What is Telehealth?

Telehealth involves the use of electronic communications to enable providers at different locations to share individual client information for the purpose of improving client care.  Providers may include primary care practitioners, specialists, and/or subspecialists.  The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: 

• Client health records
• Live two-way audio and video
• Output data from health devices and sound and video files
• Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 

Expected Benefits: 

• Improved access to care by enabling a client to remain in his/her provider's office (or at a remote site) while the providers obtains test results and consults from practitioners at distant/other sites.
• More efficient client evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks:

• There are potential risks associated with the use of telehealth.  These risks include, but may not be limited to: 
• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
• In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors;

 By signing this form, I understand the following: 

1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time.  My provider has explained the alternatives to my satisfaction.
5. I understand that telehealth may involve electronic communication of my personal health information to other practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

The Benefits and Risks of Counseling

There are many benefits to counseling. One major benefit that may be gained from participating in counseling is the resolution of the concerns brought to therapy. Other possible benefits may be a better ability to cope with marital, family and other interpersonal relationships, and /or a greater understanding of personal goals and values. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages. There are certain risks involved in counseling. Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. In order to be most successful, you will have to work on things we discuss outside of sessions. The greatest risk of counseling is that it may not by itself resolve your concerns. Psychotherapy is a collaborative process and the progress you, make will depend in large measure upon your investment in the process.

Ardent Grace Counseling and Teletherapy Crisis Policy and Protocol

If you experience a mental health emergency, and require a visit with your therapist, call or text 254-271-0055.  Your therapist will make every effort to see you in a timely manner.

If you are unable to reach your therapist, call 911 or visit your local emergency room promptly.

If you experience a mental health crisis during or outside of a session, your therapist will utilize clinical judgement to determine if you pose an immediate risk of harm to yourself or someone else.  If it is determined that you do pose a risk, your therapist will attempt to reach your emergency contact and/or emergency law enforcement personnel, your psychiatrist or social worker (if you have one), and coordinate care with applicable emergency healthcare personnel.  If you reside on a military installation, steps will be taken to reach your command chaplain or umbudsman to access/coordinate required care.

Court Fees

If you choose to share your therapy information with an attorney or the court, and this results in a demand for the therapist’s involvement, you will be charged $400 per hour for any subsequent court or related demands for the therapist’s time. This may include the cost of consultation with attorneys, court appearances, letter or report writing, or preparation and travel time as well as the therapist's travel fare.  If you anticipate court involvement, or you are seeking an evaluation for legal reasons, please discuss this with your therapist prior to beginning treatment.

Should your counselor be subpoenaed or ordered by a court of law to appear as a witness in an action involving you or your child in a custody dispute, the client agrees to reimburse the counselor for any time spent for preparation, travel, or other time in which they have made themselves available for such an appearance at a rate of $400 an hour. A deposit of $2000 will be required for them to cancel all their clients and set aside a day for which they may have to appear in court.

What is HIPPA?

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about:

Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:  

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2.  It is the policy of this office to remind patients of their appointments. We may do this by telephone, SMS text message, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3.  The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4.  You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5.  You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.

6.  Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7.  We agree to provide patients with access to their records in accordance with state and federal laws.

8.  We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

9.  You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

What are the limits to confidentiality?

You may always share your PHI with someone else if you so choose.  Your therapist will ask you to sign a relaeas of information if you decide to share your PHI.  

There are some acceptions to confidentiality.  These acceptions consist of five major contexts:

1. Billing and insurance issues;  

2. Situations involving a client who is minor or an incapacitated adult;

3. Situations where risk of harm to self or others exists;

4. When an LPC discovers that a client is already under the care of another provider;

5. And situations involving subpoena of client records by a court of law.

Exceptions to confidentiality are discussed in some detail below:

With regard to billing and insurance issues, Christi Kersten, MA, LPC will advise the patient of the types of information that must be released to ensure payment, and which entities (or types of entities) are entitled to receive such information.

Christi Kersten, MA, LPC will also ask the client whether he or she is under the care of another counseling provider and advise the client that, if so, the counselor must inform the other provider.

With a client who is a minor or an incapacitated adult, Christi Kersten, MA, LPC will inform the client that the law may require her to breach confidentiality in the below cases:

a. obtaining consent from parent(s) or guardian(s) in order to provide therapy;

b. seeking payment from a parent or guardian for services rendered; 

c. if therapist reserves the right to notify the parent/guardian in cases where the therapist believes there is a risk of harm to the child or harm to someone else by the child;

d. informing the parent in the event the therapist discovers the child is involved in dangerous or risk taking behavior such as sneaking out of the house, unusual sexual promiscuity, sex with someone over the age of 18 (if a client is a minor), criminal behavior or illegal drug use.

With regard to risk of harm, Christi Kersten, MA LPC may be be required by law to breach confidentiality in a variety of contexts pertaining to risk of harm to self or others:

a. where the LPC has reason to believe that a child (patient or other minor) is being abused (whether the client is the child or the suspected abuser);

b. where the LPC has reason to believe that the client poses a risk to others (homicidal thoughts or behaviors);

c. or where the LPC has reason to believe that the client poses a risk of self harm or suicidal thoughts or behaviors.

d. if the client's records are ever subpoenaed by a court of law for any reason, the therapist will comply with such orders within the extent allowed by law.  

 

 

Couples Therapy Non-Collusion Agreement (applicable only to couples counseling):

I understand that should I choose to participate in both couples counseling and individual sessions with the same counselor, that my counselor may not be able to keep all information I share in indidual sessions confidential from my partner, especially when it it would cause clinical harm to do so.  I understand that every situation is different, and my couples therapist may choose to refer me to a collegue for individual therapy if it is in my best interest or clinically advisable for the success of the couples counseling process to do so.  

Christian counselors do not presume that all clients want to or will be receptive to explicit spiritual interventions in counseling.

Christi Kersten, MA, LPC obtains consent that honors client choice, receptivity to these practices, and the timing and manner in which these things are introduced:

• prayer for and with clients 
• Bible reading and/or reference
• spiritual meditation
• the use of biblical and religious imagery
  assistance with spiritual formation and self discipline
  other spiritual practices common to mainline evangelical Christianity

Christi Kersten, MA, LPC adheres to the Code of Ethics put forth by the American Association of Christian Counselors.  More about the Christian Counseling Ethics may be found at www.aacc.net.

Fees for Services

All fees should be paid at the time services are rendered. Cash, personal check, debit, HSA cards and credit cards are welcome and will be processed prior to the session. If your therapist is not a participating provider for your insurance plan, she will supply you with a receipt of payment for services, which you can submit to your
insurance company for reimbursement. Please note that not all insurance companies reimburse for out-ofnetwork providers.

Fees for Self Pay (without insurance)

Costs for therapy are the same whether in office or virtual. Your cost may differ if you use insurance or set your appointment from a directory like Telemynd or Headway.  

Self Pay Rate: 

• $225 per 60 minute individual or couples session                                                   
• $300 for 90 minute individual or couples session                                               
• $375 for 120 minute individual or couples session

 

In general, it is recommended that you attend therapy weekly or bi-monthly to start so that you can start making progress faster.  The number of sessions initially recommended can range from 4-16, depending on your diagnosis and the rate at which you progress to meet your goals.  This will be re-evaluated with your input every 3-4 months. 

Christi, your therapist at Ardent Grace Counseling and Teletherapy, always honors client choice in how often (once a week, twice a week, once a month, etc) and how long (60, 90, 120 minutes) your sessions will be.  She is a partner in your mental health, and you are always in control of the goal setting process.  

You may apply for lower rates within a sliding scale with sufficient proof of household income. Depending on your income and/or other factors you may wish to discuss with your therapist, your session costs may be between $35 and $85 for a 60 minute session. Call or Text (254) 271-0055 for more information.

If you are using insurance, you must pay your predetermined copay, set ahead of time, according to your plan and coverage. The platform that you schedule with will collect your credit card information and process your copay. 

Depending on your insurance, scheduling and fees will be coordinated through one of the following.  You MUST enroll in autopay before begining therapy if you are seeing the threapt through Alma.

Headway

Alma

GrowTherapy

Telemynd

In some cases, depending on your insurance, the cost of the copay can be higher than the self-pay rates listed above, and you always have the option to switch to self-pay for the next session.  Just be sure to let your therapist know that you would like to do so, and schedule the next session through the self-pay scheduling link on ardentgracetherapy.com or the AG app.  

A credit card will be required to book your session. You may cancel for a full refund or reschedule your session up to 24 hours before the scheduled appointment time. If you cancel after that time or if you do not arrive or check into the online waiting room, you may be charged up to the full fee of the session self-pay rate.  These fees may be avoided by simply calling or texting your therapist or rescheduling/cancelling on-line within the above time frame.

It is understood that sometimes there can be a legitimate reason for a last minute cancellation/no-show, which is why you must contact your therapist by the end of the day if you miss a session, and you want your situation to be taken into consideration for a waiver. The no-show fee may be waived on a case by case basis.  Please note, no more than 2 last minute cancellations/no-shows will be waived for any one client/couple.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than your Good Faith Estimate you have the right to dispute the bill. 

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call (877) 696-6775.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (877) 696-6775.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

I understand and agree to the terms set forth in my good faith estimate, and I understand that I may request a copy of it, and/or all or any portion of this New Patient Intake Document at any time.