, and/or a client’s representative(s). 

3. Qualifications of  Owner & Staff of Wellness Solutions, LLC:

• Danielle C. Ellis, MA, MCJ, LPC, NCC has a BA in Psychology, MA in Professional Counseling Psychology, and a MA in Criminal Justice Administration. Dani is a Licensed Professional Counselor (LPC) in the State of Texas (License Number 63315). Additionally, she is also a National Certified Counselor (NCC) by the National Board of Certified Counselors. She is the CEO, Owner, and Clinical Director for Wellness Solutions, LLC. For additional information on her education, experience, licensure, and work history please see the Wellness Solutions, LLC website (WWW.WellnessSsolutionsLLC.COM). The provider commits that any and all clinical staff providing direct care to clients meet or exceed the minimum requirements by law in the State of Texas for the position in which the staff provides care. Further, all Wellness Solutions, LLC clinical and non-clinical employees are professionally trained, educated, and meet all ethical and legal requirements by law. Licensed Professional Counselors are licensed by The Texas State Board of Examiners of Licensed Professional Counselors and comply with The Texas State Board of Examiners of Licensed Professional Counselors Rules, Regulations & Ethics Standards. Wellness Solutions, LLC also complies with the professional and ethical standards of The Texas Counseling Association Code of Ethics, The National Board of Certified Counselors Code of Ethics, &  The American Mental Health Counselors Association

4. Definition of Counseling, Coaching, Therapy, Treatment, & Psychotherapy:

• There are many interpretations and definitions to distinguish between counseling, psychotherapy, and treatment; however, contained herein is a general explanation of these terms to provide a basic understanding. Counseling includes assistance, guidance, and support resolving personal, emotional, and other difficulties or stressors. Psychotherapy is the treatment of psychological disorders or maladjustments utilizing clinical techniques. Counseling and psychotherapy are terms that are often used interchangeably though psychotherapy is best understood as based in clinical acuity including diagnosis and treatment of mental and behavioral disorders whereas counseling includes problems of everyday living that cause distress. Treatment or therapy may also be used as a synonym for counseling and psychotherapy. Counseling, psychotherapy, and treatment focus on problems or symptoms that rise to a level of severity that impair one’s ability to function at their optimal levels. The goal of counseling, psychotherapy, and treatment is to reduce, extinguish, or resolve symptoms and problems so the individual may recover and return to his/her previous optimal level of functioning.
• Counseling, psychotherapy, and treatment achieve this through clinically appropriate evidence-based and empirically supported and validated interventions. Counseling and psychotherapy are provided by licensed mental health professionals who receive extensive education, training, supervision, and experience to develop and refine clinical and professional expertise. Counseling and psychotherapy education and licensure require a bachelor's degree and a master's degree, Ph.D., or PsyD in clinical psychology, clinical social work, or counseling. Counseling and psychotherapy education and licensure require ongoing training and consultation throughout one’s career. Counseling and psychotherapy licensure and treatment provide professional protections to clients, such as, privacy, confidentiality, and privileged communication. Licensed professional counselors follow professional, ethical standards, codes, and guidelines that are standardized and protected by law. In most circumstances, counseling and psychotherapy are covered benefits for managed care insurance policies. Coaching is a process to empower individuals to develop strategies for achieving their personal best. Coaching assists individuals identify and augment strengths. Coaching focuses on holistic health and wellness. Wellness is a state of optimal performance and is not merely the absence of disease. Coaching assists individuals with identifying and exploring strengths, goals, and future-oriented plans. Coaching does not include the assessment, diagnosis, intervention, or treatment of mental, behavioral, or psychological disorders. Though many counselors and psychotherapists do utilize coaching as a change-facilitation strategy to assist their client's coaching is not a treatment and does not have requirements for education, training, supervision, or licensure. Coaching does not provide a client with legal or ethical protections for privacy, confidentiality, and privileged communication. Further, coaching is not a covered benefit for managed care insurance policies. 

5. The Therapeutic Process:

• The therapeutic process includes the following: Identifying strengths, developing problem-solving techniques, coping skills, assertiveness skills, impulse control skills, boundary-setting skills, and communication skills. It may also include receiving positive supportive and empathic feedback, impartial objective feedback, polite challenges to illogical thought processes, respectful confrontation regarding maladaptive or inappropriate thinking, feeling, and behaving. 
• The therapeutic process may entail education regarding mental health treatment and diagnosis, healthy nutrition and lifestyle choices as it relates to mental and behavioral health, stress management, spiritual or value identification and development, existential exploration, insight development, awareness of emotions, thoughts, and behaviors, assisting with goal development and achievement, accountability to support goal attainment, and learning about emotions, cognitive processes, and personal development. Further, the therapeutic process may include the following, but not limited to: Positive emotional support and validation, reframing experiences, resolving trauma, increasing understanding regarding motivation and behavior, and having a physical and emotionally safe place to explore one’s thoughts, feelings, and behaviors in a healing positive, and non-judgemental environment. The desired outcome of therapeutic treatment is to reduce or eliminate symptoms, reduce maladaptive thoughts, feelings, and behaviors, to reduce or eliminate distress, and to explore, as well as, implement individualized strategies and interventions to help a client achieve his/her goals. Further, desired outcomes of treatment may include but are not limited to the following: Increasing relationship satisfaction, improving relationship quality, assisting with identifying and augmenting strengths, learning healthy coping strategies, increasing functioning in specific areas of a client’s life, to identify and utilize resources, develop resilience and resourcefulness, to increase self-esteem, self-confidence, and self-efficacy.

6. The Therapeutic Relationship & Professional Boundaries: 

• Although therapy sessions may be very personal, the relationship between a client and therapist/provider is a professional relationship. A therapeutic relationship is an integral tool necessary for change to take place and to successfully achieve treatment goals. Therefore, there are very specific ethical and legal mandates pertaining to the therapeutic relationship to protect the client and facilitate positive change. The therapeutic relationship is a unique relationship where a client is able to explore, process, and develop insight, awareness, and skills to address symptoms, stressors, functional impairments, and issues that are personal, sensitive, painful, and vulnerable. 
• The therapeutic relationship is private, confidential, and non-judgemental. It includes clearly defined rules and expectations. This is a unique relationship where clients can safely explore personal issues. The therapeutic relationship respects the beliefs, values, and dignity of the client. The only beliefs and values that are relevant in the therapeutic relationship are that of the client. The provider’s personal beliefs and values are not relevant in the therapeutic relationship and are not part of professional expertise or evidenced-based interventions. The therapeutic relationship promotes emotional safety and healing. Clients receive impartial, fair, objective, evidenced-based interventions and feedback. The client receives impartial feedback from a professional who has demonstrated expertise based on education, training, and experience in the assessment, diagnosis, and treatment of emotional and psychological disorders. The therapeutic relationship, though emotionally intimate, is not friendship nor is it permitted to extend beyond a professional relationship. The therapeutic relationship is time-limited, professional, and one-sided as it exists to meet the emotional needs of the client and not the provider. The provider takes the privileged position of a therapeutic relationship with clients very seriously and maintains a strict adherence to the ethical and legal boundaries inherent to that relationship. 
• The client and provider do not engage in multiple relationships or dual relationships nor do they engage in activities or situations outside of the therapeutic treatment session. The provider does not engage in dual relationships which means that the provider will not have social relationships with clients or accept clients with who the provider may have a social or family relationship. The client and provider do not engage in communication unless it is of a professional or clinical subject matter.  Professional boundaries are maintained at all times. The therapeutic relationship is professional and based on timed sessions that are fee for service. The provider does not accept gifts from clients. The provider does not barter services due to potential conflicts of interest. 
• If the client and provider should see one another in public the provider will not acknowledge the client unless the client acknowledges the provider first. The provider will make every effort to protect the client’s confidentiality. The provider will not confirm or deny that any individual is a client without consent to release information. Any and all concerns with regard to clinical boundary violations should be reported to the provider and provider’s supervisor immediately. 

 7. Therapeutic Journey and Motivation: 

• Therapy is a client’s personal journey of change to develop insight, awareness, positive skills, and methods to think, feel, and behave in a healthy, adaptive, resourceful, and resilient way. If a client is not dedicated, motivated, and willing to demonstrate perseverance and commitment to the therapeutic process, then therapy will not help the client. Therefore, the counseling journey is the client’s responsibility. There is no help a provider can give a client that will overcome a lack of motivation, willingness, or compliance of the client. It is the client’s responsibility to participate in counseling in an honest, forthcoming, transparent, and proactive manner. The client is strongly encouraged to take ownership of his/her therapeutic journey through authentic engagement and participation in the process. In order for treatment to be successful, the client must do the work. There are no shortcuts to personal change. Simply talking about a problem or a symptom is not enough to facilitate necessary, sufficient, and measurable change. One must actively engage in the process of change and participate pro-actively for legitimate meaningful change to occur. The provider is a guide to help the client through the therapeutic journey and is not responsible for doing the work of therapy and change for the client. It is important to have realistic expectations regarding one’s potential for change and one’s willingness to participate and engage in the treatment process in an authentic and genuine manner. The desire for change is insufficient to facilitate and achieve actionable lasting personal change and transformation. The client is encouraged to recognize that really meaningful change is a process for which he/she is ultimately solely responsible.

8. Services Provided: 

• Wellness Solutions, LLC offers individual, couples, family, and group services. Services provided may include but are not limited to the following: Problems with interpersonal relationships, work/life balance, stress management, career counseling, behavior modification, grief counseling, trauma recovery, coping with depression or anxiety, and other services. Wellness Solutions, LLC provides outpatient counseling and/or psychotherapy for mild, moderate, or severe mental health disorders, substance abuse disorders, eating disorders, self-injurious behaviors, and problems of everyday living. Services are provided by appointment only. Wellness Solutions, LLC does not accept walk-in appointments. Wellness Solutions, LLC provides both in-person and telehealth appointments to clients who are physically located in the state of Texas. Wellness Solutions, LLC also provides or engages in community-based services such as food drives, clothing drives, toy drives, classes, seminars, mental health advocacy, educational advocacy, disability advocacy, and other pro-social activities. Wellness Solutions, LLC also provides coaching based on holistic positive psychology concepts. 

9. All Services are Provided on a Voluntary Basis: 

• The client has the right to consent to receive or refuse services at any time and for any reason. The client has the right to rescind consent for services at any time and for any reason. The client is provided services on a voluntary basis. The provider also reserves the right to refuse services to the client for any reason and at any time. The provider reserves the right to terminate care if the client is non-compliant with the treatment plan is non-compliant with a safety plan is unwilling/unable to pay for services, or for any reason deemed appropriate by the provider. 
• Wellness Solutions, LLC does not provide court-ordered or mandatory outpatient counseling, psychotherapy, or treatment and will not provide care or participate in the treatment of a client or clinical case involving interactions with the legal system. In the event a current client under the care of Wellness Solutions, LLC is court-ordered for treatment or begins participation in or with the legal system then the client will receive three sessions to appropriately transition and terminate from treatment, be discharged from care, and be referred to another provider. 

10. Populations Serviced: 

• Wellness Solutions, LLC serves clients who are 13 years of age and older. Wellness Solutions, LLC services include but are not limited to the following: Individuals, couples, families, and groups.

11. Special Circumstances Regarding Providing Services to Minors and/or Minors or Adults Under Guardianship Court Orders, and/or Minors or Adults Subject to Custody Decrees or Court Orders: 

• Wellness Solutions, LLC believes that both parents play important roles in the lives of their children, regardless of the parent's marital status or custody situation, as a result, it is necessary to include both parent(s)/guardian(s) and/or client’s representative(s) in the treatment process. Wellness Solutions, LLC requires both legal parent(s)/guardian(s) of minors to sign all clinical documentation. Wellness Solutions, LLC requires all clients, regardless of age, to sign all clinical documentation. Wellness Solutions, LLC requires the parent(s)/guardian(s) of minors subject to a custody agreement to submit the final divorce decree with the case number located on each page prior to scheduling an appointment. The decree must include the signature page with the judge’s signature and dated. 
• If the mental health/psychological rights have been modified in a modification order, the parent(s)/guardian(s) is/are required to submit both copies (divorce decree and modification order) to Wellness Solutions, LLC prior to scheduling an appointment. Further, both of the aforementioned orders must be filed with the court and have a case number for verification purposes- the attorney’s initial court filing copies will not be accepted. 
• This is to verify which parent has legal custodial guardianship with the legal right to consent for non-emergent outpatient mental health treatment. This is both a legal and ethical requirement for providers in the state of Texas. Individuals who provide false or misleading information may be in violation of the law, as well as, court order.
• For minor clients who are adopted, it is required to provide Wellness Solutions, LLC a copy of court-recorded adoption papers and/or a birth certificate. This information verifies that the child is legally in your custody and that the individual providing consent for non-emergent outpatient mental health treatment has the legal right and authority to do so. The relevant aforementioned requirements also apply. For minor clients who were not subject to a custody agreement at the time of admission and become subject to a custody agreement or guardianship while under the care of Wellness Solutions, LLC the aforementioned requirements and standards apply. For adult clients who are the subject of guardianship it is required to provide Wellness Solutions, LLC a copy of court recorded adoption papers. The relevant aforementioned requirements also apply.
• We understand that the above can be a burden and it is certainly not our intention to cause undue stress. The aforementioned policies are legal and ethical requirements to ensure providers engage in due diligence to determine who has mental health rights as a minor or adult with guardianship prior to treatment. It is in everyone’s best interest that we follow all relevant ethics and laws pertaining to child custody and adult guardianship. 
  If there are significant conflicts between the minor client and a parent then Wellness Solutions, LLC maintains that the issues in the conflicted relationship are areas of clinical concern and require clinical intervention. Wellness Solutions, LLC does not condone or participate in parental alienation. Therefore, Wellness Solutions, LLC will not provide treatment to an individual without the knowledge and/or participation of a parent. In the event that a parent/guardian refuses to sign the Wellness Solutions, LLC intake documents then the prospective minor client will not be permitted to schedule an appointment. 
• Wellness Solutions, LLC will not provide treatment to any individual where there is conflicted parent or guardian consent. In order to verify the authenticity of the individual signing all intake documents Wellness Solutions, LLC requires three forms of identification including one official picture ID to be included with the completed documents. At least one parent/guardian/client representative is required to accompany minors to the first appointment and, dependent upon the age of the client, to all subsequent sessions. 

12. Special Circumstances: Providing Services to Couples and Families:

• Wellness Solutions, LLC provides counseling, psychotherapy, and treatment to couples and families. Clients who pursue couples and/or family treatment are advised that there are unique confidentiality concerns and boundaries. The clients who receive couples and/or family therapy are advised that the confidentiality of the clinical information contained in couples and/or family session clinical documentation is significantly limited and reduced for all parties in order to protect the privacy and confidentiality of all parties. Wellness Solutions, LLC advises all clients who seek couples and/or family treatment from more than one Wellness Solutions, LLC provider (for example if each member of the couple or family have an individual counselor and a family counselor employed by Wellness Solutions, LLC) then in accordance with best-practice standards and ethical clinical practice providers will coordinate care with one another in team staffing sessions and will require a consent to release information for all parties concerned. 

13. Special Circumstances: Multiple Outpatient Providers & Continuity of Care and Coordination of Care:

• Wellness Solutions, LLC declines to provide outpatient mental health services and treatment to individuals who prefer to engage in counseling, coaching, or psychotherapy with other outpatient mental health professionals simultaneously. 
• Wellness Solutions, LLC will coordinate care and provide continuity of care to clients who are in higher levels of outpatient care or receive outpatient medication management psychiatric care from a psychiatrist. 

14. Modalities of Treatment: 

• The treatment modalities, theoretical orientations, clinical interventions utilized by Wellness Solutions, LLC may include but are not limited to, the following:  Psychotherapy, Counseling, Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Rational Emotive Behavior Therapy (REBT), Person-Centered Therapy, Mindfulness-Based Cognitive Therapies, Boundary Setting, Communication Skills, Assertiveness Skills, and counseling and therapeutic interventions and activities.  Wellness Solutions, LLC only utilizes and endorses therapeutic interventions that are Empirically Supported Treatment (EST) validated and Evidenced-Based Treatments (EBT). 

15. General Session Description: 

• Sessions are 45-50 minutes in duration. In the event, a session exceeds 45-50 minutes the client will be charged in accordance with Wellness Solutions, LLC fees. The client should be aware that fees for session time overage are not covered by insurance. Sessions include the client and clinician discussing problems, symptoms, and presenting concerns. Sessions include encouraging the client to explore, develop, learn, and practice coping skills, problem-solving skills, accessing appropriate support systems or resources, and other psychotherapeutic skills to decrease symptoms, improve functioning, and resolve areas of distress. Sessions include assisting the client to attain the client’s highest level of functioning, alleviate symptoms causing distress to the client, and provide the client with skills, strategies, resources, and supports. Sessions may include exploring, learning, practicing, utilizing, and accessing treatment resources, such as articles, worksheets, books, apps, therapeutic homework assignments, and videos to assist the client complete treatment objectives and achieve treatment plan goals. Sessions may include reviewing and processing assignments to be practiced or worked on outside of the session to assist clients with skill development and goal achievement. Sessions may include assignments outside of the sessions to assist the client to learn, develop, and practicing skills to assist the client to achieve his/her goals. The assignments are not “busy work.”  Interventions are individualized based on the specific identified symptoms, problems, needs, objectives, and goals of the client. Interventions and assignments range from a diverse range of media, technology, information, resources, and supports that best suit a client’s learning style and preferences. Clients are strongly encouraged and recommended to bring three topics or areas of concern to address in the session. This policy empowers a client to take responsibility for his/her sessions. It is not the responsibility of the clinical staff to determine or uncover the topics a client wants to discuss. 

16. First Session/Intake Session Description:

• In the first session, the provider will discuss and explain informed consent and other relevant and useful information. 
• The provider will conduct an assessment that includes asking questions regarding the client’s history, precipitating events for seeking treatment, current strengths and stressful concerns, goals of treatment, and obtain information to assist in the treatment process. The client and the provider collaborate to share information, establish rapport, and develop an understanding of the expectations and goals of treatment. 

17. Subsequent Session Description (Second Session And Further):

• Sessions include discussing problems, symptoms, and areas of concern, as well as, strengths, resources, and interventions to assist the client to develop coping skills, decision-making skills, strategies to increase effectiveness, and other clinical techniques to help a client achieve his/her goals. Sessions may feel uplifting and energizing. Sessions may also feel tired, heavy, or anxiety-provoking. There is a vast array of thoughts and feelings one may experience throughout the course of treatment. Sessions vary in content and results based on the content of topics and symptoms identified or the types of skills being learned and developed. A client is expected to inform the provider if the client is having concerns regarding safety, suicidal thoughts or feelings, homicidal thoughts or feelings, self-harm thoughts or behaviors, psychotic symptoms, or any other thoughts, feelings, or behaviors that may cause risk for harm or safety. A client is expected to be prepared for the session and bring topics that he/she would like to discuss in session and not anticipate that the provider will “mind read” or “guess” what topic, symptom, or problem that the client may want to address. Having expertise in mental health does not include mind-reading as a skill set. Your provider cannot assist you if you are not forthcoming, honest, transparent, and engaged in your care. The subject matter of sessions is the ultimate responsibility of the client, however; a provider may exercise clinical discretion in guiding a session and addressing symptoms, skill development, problem-solving, and interventions. 

18. Treatment Duration/Progress In Treatment/Length of Stay In Treatment: 

• The duration of time in therapy and anticipated length of stay for outpatient counseling, coaching, and psychotherapy is dependent on multiple variables, which include but are not limited to, the presenting problem, diagnosis, severity of areas of concern, compliance to the treatment plan, and motivation of the client. The length of time in treatment and progress towards goals is based on many variables which include the client’s specific needs, objectives, and goals. Treatment duration and progress, regardless of symptom severity or acuity, is significantly impacted by a client’s willingness to participate honestly and authentically, as well as, one’s consistent and determined motivation, access to resources, and the presence of a positive healthy support system. The average length of stay for short-term solution-focused mild stressors that include problems of everyday living is approximately ten sessions; however, every individual and presenting problem is unique. Individuals with moderate to severe clinical mental health or substance abuse presenting problems may expect an extended length of stay that exceeds 35-50 sessions in one year, again every individual and presenting problem is unique. Individuals seeking treatment for trauma recovery, eating disorders, psychosis, or self-injury may generally expect significantly extended lengths of stay in treatment compared to other moderate to severe mental health presenting problems. Treatment progress is determined by achieving identified objectives and goals. Periodically, treatment objectives and goals will be evaluated to ensure one is benefiting from treatment. Throughout the treatment episode, a client may achieve objectives and goals only to determine that he/she has new needs and concerns to be addressed, at which time, the client and provider collaborate together and develop new objectives and goals. Further, a client may initially seek treatment for a specific area of concern and discover additional areas of concern to be included in his/her treatment plan.  

19. Excluded Services: 

• Excluded conditions, diagnosis, or client circumstances may include but are not limited to the following: Clients who are in a domestic violence situation (as a victim or perpetrator), anger management or impulse control disorders, clients who have a history of or are currently seeking treatment for sexual compulsion, sexual dysfunction, sexual addiction, or compulsive gambling. Wellness Solutions, LLC does not provide services to any individuals with a history of presenting problems of aggression, violence, threatening behavior, and or violent criminal behavior or is the subject of a current or previous order of protection/restraining order (as the perpetrator/defendant). Further excluded services are as follows but not limited to: Consultation, evaluation, or counseling in regards to child custody of ANY nature, home assessment, or evaluations for custody or making recommendations for child custody, psychological testing services, neurological testing, fitness for duty evaluations for law enforcement or military, substance abuse professional evaluations (SAP), social services evaluations, CPS evaluations, or wrap-around services for community-based supports, Social Security evaluations, dementia evaluations or assessment, issues specifically related to developmental disorders as a primary diagnosis, or early childhood problems or concerns for mental retardation as a primary diagnosis. Wellness Solutions, LLC utilizes the 12 Step Model to addiction and will also include additional substance abuse treatment/self-help models as long as said models are part of an abstinence-based treatment model. Wellness Solutions, LLC does not endorse nor provide treatment for any individually prescribed Methadone maintenance or Suboxone. Wellness Solutions, LLC does not provide services to clients who have situations or circumstances that may include interactions with the legal system. Wellness Solutions, LLC does not provide forensic services of any kind and does not provide court testimony. Wellness Solutions, LLC will attempt to quash and/or declare privilege in any/all cases. Wellness Solutions, LLC does not provide services to clients participating in clinical cases involving worker's compensation concerns and/or claims. Wellness Solutions, LLC does not provide emergency behavioral health, mental health, and/or chemical dependency services or emergency services of any kind. Wellness Solutions, LLC does not have 24-hour emergency behavioral health, mental health, and/or chemical dependency crisis intervention services. Wellness Solutions, LLC does not assess or provide assistance with short-term disability, long-term disability, workers compensation, or FMLA assessment, claims, or filing. Wellness Solutions, LLC does not assess or provide assistance with social security disabilities.  Wellness Solutions, LLC does not provide off-site or in-home behavioral health, mental health, and/or chemical dependency services. Wellness Solutions, LLC does not provide court-ordered therapeutic services of any type. Wellness Solutions, LLC does not provide court-ordered or mandatory outpatient counseling, psychotherapy, or treatment and will not provide or participate in care to/for any clinical case involving interactions with the legal system. Wellness Solutions, LLC does not provide involuntary therapeutic services of any type. Wellness Solutions, LLC reserves the right to refer a client to another provider if it is determined that a client’s presenting problem, symptom, diagnosis, acuity, or a specific situation is outside the scope or area of expertise of current practice. 

20. Experimental & Non-Traditional Treatments: 

• Wellness Solutions, LLC does not use experimental or unusual treatment modalities. The provider does not use therapeutic interventions considered experimental or not-customary to standard treatment protocols. An example of an experimental and/or non-traditional treatment includes recovering repressed memories. Wellness Solutions, LLC does not provide treatment to individuals participating in experimental and/or non-traditional treatments with other providers. 
• Wellness Solutions, LLC does not provide treatment that is outside of the area of expertise relevant to the client’s presentation of symptoms, referral to a higher level of care such as an intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment program (RTC), or inpatient level of care for acute stabilization (IP), and/or referral to neuropsychological testing for diagnostic testing, and/or referral to a psychiatrist for a consultation to determine if medication management is clinically indicated. 
• The client agrees to hold harmless Wellness Solutions, LLC regarding the care he/she receives and that the client will comply with Wellness Solutions, LLC administrative policies/procedures, or billing policies/procedures of the provider. The client and/or client representative agrees that prior to filing a formal complaint with a licensure committee/board, filing a formal complaint with any accrediting body, filing a complaint with any consumer agency/body, prior to pursuing legal action of any type, or filing a lawsuit the client or client representative will following Wellness Solutions, LLC Grievances, Concerns, & Complaints Procedures. Hence, prior to any administrative, legal, or consumer action of any type, the client/client guardian agrees to follow the Wellness Solutions, LLC Grievances, Concerns, & Complaints Procedures.

21. Risks Associated With Treatment: 

• It is important to be aware that counseling, psychotherapy, and treatment have potential benefits and risks associated with treatment. Counseling sessions involve discussions of potentially sensitive information surrounding relationships, trauma, personal or emotional issues, and exploring painful psychological experiences which may be difficult to cope with and potentially cause distress. There are times when psychotherapy can cause emotional distress as you will be addressing issues that may have been upsetting in the past. Discussion of previous distressing events and feelings may include re-experiencing these events and possibly recalling information that one did not remember previously which can cause increased negative feelings, symptoms, and functional impairments. Therefore, one should know that there are risks involved with seeking treatment. If the client begins to experience an increase in symptoms it is very important to inform your provider. There is the possibility that a client may experience an increase in symptoms, resolve some symptoms only to develop new symptoms, or have unintentional or unforeseen consequences as a result of engaging in the therapeutic process. There are times when personal growth and development are preceded by emotional discomfort. Upon knowledge that treatment may be increasing distress, the client and provider can work together collaboratively to ensure that the client’s treatment plan, safety plan, coping skills, support system, and resources address the client’s needs to address these clinical issues and reduce distress. Sessions can significantly reduce the number of symptoms or impairment in functioning a client is experiencing, improve relationships, and or resolve specific areas of concern or distress. While counseling, psychotherapy, and coaching have the potential to improve quality of life, there are occasions in which you may experience increased symptoms until sufficient progress is achieved. Counseling, itself, may not resolve all concerns and symptoms. The attainment of treatment goals is dependent on multiple factors including the quality of work from the client, the client’s support system, the client’s access to resources, and the client’s ability to access healthcare. In the event, a client does not experience positive progress, especially once made aware of concerns regarding a resurgence in symptoms, and treatment plan changes have been sufficiently pursued, then it may become necessary to refer the client to an alternate provider. Please be aware, to derive maximum benefit from treatment and the counseling relationship it is imperative to engage with honesty, transparency, motivation, willingness to change, and take ownership and responsibility for one’s thoughts, feelings, and behaviors. Wellness Solutions, LLC is not able to make any type of guarantee for any specific results regarding counseling outcomes or treatment goal attainment. It is unethical and illegal for licensed mental health professionals to make guarantees or promises regarding treatment results, cures, or offer misleading or false expectations regarding treatment outcomes. There may be clinical situations or circumstances where a client may require a referral to a higher level of care to stabilize his/her symptom severity and decompensation in functioning. Wellness Solutions, LLC may recommend alternative providers or treatments based on a client’s lack of therapeutic progress or decompensation in function in order to ethically attend to the client’s needs. Examples of potential treatment alternatives may include the following: A referral to another outpatient provider who specializes in the area of expertise relevant to the client’s presentation of symptoms, referral to a higher level of care such as an intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment program (RTC), or inpatient level of care for acute stabilization (IP), and/or referral to neuropsychological testing for diagnostic testing, and/or referral to a psychiatrist for a consultation to determine if medication management is clinically indicated. 

22. Notice of Potential Conflicts of Interest:

• Please be aware that Wellness Solutions, LLC includes a vast array of clients and a large community population served.  Wellness Solutions, LLC may provide services to individuals who know one another as friends, family, or co-workers, etc at times. In situations where our clients may know one another all aspects of privacy and confidentiality apply to all parties. It is entirely possible that one may encounter an individual served by Wellness Solutions, LLC that he/she also knows either professionally, socially, or personally. Chance meetings or encounters between individuals who may know one another are expected to include respect for the treatment environment and the confidentiality and privacy of all individuals. As such, it is expected that the privacy and confidentiality of all Wellness Solutions, LLC clients be maintained by all clients, client support system members, and any and all individuals. It is possible that individual members of the same family, social group, employer, or other have some type of relationship could be served by Wellness Solutions, LLC without the knowledge of another. The client or client’s representative and/or parent(s)/guardian(s) agrees to hold harmless Wellness Solutions, LLC in any and all situations or circumstances where Wellness Solutions, LLC may have/had or does have a potential or actual conflict of interest. The client or client’s representative and/or parent(s)/guardian(s) agrees to hold harmless  Wellness Solutions, LLC in any and all situations or circumstances where Wellness Solutions, LLC may have/had a potential or actual conflict of interest where Wellness Solutions, LLC may/does/did provide care or services to or for multiple individuals in the same social group, family system, and/or employer or have/had any type of mutual relationship. The client or client’s representative and/or parent(s)/guardian(s) agrees to hold harmless Wellness Solutions, LLC in any and all situations or circumstances where Wellness Solutions, LLC may have/had or does/did have a potential or actual conflict of interest providing current or former treatment to/for clients with competing interests, agendas, or relationships.

23. Client Administrative Discharge, Financial Discharge, & Self-Discharge From Services:  

• Clients who self-discharge, cancel upcoming appointments and do not reschedule appointments, or no show for appointments, and do not respond to outreach are considered auto-discharged from care or an administrative discharge from care. In order to ensure discharged clients do not incur any considerations regarding abandonment, please be aware that the proper referrals are contained herein, and that Wellness Solutions, LLC provides proper termination in any and all circumstances allowing for three termination sessions. Clients who have not had an appointment for more than 2 months or 60 days are considered discharged from care. If a former client would like to re-admit to care then he/she is welcome to do so as long as he/she is in good standing. If a client self-discharges from care and the client would like to receive discharge disposition information or referrals to another provider the client is responsible for contacting Wellness Solutions, LLC to request the aforementioned information. Clients do not receive specific individualized discharge disposition information unless the client terminates appropriately, which includes but is not limited to, the client discharges in the presence of the provider or in session, or unless the client calls the provider and requests specific individualized discharge disposition information. The client will find referral resources contained herein should the client require or need outpatient resources and referrals and he/she opts to self-terminate care without receiving discharge recommendations. The referral resources contained herein act as discharge disposition in the absence of a termination session and/or a discharge termination summary or documentation and absolves any/all provider(s) of abandonment responsibilities. The client agrees to hold harmless Wellness Solutions, LLC from any and all concerns pertaining to improper termination, improper discharge, or abandonment when a client discharges administratively, financially, or without the proper transition of care. 
• The following is the recommended resources and generalized administrative discharge, financial discharge, and clinical discharge information for all clients who choose to self-discharge: 
  • Call the 800 number for one’s insurance company (found on an insurance card) and request a list of in-network providers
    Visit the member website for one’s insurance company to perform an online search for in-network outpatient providers. 
  • Visit www.psychologytoday.com , www.goodtherapy.org , or www.theravive.com to search for and find outpatient providers. 
  • Call Family Psychiatry of The Woodlands (281-367-1015) or visit http://www.woodlandspsych.com/
  • Call The Woodlands Behavioral Health and Wellness Center (281-528-4226) or visit http://www.addwoodlands.com/
  • Call Lone Star Family Health Center (936-539-4004) or visit https://www.lonestarfamily.org/
  • If you are in an emergency situation or crisis situation you can refer to the Wellness Solutions, LLC website for resources, or go to the nearest emergency room. 

24. Client Termination & Discharge From Care: 

• In the closing phase of the treatment process, a client may decrease the frequency of sessions as the necessity or need for services also decreases. It is helpful to discuss and process the pending discharge from care which is also referred to as client termination so a client may have the opportunity to reflect and process on his/her treatment journey. It is beneficial to utilize the treatment environment and client termination process to identify one’s views on change, achievement, struggles, and most importantly have the opportunity to experience grief through a relationship ending. Discharge from care based on achieving treatment objectives and goals is a positive outcome; however, many clients encounter uncomfortable emotions as they participate in the termination process as the therapeutic relationship is both professional and a very emotionally meaningful and powerful relationship. Therefore, the client is encouraged to terminate appropriately in order to avoid emotional unfinished business. A client may discharge from treatment at any time. However, engaging in the termination process assists a client to appropriately say goodbye in a purposeful and meaningful way. Clients who discharge from care are welcome to return to care should new areas of concern arise, he/she recognizes that he/she may benefit from returning to treatment,  and he/she is in good standing. Clients who discharge from care based on achieving treatment objectives and goals will receive a specific individualized discharge disposition with instructions regarding how they should continue their progress and include referrals and resources to assist the client. 

25. Privacy, Confidentiality, & Privilege: 

• Please be advised that there are ethical and legal considerations regarding privacy, confidentiality, and privilege as it relates to one’s information disclosed in treatment and one’s expectation to maintain control over his/her information. 
• Privacy: Involves an individual’s right to control the disclosure of personal information and to keep information to oneself. When a client gives professional permission or consent to release information the professional only releases the minimum information necessary for the disclosure and within the parameters the client specifically allowed in the consent.
• Confidentiality: Refers to the professional’s ethical duty to protect private information, including all information obtained in the professional therapeutic relationship. A mental health professional has a professional, ethical, and legal duty to safeguard confidential information from unauthorized disclosure. As a general rule, confidential information is disclosed only when mandated by law or with the client’s written authorization. There are limitations and exceptions, however; which include dangerousness to self or danger to others, or the abuse, neglect, or exploitation of minors, the elderly, or individuals considered vulnerable or at risk.
• Privilege: A legal concept limited to the protection of confidential information from forced disclosure in court and other legal proceedings. Privilege refers to the legal obligation that protects a client against forced disclosure of confidential information in court and in other legal proceedings. Privilege also has limits in legal parameters. 
• The provider will respect, protect, and adhere to all ethical and legal obligations with regards to protecting your privacy, confidentiality, and protected health information (PHI). The client or client’s representative and/or parent(s)/guardian(s) must be aware that no one has complete absolute confidentiality. The client may sign a consent to release information form if he/she would like to give permission to the provider to coordinate and/or share the client’s confidential information with a third party.
• The provider is legally and ethically obligated to report the imminent threat of harm to self or others to proper authorities. The client is advised that the provider will report threats of imminent harm to oneself or others in order to facilitate and ensure the safety of the client and/or others. In circumstances where Wellness Solutions, LLC requests the client for consent to release information to ensure safety and the client declines the consent to release information then Wellness Solutions, LLC will discharge the client from care, and the client will not be permitted to readmit to Wellness Solutions, LLC at any time in the future. The provider is legally and ethically compelled to report suspected child abuse, elder abuse, and/or abuse of adults who are disabled or unable to care for themselves. The provider is legally and ethically compelled to report when clients may pose a risk to the public. The provider may be compelled to provide confidential information related to treatment and diagnosis to third-party payors and insurance companies as part of the claims submission and utilization review process. The client is advised that confidential information, such as diagnosis codes, provided to third-party payors and insurance companies may result in changes to his/her coverage and ability to secure insurance coverage in the future. Further, clients in the areas of employment where the pursuit of treatment may have implications on his/her employment are advised that the submission of claims to third-party payors and insurance companies may be shared with his/her employer. The provider advises the client information regarding the care of the client may be released or shared with third-party payers, insurance providers, and employee assistance plans (EAP). The provider advises the client information may be shared based on need and to allow access to the minimum necessary client information required for purposes of standard business practices, quality control, quality improvement, clinical quality measures, client safety, legal procedures, audits, coordination with insurance companies or third-party payors, audits from governmental bodies, credit card vendors, billing purposes, and for other similar purposes. The provider is legally compelled to comply with a subpoena and other actions of the court system in specific situations and circumstances. The client is advised that a client's treatment and all documentation with regard to treatment can be subpoenaed in a court of law. The client is advised that there is no complete and total confidentiality, privacy, or privilege for anyone regardless of circumstances. There are limitations ethically and legally to confidentiality, privacy, and privilege. The provider is legally compelled to allow government agencies access to client information and records for purposes of audits, investigations, and other official purposes. The client relinquishes all rights to privacy and confidentiality in the event the client/client guardian or any agent of the client provides a threat of any type and through any type of communication to Wellness Solutions, LLC and/or staff such that Wellness Solutions, LLC will protect the Wellness Solutions, LLC staff, clients, premises, and reputation. The client is advised that any and all legal and/or ethical rights to privacy and confidentiality are void in the event of legal, ethical, regulatory, or consumer complaints, investigations, audits, hearings, or other legal actions or proceedings. The client’s privacy and confidentiality relinquish all rights to privacy and confidentiality if the client brings a complaint or action against the provider for ethics investigations, HIPAA ONC investigations, or other legal activities, such as, arbitration, mediation, depositions, discovery, or lawsuits. The client is advised that the provider shares information with the following, but not limited to, partners called business associates and has contracts with said associates called Business Associate Agreements (BAA) for normal standard business practices with whom protected health information (PHI) may be shared. Though minors do have a right to privacy, in most sets of circumstances, they do not have confidentiality with the same rights as an adult. Minor clients are advised that there are limitations to confidentiality especially with parents and/or legal guardians.

26. Mandatory Court Reporter: 

• The provider is a mandated court reporter, as such, the provider is legally and ethically compelled to report ANY suspected or reported abuse to minors, the elderly, adults who are at risk for exploitation/abuse or are disabled or unable to care for themselves. Wellness Solutions, LLC is ethically and legally mandated to report any and all suspected verbal, emotional, psychological, physical, financial, and sexual abuse. The provider is not permitted to investigate suspicions or claims of abuse, neglect, or exploitation. The provider is legally and ethically compelled to report to proper authorities who investigate concerns regarding abuse, neglect, or exploitation. Information necessary for making a report is not covered under confidentiality, privacy, or HIPAA laws, or ethical guidelines. The provider is a mandated court reporter for all concerns regarding abuse, neglect, and/or exploitation and makes said reports to Texas Child Protective Services (CPS) or Texas Adult Protective Services (APS). 

27. Client Safety: 

• The client agrees to inform the provider if the client is non-compliant with his or her treatment plan if the client is non-compliant with medication management from his/her prescriber if the client is using illegal drugs if the client is abusing prescription drugs if the client is abusing over the counter drugs if the client is actively engaging in self-injurious behavior, and/or is being abused or is abusing others. The client also agrees to inform the provider immediately if the client has relapsed on drugs, relapsed on alcohol, relapsed on a nutritional plan (for eating disorder clients), or is engaging in any activities that may put the client or someone else at risk or harm. The client acknowledges that failure to disclose this information to the provider may be seriously detrimental to the client and may result in immediate discharge from services. The provider takes the client's safety and the safety of the public very seriously. The provider is legally and ethically obligated to take any and all threats to self, to others, or to the public seriously and report these concerns to the proper authorities. 
• All clients are expected and responsible for cooperating and complying with his/her treatment plan and safety plan. In the event a client is uncooperative, non-compliant, or does not meet his/her expectations and responsibilities with his/her treatment plan, safety plan, the Wellness Solutions, LLC informed consent and disclosures, Wellness Solutions, LLC policies and procedures, and/or the Wellness Solutions, LLC client’s expectations and responsibilities then the provider is not responsible for any clinical complications, clinical complexities, negative clinical outcomes, lack of clinical progress, or unanticipated clinical events the client may have as a result. The provider will not be held responsible for the client’s failure to accurately, honestly, and proactively self-report symptoms, behaviors, thoughts, or compulsions that constitute a safety risk or concern. The provider will pursue any and all ethical and legal options available to protect the client and/or the public when there is a clinical reason to believe that there are safety concerns for a client and/or the public which may include breaching confidentiality to protect the client, protect the public, or to intervene or prevent a potential safety or risk related concern or behavior. 

28. Maintaining Integrity and Privacy in the Treatment Session and Treatment Environment: 

• Clients are not allowed to use any type of electronic device to audio record, video record, or document in any way the private and confidential therapy sessions with Wellness Solutions, LLC. Any/all audio or video recording of counseling sessions is strictly prohibited. Wellness Solutions, LLC does not permit any form of electronic recording on Wellness Solutions, LLC premises and inside client sessions on the part of staff or clients or client parent(s)/guardian(s)/representative(s) or other parties in compliance with state and federal privacy laws, HIPAA compliance, ethical standards, and Wellness Solutions, LLC policies and procedures. Clients are hereby advised that they do not have permission to engage in electronic recording on Wellness Solutions, LLC premises or with in-person communications, including but not limited to, Wellness Solutions, LLC treatment sessions. Further, any and all confidential or professional correspondences with the provider are prohibited from the publishing of any type of media. In the event, a client recognizes another client while on the premises of Wellness Solutions, LLC it is expected that both clients will respect one another’s privacy and confidentiality in the treatment environment. Wellness Solutions, LLC, may share office space with other outpatient providers, depending on the location in question, who have separate practices. 

29. Grievances, Concerns, & Complaints Procedures: 

• The provider welcomes client constructive feedback, concerns, comments, and complaints. Wellness Solutions, LLC views all client feedback as an opportunity to grow, develop, and improve services and quality of care. Should a client/client guardian have a concern, complaint, or grievance regarding the care he/she receives, administrative policies/procedures, or billing policies/procedures of the provider then the client and/or client representative agrees that prior to filing a formal complaint with a licensure committee/board, filing a formal complaint with any accrediting body, filing a complaint with any consumer agency/body, prior to pursuing legal action of any type, or filing a lawsuit the client or client representative will following Wellness Solutions, LLC Grievances, Concerns, & Complaints Procedures. Hence, prior to any administrative, legal, or consumer action of any type, the client/client guardian agrees to follow the Wellness Solutions, LLC Grievances, Concerns, & Complaints Procedures. The Wellness Solutions, LLC Grievances, Concerns, & Complaints Procedure Is As Follows: 1.) Inform the Wellness Solutions, LLC Administrator of the issue both verbally and in writing detailing the specific concern and how the client/client guardian would like the issue resolved. The client/client guardian must have the ability or right to discuss the client’s care with the provider in order to bring forth a complaint. 1a.) To contact the Wellness Solutions, LLC administrator please call the main number and request the administrator. The Wellness Solutions, LLC main number is 713-893-3989. 1b.) The Wellness Solutions, LLC administrator may be reached by email: Admin@WellnessSolutionsLLC.COM and/or Clinical@WellnessSolutionsLLC.com 2.) The client/client guardian must provide specific suggestions that Wellness Solutions, LLC can address the specific concern that is being brought forth in order to ensure that Wellness Solutions, LLC can effectively efficaciously, and

WS Informed Consent & Disclosure Addendum:

 

Complete all intake forms accurately. If a client does not complete the WS Billing Registration Form correctly then WS is not responsible for any billing-related problems or concerns that result from the client’s failure to provide the information correctly. 

Take personal responsibility for your own insurance eligibility, benefits, and claims information. Clients are responsible to know their own insurance benefits. Clients who make the active decision to be willfully ignorant of their own outpatient mental health eligibility, benefits, claims, or the network status of the provider are still financially responsible for their benefits and patient responsibilities for treatment. 

Patient account information & receipts for services. WS provides receipts via email every time a client’s credit card on file is charged. Clients are also provided with an account summary at the end of every month via email if there is a balance on the account. Clients can check their patient portal 24/7/365 for information on the balance on their client account. 

Credit Card Charges to the Client Account. If a client opts for sliding scale or to pay the full fee for services and submit his or her own claims to their out-of-network insurance then the client’s credit card on file is charged the patient responsibility for services the day of the appointment. Payment for services rendered is due at the time of service. If the client uses their in-network insurance then the client’s credit card on file will be charged the patient responsibility for services when the claim for each date of service completes the insurance adjudication process. Any other fees for services are charged to the client’s credit card on file as the client incurs these fees. Clients with credit cards that are declined will receive a $25.00 charge assigned to their existing balance. 

Clients are responsible to know their own insurance benefits. Clients pay their insurance company to manage their benefits, answer their questions about their benefits, and keep track of their claims information. If clients have questions regarding their insurance then the client should contact their insurance company to obtain this information. WS is not responsible for knowing a client’s insurance benefits better than the client. Clients who have questions about their insurance or complaints about their insurance should direct those questions and complaints to the appropriate party - their insurance company. This is the client’s responsibility. Taking responsibility, ownership, and accountability for one’s own healthcare journey includes financial responsibility.

Clients are responsible for obtaining Employee Assistance Plan (EAP) authorizations if they would like to access that benefit. WS accepts a limited number of EAP insurance benefits. If a client wants to access his or her EAP benefits then the client is responsible for calling their insurance company, obtaining the EAP Authorization Number, and the exact number of authorized sessions. The client will be asked to provide this information in the WS Billing Registration Form. WS does not contact insurance companies or EAP programs to obtain authorization numbers and the number of sessions covered. WS will submit EAP claims for clients for one treatment series only. Clients who have EAP benefits that can be renewed can only use those benefits with WS once. WS will not bill for repeated EAP series. Clients are responsible for calling their insurance company to obtain BOTH the EAP Authorization Number AND the number of authorized sessions to utilize and access this benefit. 
 

Clients are responsible for knowing if they have a mental health carve-out of their benefits. Many clients have insurance benefits that include a mental health carve-out. A mental health carve-out is when the client’s mental and behavioral health benefits are managed by a different insurance company than the client’s medical benefits. This means that the client’s medical insurance is managed with one company and their mental health benefits are managed with a different company. The name of the mental health carve-out insurance company is usually NOT listed on the client’s insurance card. This can be confusing and complicated because if the client is not informed about his or her mental health carve-out then the client will provide insufficient information to WS regarding their insurance. This causes problems with insurance claims being rejected or denied. This also causes problems because in many situations the mental health carve-out insurance company is out of network. Clients may choose WS thinking that WS is in-network with their insurance only to learn that is not the case because the client did not check to see who manages their mental and behavioral health insurance benefits. In this situation, the client will provide WS with the medical insurance company information and the mental and behavioral health benefits are with a completely different company. The only way for a client to know if they have a mental health carve-out is to check their outpatient mental health benefits. It is the client’s responsibility to know his or her outpatient mental health benefits. It is the client’s responsibility to inform WS if the client has a mental health carve-out. If the client has a mental health carve out the client is responsible for informing WS of the managed care company’s information so WS can bill the client’s insurance correctly.  

Clients Without Insurance or Clients With Out of Network Insurance- Payment Options. If a client does not have insurance or only has out-of-network benefits then WS provides two possible payment plan options. Option 1: The client can pay the full fee for services and then submit claims to their out-of-network insurance. WS will provide the client with a “superbill” which is required for the client to submit his or her claims to the out of network insurance. (Please see below for additional information). OR Option 2: The client can pay the sliding scale discounted fee for services. This is for clients who would not be able to access care or the cost of accessing care is prohibitive so WS provides a compassionate discount. This is an either-or option. You cannot do both. This is not a WS rule, this is the law. A client can change his or her mind at any time. No, we will not backdate to accommodate when a client changes his or her mind. The change will take place currently and moving forward. If a client chooses a sliding scale then the fees paid for services will not go towards his or her out-of-network deductible or out of pocket. WS does not submit claims to out-of-network insurance. WS also does not check insurance eligibility, benefits, or claims for out-of-network services.   

Superbill Documentation Information. If a client opts to pay for the full fee for service and submit claims to his or her out-of-network insurance then WS will provide the required “superbill” documentation. The superbill will be provided no more than once per month, at the beginning of each month, and will be for the sessions in the previous month. There is a fee of $25.00 for WS to compile the information for each superbill. To request the superbill documentation go to the WS website - Click on Current Client Portal & Self-Service Forms - Click on the WS Documentation Self-Service Request Form - then complete the form. To receive the superbill the client must request the documentation each month. If a client misses a month then WS will not provide a superbill for the month missed. WS will not process documentation requests made without completing the WS Documentation Self-Service Request Form. It is the client’s responsibility to stay on top of the required information and documentation that he or she requires to submit their out-of-network claims to insurance. 

Additional billing-related documentation requests. If a client would like any additional documentation regarding billing, such as, extra receipts then he or she needs to submit the request by going to the WS website - Click on Current Client Portal & Self-Service Forms - Click on the WS Documentation Self-Service Request Form - then complete the form. All billing documentation requests, outside from what WS already provides, will incur a $25.00 fee. Depending on the nature of the documentation request additional fees, such as case management fees may also apply. WS will not process requests made without completing the WS Documentation Self-Service Request Form.

WS Reserves the Right to Refrain from Business with Insurance Providers. WS does not submit claims to open access self-funded indemnity plans or similar insurance plans and benefits. WS reserves the right to refrain from insurance and claims submissions to companies or third-party benefits administrators who do not provide adequate support to providers for insurance eligibility and benefits checks, claims follow up, electronic claims submissions, electronic remittance advice, or electronic funds transfers. WS reserves the right to refrain from insurance and claims submissions for companies who do not use the WS clearinghouse. 

Communication Expectations & Turnaround Times. WS reviews client communication in the order in which they are received and then screens the communications based on risk and safety concerns. 

The WS Billing & Insurance Turnaround Time Expectations are As Follows:
Billing & Insurance Texts: 3-4 Business Days
Billing & Insurance Emails: 3-4 Business Days
Billing & Insurance Patient Portal Messages: 3-4 Business Days
Billing & Insurance Phone Calls & VM: 4-5 Business Days
Billing & Insurance Documentation Requestions: 10-14 Days*
*Once the client submits the WS Documentation Self-Service Request Form

*Most general insurance and billing questions can be answered by reviewing the information provided on the WS website. This includes how to check your insurance eligibility, benefits, and claims information. 

*WS communications turnaround time expectations may vary depending on staffing and other variables. 

Administrative & Appointment Management Information:

WS provides outpatient counseling, coaching, and psychotherapy. WS does not provide immediate, urgent, or emergent services. WS does not provide urgent services, emergency services, or 24/7/365 services. If you are in an emergency please call 911 or go to the nearest emergency room. If you are unable to schedule an appointment and feel that you cannot wait for an appointment please call 911 or go to the nearest emergency room. Clients who would like to schedule new appointments are often anxious to begin services. We appreciate their motivation and desire for change. If a client is experiencing symptoms that are so severe that he or she requires immediate, urgent, or emergent care then Wellness Solutions is not the appropriate type of care that you need. Please pursue treatment that can provide you with the emergency care you require to ensure safety. 

Be Kind. Be Respectful. Take Ownership of the Energy You Bring to a Space. 

WS makes every effort to provide a cozy, comfortable, peaceful, safe, and accommodating environment for our clients and staff. WS is a therapeutic environment, “community,” and group practice that is welcoming, compassionate, open-minded, and accepting. WS honors, values, and appreciates the professionalism, dedication, and commitment of our staff. WS will protect the energy of our healing space and the peace of mind, safety, and wellbeing of our staff. Anyone who is unkind, disrespectful, rude, demanding, argumentative, intimidating, mean-spirited, abusive, or presents with behavior, communication, personality, attitude, or temperament that brings negative energy to WS will be refused services. In the event, any individual brings negative energy to WS and especially to WS staff the individual will not receive services from WS. WS staff are not obligated to be the recipients of anyone’s projected, displaced, or inappropriate behavior or anger. Our administrative, billing, and clinical staff will be respected as humans and as professionals. Anyone who mistreats, disrespects, or abuses WS staff will be immediately discharged from care, refused services, or banned from communications or behaviors that jeopardize or infringes upon the WS healing sanctuary. WS will not provide warnings for or enable inappropriate behavior. WS reserves the right to refuse services to anyone, at any time, and for any reason.

If you would like a returned call then leave a voicemail with the information to return that call. If you would like your phone call returned, leave a message with the required information to return the call. If you call WS and do not leave a voicemail with the information needed to return the call then our staff will not call you back. This means if you call and do not leave a message at all or if you do not provide the needed information to return the call we will not call you. (If you are wondering, yes this is actually a real thing.) The following information is required to leave a voicemail: The caller’s first and last name, the client’s first and last name, the DOB of the client, the secure private phone number where WS can return the call and leave a voicemail if needed, and the reason for the call. 

Clients are responsible for their own appointment management. Adult clients are expected to take adult responsibility for their appointment management. WS will not allow any adult other than the adult client to schedule appointments for himself or herself. WS will not communicate with any adult other than the adult client regarding any care or treatment. Adolescent clients may schedule for themselves or their parents may schedule for them. Adolescent clients may have parents communicate with WS if they choose to do so. 

Telehealth Services. WS is currently providing all services via telehealth. We do not know if or when we will return to in-person services. We are unable to provide any estimate of when services may return to in-person appointments. Your clinician will send an email with a link to your appointment at the time of your scheduled appointment. The links are NOT sent in advance. The links are NOT reused each session. The emails with the links are sent at the start time of the session. We do not send the links in advance. We will send the email with the link to the appointment to the email account that the client registered with their intake forms. 

WS Provides Services for Clients Physically Located in the State of Texas. WS clinical staff are licensed mental health professionals in the State of Texas. All clients receiving WS telehealth services are required to be physically located in the State of Texas at the time of their telehealth appointment. WS is not able to provide services to clients who are physically located outside the State of Texas. 
 

Communication Expectations & Turnaround Times. WS reviews client communication in the order in which they are received and then screens the communications based on risk and safety concerns. 

• The WS Administrative, Appointment Management, & Clinical Turnaround Time Expectations are As Follows:
  
  • Administrative, Appointment Management, & Clinical Texts: 2-3 Business Days
  • Administrative, Appointment Management, & Clinical Emails: 2-3 Business Days
  • Administrative, Appointment Management, & Clinical Patient Portal Messages: 2-3 Business Days
  • Administrative, Appointment Management, & Clinical Phone Calls & VM: 3-4 Business Days
  • Appointment Management Documentation Requests: 10-14 Business Days*
    *Once the client submits the WS Documentation Self-Service Request Form

*Most administrative, appointment management, and clinical policy questions can be answered by reviewing the information provided on the WS website. 

*The WS communication turnaround times may vary depending on staffing and other variables.

Wellness Solutions, LLC Business Hours:

WS Administrative & Billing Business Hours:

Monday - Thursday: 9:30 AM - 2:00 PM 

Friday: 9:30 AM - Noon  

Saturday: Closed

Sunday: Closed

WS Clinical Appointment Business Hours:

Monday 9:00 AM - 5:00 PM

Tuesday 9:00 AM - 5:00 PM

Wednesday 9:00 AM - 5:00 PM

Thursday 9:00 AM - 5:00 PM

Friday 9:00 AM - 5:00 PM

Saturday 9:00 AM - 5:00 PM

Sunday 9:00 AM - 5:00 PM

*All WS staff maintain individual schedule availability. 

*WS staff schedules are subject to change.

 

With my signature below I submit to, agree with, and will comply with this information:

Attestation & Signature:

Attestation: To the best of my knowledge and understanding all information provided in this document is accurate, true, and honest. Further, I make a genuine commitment to begin my counseling, psychotherapy, and coaching journey with transparency, accountability, responsibility, open-mindedness, and willingness to engage in a positive and forthcoming manner. I accept and understand that my personal journey is my personal responsibility and I take ownership of my process. I will provide earnest and proactive communication to participate and direct my care and to collaborate with my team. 

• I accept receipt of and understand, agree, and will comply with the WS Client Rights, Expectations, & Responsibilities.
• I accept receipt of and understand, agree, & will comply with the WS Client Notice of Privacy Practices (NOPP).
• I accept receipt of and understand, agree, & will comply with the WS Client Informed Consent & Disclosures.
• I understand and agree that there are limitations to confidentiality. I also understand the legal and ethical standards of privilege, confidentiality, and privacy as explained in this document. I further understand that in cases of suicidal, homicidal, psychosis, abuse, and other areas of risk behaviors, thoughts, and feelings there are limitations to confidentiality and that Wellness Solutions, LLC will take any and all actions necessary to protect the health, well being, and safety of a client, client support system, and members of the public. Wellness Solutions, LLC will breach confidentiality for concerns for the safety of any individual and/or the public.
• I understand, agree, and will comply with all information contained herein. Further, I provide consent for Wellness Solutions, LLC to provide mental and behavioral health services, substance abuse counseling, counseling services, coaching services, psychotherapy services, and any and all related services.
• I give consent for Wellness Solutions, LLC to accept insurance payments and assignments from insurance and/or third-party payors.
• I give consent for Wellness Solutions, LLC to check eligibility and benefits, submit information, such as claims to insurance and/or other third parties for claims remunerations and other appropriate and related business activities necessary for payment.
• I give consent for Wellness Solutions, LLC to accept assignment and payment from insurance and/or third-party payors on behalf of the client as part of the claims submission process.
• I give consent for Wellness Solutions, LLC to charge the client's account for fees and to maintain a credit card on file for all client charges or fees. I give consent to charge the client's credit card on file for all charges and fees for services. I also recognize and accept that Wellness Solutions, LLC has the legal right to pursue collections for fees charged to the client's account that is not collected. I further recognize that any fees or charges to the client's credit card on file that are denied or challenged or declared as fraud by the client or his/her representative will be pursued criminally as theft for services. Wellness Solutions, LLC will charge the client for fees incurred by Wellness Solutions, LLC to pursue outstanding balances, pursue collections, or other such activities. 
• I acknowledge and understand that the client is responsible for all fees for service rejected, denied, or not covered by his/her insurance. Further, I acknowledge and understand that the client may incur fees not covered by insurance.